Practice Managers Meeting March 19, 2015
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- Berniece Hines
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1 Practice Managers Meeting March 19, 2015
2 2
3 Accountable Care Network 101 Aligning hospitals, their staffs, and community physicians into clinically integrated networks
4 Accountable Health Partners Vision To bring together community and faculty physicians, hospitals and other affiliated providers to develop a clinically integrated care network with aligned financial incentives, to improve population health, to provide patient-centered care and to promote efficient use of resources. 4
5 The Growing AHP Network Adult PCPs PCP Pediatricians Specialists CNMs Total Community URMFG Total
6 Network: Ten-County Region
7 Network: Hospitals 7
8 Intro to AHP Gain Sharing Contracts Sits on top of existing fee-for-service contracts For 2014, upside only Payer sets a budget and quality goals for the attributed population Network performs under the budget and meets quality goals The dollars saved (the gain ) are shared between payer and network 8
9 MVP TAG Contract Term: ,000 attributed members Upfront clinical integration payments to PCPs HEDIS-based quality measures Opportunities for gainsharing if quality goals are met 9
10 Excellus ACQA Contract Term: 2014 ( contract still being negotiated) 128,000 attributed members Commercial only (including self insured) Upfront clinical integration payments to PCPs Opportunities for gainsharing if quality goals are met ARCADIA!! 10
11 Arcadia Analytics Connection & Validation Work plan DRAFT Jan 15 Feb Wave #1 (1/30-3/27) UR Primary Care (EPIC) Wave #1b (2/27-3/29) Office of Dr. Kerper (EPIC) Wave #2 (2/20-4/17) Victor Health (Medent) Stonybrook Ped (ecw) Wave #3 (3/13-5/8) Office of Drs. Cahn-Hidalgo, Minnella, Plain, Tan, Yoon (Chartmaker) UR Thompson (Medent) Elmwood Ped (Medent) Letchworth Family (Medent) Alexander Medical (Medent) Wave #4 (4/3-5/29) Finger Lakes Family(Amazing Charts) Honeoye Valley Family (HST) Tri-County Family (ECW) Lewis Ped (Medent) Keuka Family (Medent) Naples Valley (Medent) Wave #5 (4/24-6/19) Canandaigua Medical (Vitera) Brighton Family(HST) Zoneci Medical (HST) Jefferson Family (HST) Goodman Peds(Medent) Pathway Peds (Medent) Wave #6 (5/15-7/10) Sheikh (CureMD) His Branches Health (Medent) Twelve Corners Ped(Medent) Office of Dr. Tinkelman (Medent) Office of Drs. Mahoney, Horohoe & Garneau (HST) Wave #7 (6/5-7/31) Family Medical Alfred Office of Dr. Qureshi (Chartmaker) (Practice Fusion) Bayoumi Medical (Chartmaker) University Health Services Abbasey Medical (Chartmaker) (Pyramed) Hope Internal (Amazing Charts) Office of Dr.Akowuah (HST) Northern Allegany (Amazing Charts) Bloomfield Family (Medent) Lake Country Family (Amazing Charts) Wave #8 (6/26-8/21) Shifa Medical (ecw) Noyes Health Employed(eCW) Wayland Family(eCW) James Three Seventeen Medical (Practice Fusion) Depner(Medent) Eastside Peds (Medent) Wave #9 (7/17-9/11) Breen and Assoc (HST) Sunrise Ped (Medent) Valley View Family (Medent) Pinnacle Family (Vitera) Jones Memorial (LSS) Wave #10 (8/7-10/2) Wave #11 (8/28-10/23) Blossom Rd Internal (Practice Fusion) Wave #12 (9/18-11/13) Arnot Medical (ecw) Legacy Peds (TBD) Brighton Peds (Soapware) Mar Apr May June Jul Aug Sept Oct Nov Wave #1 Wave #8 Wave #2 Wave#9 Wave #3 Wave#10 As of: 2/6/15 Wave#4 Wave#11 Wave#5 Wave#12 Wave#6 Wave#7
12 UR Health Plan Contract Term: ,000 covered lives Tier One Network Employees pay lowest copay/deductible when obtaining services from AHP providers Quality measures and integration measures TBD 12
13 Patient Population Employees and their dependents covered under the University of Rochester Employee Benefit Plans Excludes: Affiliates Medicare-eligible retirees Members of 1199 SEIU 30,000 individuals are covered by the UR employee benefit plan Approximately 10,000 are seeing an out-of-network PCP 13
14 Benefits Basics Two TPAs: Excellus BCBS and Aetna Two plans: PPO Plan HSA-Eligible Plan Both plans: Three tiers of benefits No PCP required Preventive care covered at 100% whether AHP or Aetna/Excellus network 14
15 PPO Plan Deductibles: Single AHP Aetna/ Excellus OON Deductible $400 $800 $1600 Coinsurance 90% 80% 60% RC OOP Max $2000 $2500 $2500 $3000 $4000 $4000 Deductible applies to all health care expenses except office visits. 15
16 PPO Plan Deductibles: Family AHP Aetna/ Excellus OON Deductible $1000 $2000 $4800 Coinsurance 90% 80% 60% RC OOP Max $4000 $5000 $5000 $6000 $8000 $8000 Deductible applies to all health care expenses except office visits. 16
17 PPO Plan Coverage: Office Visits AHP Aetna/ Excellus OON PCP $15 $30 60% of RC Specialist $30 $60 60% of RC Preventive Care 100% (no copay) Not covered Chiropractor $30 60% of RC PT/ST/OT $30 60% of RC Optometrist $30 60% of RC 17
18 PPO Plan Coverage: Maternity AHP Aetna/ Excellus OON Prenatal 100% 100% 60% of RC Postnatal 100% 100% 60% of RC Hospital 90% 80% 60% of RC 18
19 PPO Plan Coverage: Hospital AHP Aetna/ Excellus OON Inpatient 90% 80% 60% of RC Outpatient 90% 80% 60% of RC 19
20 HSA Plan Deductibles: Single AHP Aetna/ Excellus OON Deductible $1300 $1800 $2500 Coinsurance 90% 80% 60% RC OOP Max $2500 $3000 $3500 $4000 $4750 $4750 University HSA contribution: $200 20
21 HSA Plan Deductibles: Family AHP Aetna/ Excellus OON Deductible $2600 $3600 $5000 Coinsurance 90% 80% 60% RC OOP Max $5000 $6000 $7000 $8000 $9500 $9500 University HSA contribution: $400 21
22 Deductibles Cross Apply Tier One-AHP Tier Two Non AHP Specialist 80% covered $1800 Non AHP Labs $350 Non AHP PCP visit $150 AHP Specialist Visit 90% covered $1300 Specialist Visit $250 $250 Specialist Visit $250 $250 Chest X-Ray $650 $650 PCP visit $150 $150
23 HSA Plan Coverage: Office Visits AHP Aetna/ Excellus OON PCP 90% 80% 60% of RC Specialist 90% 80% 60% of RC Preventive Care 100% (no copay or deductible ) Not covered Chiropractor 90% 60% of RC PT/ST/OT 90% 60% of RC Optometrist 90% 60% of RC 23
24 HSA Plan Coverage: Maternity AHP Aetna/ Excellus OON Prenatal 100% 100% 60% of RC Postnatal 100% 100% 60% of RC Hospital 90% 80% 60% of RC 24
25 HSA Plan Coverage: Hospital Inpatient Outpatient AHP Aetna/ Excellus OON 90% 80% 60% of RC 25
26 Two Tiered Services/Providers AHP does not include all of the providers that deliver health care services (e.g., optometrists, podiatrists) For these specialties, the UR employee claims will process at the highest benefit level (Tier One) if the provider is in the Aetna/Excellus networks. If the provider is not in the Aetna/Excellus networks, the claim will process at the Tier Three benefit level. 26
27 Examples of Non-AHP Provider Services Covered at the Tier 1 Benefit Level Acupuncture Ambulatory Surgery Center Audiology Chest and respiratory therapy Chiropractic Dialysis DME Dentistry Infusion (facility and home) Oral Surgery/Endodontics (covered under medical) Optometry (routine)/eyewear Inpatient/outpatient Mental Health Inpatient/Outpatient Substance Abuse Midwifery Podiatry PT/OT/ST SNF Speech Pathology Urgent Care 27
28 Important!! Anesthesia in ASCs ASCs are not tiered UR health plan patients will have tier one benefits for their AHP surgeon and the ASC Not all ASCs have AHP-par anesthesiologists Example: Unity Linden Oaks Facility Untiered Surgeon AHP par Anesthesiologist not AHP Par Tier One Benefits Tier One Benefits Tier Two Benefits 28
29 Exclusive Benefits: BHP Behavioral Health Partners Comprehensive mental health services for UR employees and dependents (18+) enrolled in a UR benefit plan. A team of therapists, NPs, psychiatrists and RNs. Covered dx: depression, anxiety, stress Services: diagnostic assessments, psychotherapy, medication management, consults with PCPs Referrals or consults:
30 Exclusive Benefits: BHP continued PPO: no out-of-pocket costs HSA: no out-of-pocket costs after deductible is met Free parking One week timeframe for initial consults Day and evening appointments available Referrals or consults:
31 Condition Management No cost to employee or employee s spouse/partner Programs to help employees with a chronic disease manage the condition. Programs include lifestyle modification and behavior change counseling Referral by screening results or PCP Seamless communications with PCPs to ensure effective, coordinated care 31
32 Condition Management Comprehensive Programs for: Asthma COPD DM CAD A-fib CHF Hypertension High cholesterol Lower back pain Stroke 32
33 Lifestyle/Wellness Programs Evidence-based lifestyle programs No cost to employee or employee s spouse/partner Programs delivered in individual and group settings Patients can self-refer 33
34 Lifestyle/Wellness Programs Programs for: Tobacco Cessation Blood Pressure Control Weight Loss for Life Cholesterol Control Weight Loss Stress Reduction 34
35 Contact the Center for Employee Wellness Phone: Fax Referral Form to
36 Identifying AHP Providers 36
37 Helping UR Patients Save $$ Remember to send UR patients to AHP-par: Labs Imaging Hospitals Specialists 37
38 Helping Patients Know You re in AHP Web site info is correct Window clings Phone staff Front end staff Check-out staff Billing Staff Don t forget your Front End Fast Facts document and card images 38
39 The Most Important Thing to Learn Today Yes! We are an 39
40 PCMH Consulting Accepting apps for consultant funding soon Eligible to apply: o PCP office with EMR o Eligible to participate in ALL AHP payer contracts o No NCQA recognition or existing 2011 recognition with fewer than 12 months before re-attestation is due.
41 Physician Practice Eligibility PCP specialty EMR fully implemented or go-live planned imminently Eligible to participate in all AHP payer contracts No NCQA recognition or existing 2011 recognition with fewer than 12 months before re-attestation is due.
42 Care Management Program Develop clinically integrated model Achieve quality and cost goals o Manage chronic disease o Improve health o Avoid unnecessary re-hospitalizations o Improve safety & decrease medical errors Meet payer contract requirements to provide care management 42
43 Internal/Family Med Team: LMSW - BHS - Pharmacist Pediatric Team: LCSW - Care Manager Embedded Care Managers 9 CMs 10 CMs (9 CMMI) 39 CMs Hospital Employed Comm. Practices with CM AHP Care Management Model Comm. Practices w/out CM
44 Surprise Bills Law Effective March 31, 2015 Holds patient harmless from OON bills if status of OON provider is not disclosed prior to visit Disclosure Requirements Participating status of healthcare providers Participation status with carriers Must be able to provide OON costs upon request Must provide name, address, phone # of OON provider(s) Biggest Impact: Surgical Assists, Anesthesiology, Pathology, Radiology
45 Surprise Bills Law (cont d) Surprise Bills Law is separate from the tiered structure that applies to UR Employee Benefits Plan Tier 1= In Network for AHP, In Network for Excellus & Aetna Tier 2= Out of Network for AHP, In Network for Aetna & Excellus Tier 3= Out of Network for AHP, Aetna, and Excellus Surprise Bills Law applies to UR patients in Tier 3
46 Chronic Care Management Code Program Patient must be enrolled in Medicare FFS program 2 or more chronic conditions that are expected to last at least 12 months, or until the death of the patient Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation because of that condition, or functional decline 20 minutes of non-face-to-face care management and/or care coordination to a patient who has agreed to receive CCM services
47 CCM Code Program (cont d) CPT Code for Medicare CCM services is $42.60 per patient per month (average) Patient pays $8.40 copayment (average) Beneficiary may only be attached to one CMS claim from one provider per month Exclusions: ESRD, Home Health Supervision, Hospice Care Supervision, TCM Must be able to track minutes and document in certified EHR
48 Potential Reimbursement for CCM Services 600 Patients w/2 Chronic Conditions 600 X $42.90 X 12months = $308,880 Annually
49 Save the Date! Next Practice Managers Meeting will take place on Thursday, June 18 th 8:00am 9:30am Advancement Center Seminar Room
50 Thank You for Attending Today s Meeting! Renee A. Sutton, Director, Physician Relations Renee.Sutton@ahpnetwork.com Jeanine M. Wilder, Sr. Physician Relations Liaison Jeanine.Wilder@ahpnetwork.com
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