Annual Medicare Update

Transcription

1 Annual Medicare Update September 21, 2018

2 Creating Alignment Presented by: Drew C. Pierce, CEO The Primary Health Network Michael F. Garczynski, Partner Arnett Carbis Toothman LLP

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6 the remedy Collaboration 6

7 Collaboration Between Hospitals and Community Health Centers / Federally Qualified Health Centers

8 Creating Alignment Creating alignment through collaborative efforts of hospitals and Federally Qualified Health Centers (FQHCs) can improve clinical outcomes, improve access for the underserved, and have a significant positive financial impact on these organizations. 8

9 Outline What are Federally Qualified Health Centers? FQHCs Facts & Stats Benefits of Collaboration Types of Collaborative Efforts Conclusion 9

10 What are FQHCs? 10

11 The History of Community Health Centers and FQHCs 1960s Office of Economic Opportunity and Department of Health, Education, and Welfare focus on community health Mid-1970s Congress authorized CHCs as a move toward consumer governed health care programs 1989 FQHC program established by Omnibus Budget Reconciliation Act (OBRA) 1990s saw significant growth in CHCs Health Care Reform Patient Protection and Affordable Care Act (PPACA) 12 11

12 Federally Qualified Health Centers Purpose of FQHC program is to enhance the provision of primary care services in underserved urban and rural communities Considered a Safety Net Provider 12

13 FQHC Benefits Grant funds for qualified grantees Minimum per encounter payment rates for Medicare and Medicaid Federal Medical Malpractice Coverage (Federal Tort Claims Act Coverage) for grantees 340B Drug Discount Program Loan Guarantees Health Professional Shortage Areas (HPSA) designation 13

14 FQHC Covered Services: What Medicare Pays For Services are covered when furnished to a Medicare beneficiary Physician services Services and supplies incident to the services of physicians Mid-level practitioners Services and supplies incident to the services of mid-level practitioners Visiting nurse services Covered drugs furnished incident to services furnished 14

15 Federally Qualified Health Center Location Requirement May be located in rural or urban areas One of the following: Medically Underserved Area Medically Underserved Population Health Professional Shortage Areas (HPSA) designation 15

16 Federally Qualified Health Center Clinical Requirements Provides primary and preventative health services typically furnished in a physician office Must also provide Lab Radiological Pharmacy Emergency Preventative Dental Others Productivity Standard 4,200 visits per FTE physician 2,100 visits per FTE mid-level practitioner 16

17 Federally Qualified Health Center Management Requirements Must have a separate independent Board of Directors A majority (at least 51%) of the Board of Directors must be registered patients of the center The Board of Directors must be representative of the service area At least 9, but no more than 25, members on the Board of Directors Of the non-patient board members, only a limited number of those members may earn more than 10% of their income from health care related industries Employees of the FQHC and their family members cannot be members of the board 17

18 Federally Qualified Health Center Management Requirements (cont.) Compliance with Civil Rights Act Submission of a non-competing continuation application Annual audit by independent CPA Ability to accurately track and record cost based reimbursement Perform an annual evaluation of the total program Prepare documentation showing physical boundaries of the area served, demographics, health needs, etc. Demonstrate need for services in the community 18

19 FQHC Medicare PPS System Medicare FQHC PPS Payment methodology is based on 80% of the LESSER of actual charges OR the FQHC Medicare PPS rate The FQHC Medicare PPS rate reflects a base rate adjusted for geographic differences in costs by applying geographic adjustment factors (GAFs). A weighted measure used to calculate regional variation of service costs based on national costs. Physicians work adjustment factor Practice expense adjustment factor Malpractice cost adjustment factor 19

20 FQHC Medicare PPS System Medicare FQHC PPS For calendar year 2018: FQHC market basket update -1.9% FQHC PPS base payment rate is $ Payment adjustments apply to the FQHC PPS payment rate: FQHC Geographic Adjustment Factor New patient adjustment Initial Preventive Physical Examination (IPPE) or Annual Wellness Visit (AWV) adjustment 20

21 FQHC Medicare PPS System Medicare FQHC PPS The FQHC Medicare PPS rates will be calculated as follows: Face to Face Encounter: Base payment rate ($166.60) x GAF (.970) = PPS rate New Patient: Base payment rate (166.60) x FQHC GAF (.970) x = PPS rate 21

22 FQHC Medicare PPS System Per-Diem Payment and Exceptions Encounters with more than one FQHC practitioner on the same day or multiple encounters with the same FQHC practitioner on the same day constitute a single visit, except when the patient has either or both of these: An illness or injury requiring additional diagnosis or treatment subsequent to the first encounter A qualified medical visit and a qualified mental health visit on the same day 22

23 FQHC Medicare PPS System FQHC COST REPORTS FQHCs must file a cost report annually using Form CMS , Federally Qualified Health Center Cost Report. Graduate medical education, bad debt, and influenza and pneumococcal vaccines and their administration are paid through the cost report. 23

24 FQHCs Facts & Stats 24

25 America s Health Centers 25

26 America s Health Centers 26

27 America s Health Centers 27

28 America s Health Centers 28

29 America s Health Centers 29

30 America s Health Centers 30

31 Pennsylvania Health Center Fact Sheet 31

32 West Virginia Health Center Fact Sheet 32

33 Benefits of Collaboration 33

34 Federally Qualified Health Center Collaborative Arrangements Benefits of collaboration Reduced emergency room visits Possible expansion of grants to cover uninsured or underinsured Reduced physician recruitment and credentialing costs Medical malpractice coverage in specific instances Shared administrative and medical leadership Improved financial viability of health care organizations Improved clinical outcomes Loan repayment program 34

35 Types of Collaborative Efforts 35

36 Federally Qualified Health Center Collaborative Arrangements Types of collaboration arrangements Referral arrangements Co-location referral arrangements Non-exclusive contractual arrangements Lease of personnel Umbrella affiliation agreement Corporate integration strategies 36

37 What it Takes to Collaborate Time and Planning Team Work Creativity Courage Willingness to Give and Take Contribution of Resources Legal Opinions Mutual Trust 37

38 Examples of Successful Collaboration The Primary Health Network Referral of Services (Specialists / Ancillary) Joint Recruitment Income Guarantees Rotation of Specialists Leased Providers Transition of Primary Care Sites Transition of Outpatient Behavioral Health Sites Transition of Dental Sites Shared Operations (Outpatient vs. Inpatient) Multi-Service Facility Co-location Residency Programs School Based Health Centers Transportation Shared Savings Inclusions 38

39 Conclusion 39

40 Summary Expansion of FQHCs is an initiative of Federal government Expansion can be a threat or an opportunity Collaborative efforts can benefit all health care providers by effectively utilizing limited resources Benefits available for all hospitals Knowledge and trust will be keys Collaboration will have positive impact on delivery of quality health care services to safety net populations Community health needs assessments will be valuable Many resources available 40

41 QUESTIONS? Drew C. Pierce, CPA, NHA, CPC Chief Executive Officer The Primary Health Network voice: Michael F. Garczynski, CPA, CGMA Partner Health Care Services Arnett Carbis Toothman LLP voice: or