UCAOA Orlando 2013 Contracting with Payers v2
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Transcript of UCAOA Orlando 2013 Contracting with Payers v2
Payment Reform and Changing
Reimbursement Patterns
Tom Pascuzzi, MD
VP/CMO Convenience Care
Presbyterian Healthcare Services
Albuquerque, New Mexico
Presbyterian Healthcare Services7 Hospitals
400 provider Medical Group
450,000 Health Plan Members
Contracting Options
• Fee For Service
– The way we were!
– An ostrich with it’s head in the sand
• Budget Based Methodologies
– Like it or not, the way we are going!
– Capitation and Bundling payments
– Pay for performance incentives
Questions for Your Practice
• What percent of my income is Fee for
Service today?
• What percent of my income do I believe
will be budgeted in the future?
Fee for Service
• A provider is paid for providing services to
enrollees solely through fee-for-service
payments based on Medicare RBRVS
• Tied to current year rates and fluctuates
• Pressure to decrease payments through SGR
• Not working for CMS, not working for
Providers
• New models being tested
Fee for Service
• Percentage of Medicare rates
– Do you know what your conversion factor
payment is?
– Can you insure that the payer is making the
correct payment?
– How do you know if bundling and denials are
occurring?
– Do you think the FFS model is going to change?
What is Coming? Change!
Payment Reform
Patient Protection and Affordable Care Act
• Establishes several demonstration programs
to test and evaluate new health care delivery
and payment models
• Effort to improve care coordination and
quality while reducing the rate of spending
• ACO’s, Bundled Payments and Medical
Home
PPACA
• The Innovation Center (section 3021 of the
Affordable Care Act) created for the
purpose of testing “innovative payment and
service delivery models to reduce program
expenditures …while preserving or
enhancing the quality of care” for those
individuals who receive Medicare,
Medicaid, or Children’s Health Insurance
Program (CHIP) benefits.
Estimated Financial Effects of PPACA
How is this going to be achieved?
CMS Center for Innovation
• Medicare Shared Savings Sec 3022
• Pilot Program on Bundling Sec 3023
– Bundled Payments for Care Innitiative
• Gainsharing Demonstration Sec 3027
• Community Team Health for PCMH Sec
3502
Budget Based Methodologies
• Quality measures and Pay for Performance
– Shared savings
– Pay for performance
– Bundled payments
– Pioneer ACO’s
– Global prepayment
Pioneer ACO
• Under the Pioneer ACO Model, CMS will
provide incentives for participating health
care providers who form an organization to
coordinate care for patients. Providers who
band together through this model will be
required to meet quality standards based on
patient outcomes and care coordination
among the provider team, as well as other
measures
ACO’s
• Accountable Care Organization
– Provider based
– Need for cheaper and easier access to care to
decrease ER and Admissions
– Global payment by ACO to include all visits
and all services provided
– Consider loss protection
– Shared savings models
Medicaid Expansion - Exchanges
Where does this leave YOU?
• Where the Government Goes – Others Will
Surely Follow
• Private payers are certain to come up with
their own models of budgeted care
• They have before and they will again
Budgeted Care
• Capitation from the 1990’s
– California and large market managed care
– Per Member Per Month (PMPM)
– Large groups and integrated systems
– Not popular but making a comeback in a new
cover – ACO’s
Capitation Model
• Medical Group provides all care
– Primary Care only
– Full Service
– Bundled conditions only
– Carve outs
• Utilization review is important – data driven
• Stop loss insurance may be necessary
Affordability: Rising Costs are Unsustainable
What can You do?
• Prepare yourself for global payment or
episodic are reimbursement
• Join an ACO?
• Accept Case Rate payment – S9083
• Know your risk – know your costs!
S9083 Case Rate
• Single payment one size fits all in the
Urgent Care setting utilized by many payers
and MCO’s
• Does not pay for ancillary lab or x-ray
• Risk with overutilization of services
• Works well with simple care; not for
complex care
• Must understand your cost of services
S9083 Case Rate
• Lacerations
• Fractures
• Complex medical services (IV’s and meds)
• Ask for a list of carve out codes
• Best interest of both parties to work
together for a fair payment system to
support the convenience and cost savings
Summary
• Payment reform is here to stay
• Know where your money comes from
• Review existing contracts and stay on top of
fee for service changes
• Be open to budgeted models such as global
payment and case rates
• Understand your costs of doing business
Resources
• AMA Practice Management Center
– Pathways for Physician Success Under Healthcare Payment and Delivery Reforms
Harold D. Miller
– Evaluating and Negotiating Emerging Payment Options, 2012
• Health Reform and the Decline of Private Physician Practice Merritt Hawkins
• www.innovation.cms.gov
• www.advisory.com