HBMA 2016: THE HEALTHCARE REVENUE CYCLE CONFERENCE

Transcription

1 HBMA 2016: THE HEALTHCARE REVENUE CYCLE CONFERENCE How Value-based Reimbursement will Effect HBMA Members Mark R. Anderson Mark Anderson, FHIMSS, CPHIMS is a leading expert in ACOs, VBR, and Physician Practice Management Best Practices Today s Industry Expert 40+ Years In Healthcare IT CIO at 4 IDNs Spent over $2B in HCIT National Speaker > 1,000 sessions since 2001 Consultant to over 25,000 physicians and over 200 hospitals Advisor to the numerous Medical Societies Annual survey of top Hospital and Physician-based EHR and RCM products by function, size, end-user satisfaction, price, ability to effect change. Expert Witness on numerous legal cases involving HCIT Software Helped establish 2,300 provider ACO run by Providers What is the new reimbursement system revenue? 1

2 What is the new reimbursement system revenue? What is Value Based Reimbursement? VBR = Value Based Reimbursement Healthcare is moving to Accountable Care for Patients with Chronic Diseases Initially started with Medicare when CMS established Accountable Care Organizations (ACOs) Payments will be based on quality improvement and improved outcomes starting in 2018 Only includes patients with Chronic conditions Medicare: 50% of payments starting 10/01/2017 Commercial Insurance: 50% starting in VBR = APM The Department of Health and Human Services (HHS) recently announced that 30% of Medicare payments will involve alternative payment models (APMs) by the end of By the end of 2018, 50% of Medicare payments will go to APMs such as ACOs, patient-centered medical homes (PCMHs), and healthcare organizations that accept bundled payments. 2

3 Who will compete for VBR Contracts? 1. Healthcare organizations with established hospitals and provider groups designed to comprehensive preventive and chronic care is specific regions 2. To date, 80% of contracts have gone to large hospitals chains with employed physicians and 20% to large Physician Groups with a minimum of 300 primary care and select specialists 3. Organizations that an restructure physician compensation to align provider incentives with value-based care. 4. Focus on care management for high-risk patients as well as other segments of the population that could become high risk in the future. 5. Embed care managers in practices wherever possible to create close relationships with patients. Software Value based reimbursement Components requires more of VBR than tracking the health of a specific population Cost and Quality Assessment Real time Care Coordination Patient Data from Home Patient Engagement Care Team Coordination Care Coordinators Point of Care clinical alerts Clinical Practice Guidelines Clinical and Cost Metrics Risk Assessment Population Health data Patient Registries Single View of all Pt Data Master Patient Index Core EHR and Pt Demo Products What is the new reimbursement system revenue? 3

4 January % by late % by VBR Not just for Medicare 20 leading insurers and provider organizations has announced their commitment to putting 75 percent of their business into value-based arrangements that focus on the Triple Aim of better health, better care and lower costs by Other major insurers previously announced their intention to move to value-based payment models. Achieving Success Making the Triple Aim Possible Engaged Communities Proactive care processes Identified patients Focused on wellness Community resource navigator Better Health for the Population Engaged Patients Identified and incorporated patient goals Focused on continuity and coordination Facilitated communication channels Improved access to care Identified Opportunities to Reduce Waste 4 Rights Duplication avoided Improved coordination/transitions Used automation to reduce resource needs Improved screening and prevention Aligned incentives to drive value 12 4

5 What is the new reimbursement system revenue? Fee for Service vs. Value Based Reimbursement Value Based Fee for Service 100% 80% 60% 40% 20% 0% The Changing Market 100% Full population care 80% 60% Partial population care 40% Condition-based care 20% Episode care Fee-for-service 0%

6 How is the Payment System Changing? Capitated payments based on population Health plans and CMS contract directly with Health Systems Health Systems selected the Physicians No longer processing claims No payments based on charges Move from charge capture to cost measurement. Effects up to 50% of payments for 35% of population Advance reporting on outcomes and clinical results What is the new reimbursement system revenue? Per Capita Health Spending Each year, the US spends roughly 2x the amount on health care as the next most spending country 6

7 Not meeting Quality Indicators The System Too Often Fails to Provide Higher Quality Care Adults receive about half of recommended care: 54.9% = Overall care 54.9% = Preventive care 53.5% = Acute care 56.1% = Chronic care Adherence to Quality Indicators Breast Cancer 75.7% Prenatal Care 73.0% Low Back Pain 68.5% Coronary Artery Disease 68.0% Hypertension 64.7% Congestive Heart Failure 63.9% Avoidable harm: 99,000 deaths in hospitals from health care acquired infection Overuse: 13 million unneeded antibiotic RX Depression Orthopedic Conditions Colorectal Cancer Asthma Benign Prostatic Hyperplasia Hyperlipidemia Diabetes Mellitus Headache Urinary Tract Infection Ulcers Hip Fracture Alcohol Dependence 57.7% 57.2% 53.9% 53.5% 53.0% 48.6% 45.4% 45.2% 40.7% 32.7% 22.8% 10.5% 0% 20% 40% 60% 80% 100% Percentage of Recommended Care Received Why is there an urgency to change? Healthcare spending growth. CMS Projections for National Healthcare Spending (Amount in Billions) CY $5,000 $4,500 $4, % $4, % 20.0% $4,000 National Health Expenditures (billions) $3, % 19.8% $3,541 $3,500 National Health Expenditures as a Percent of Gross Domestic Product $3, % 19.0% $3,111 $2, % $3,000 $2, % $2,624 $2, % 18.0% $2,500 $2,379 $2, % 17.7% 18.0% $2,113 $1,981 $2,000 $1,855 $1,735 $1, % 17.0% 16.2% $1, % 15.9% 15.9% 15.8% 16.0% $500 $0 15.0% Source: Centers for Medicaid & Med icare Services - NHE Projections , Forecast Summary and Selected Tables Chronic Diseases Specific diseases: Obesity Diabetes Depression and other mental disorders Chronic fatigue syndrome, fibromyalgia, and multiple chemical sensitivity Cardiovascular disease Celiac disease 7

8 What is the new reimbursement system income? Will VBR effect my income? How do you get paid for your services? If contracts are going to hospitals and ACOs as a capitated payment, there is no more traditional billing to insurance plans. What happens if 50% of your client s Medicare claims goes away in 2018? How do you maintain your income? What if by 2019, 40% of traditional claims processing disappears? What if 45% of private physicians will be employed by hospitals by 2019 Will VBR effect my income? Hospitals and ACOs want one financial and clinical system and most will require physicians to use their RCM and EHR applications how will that effect your income? Hospitals and ACOs will select the physicians they want to work with under VBR How will this effect your income of your clients are not selected as part for the Hospital Panel? What % of your business is related to billing for services related to chronic disease patients? 10%.. 60% We believe that ER physicians will not be effected We believe that Radiology, Pathology, and Anesthesiology providers will be effected. 8

9 What is the new reimbursement system income? What should I do? 1. Conduct internal financial review of your business to determine the effect of VBR on your income. a) Determine % of services related to patients with chronic disease by insurance plan b) Develop what if statements if 10%, 30%, 50% of the claims processing services goes away how will that effect your income? c) Become the advocate for your clients and educate them d) Become the Physician RCM company of Hospitals e) Relook at your current software applications What should I do? 2. Be proactive - Provide Education to your Clients about how VBR will effect their business. a) Continue to be the trusted advisor b) Physicians are not aware of how VBR will effect them c) Help them determine how VBR might effect their income d) Conduct operational review of each client s revenues by insurance plan for all patients with chronic diseases. e) Help them to understand what happens if 35% of their patients can no longer be treated by their practice. f) In the future, the health system will select the physicians that the patient can see moving away from health plan panels. 9

10 What should I do? 3. Relook at your current software a) Will your current RCM software interface with the hospital s RCM products so that the hospital can have one patient financial record? b) Will your current EHR software interface with the hospital s EHR products so that the hospital can have one patient clinical record? c) Develop a plan to convince local health systems to work with you because you can improve reimbursement and provide cost accounting. d) In the future, VBR is all related to controlling costs Can you provide a comprehensive Cost Accounting system that measures costs since charges will no longer matter? Conclusion Don t worry about the little things the big items are enough to worry about. The healthcare reimbursement model is changing away from Fee-for-service to VBR. To compete in the new market, physicians will need to partner with hospitals for integrated Next-Generation Enterprise wide technology built for clinicians. If this occurs, how will this effect your income? Be proactive don t wait to find out you just lost 50% of your income. Questions: 10