Upload
others
View
2
Download
0
Embed Size (px)
Citation preview
Navigating New Payment Models
James English, Florida Hospital, Vice President
Angelia Ewing, Cerner, Sr. Director
July 28, 2016
AGENDA
• Overview of the Regulatory Environment related to Alternative Payment Models
• Overview of Florida Hospital• Example: Medicare Bundled Payment• Example: Organ Transplants• Analytics and Tools
Fee-for-servicePay-for-
performanceEpisodic bundling
Partial risk /
shared savings
Full-risk:
% of premium
HMO
Episodic Cost Total Cost
Provider Accountability
Patient Centered Medical Home Accountable Care Organization
201630%
201850%
201685%
201890%
Bundled and ACO
Payments
Medicare w. Quality Measures
Latest CMS Announcements
Next Gen ACO
50%-100%
From Volume to Value– Continuum of Payment Models
MIPS – APM – CJR – DSRIP-CCM
A Model for Classifying Alternative Payment Models
PAYMENT MODEL FRAMEWORK
Alternative Payment Models Framework
HCP LAN Alternative Payment Model (APM) Framework White Paperhttps://hcp-lan.org/workproducts/apm-whitepaper-total.pdf?utm_source=LAN+Newsletter&utm_campaign=05cb367423-LAN_eNewsletter_January_12_2016&utm_medium=email&utm_term=0_1b87e2051f-05cb367423-105704389
Source: Audacious Inquiry, ONC 2016 Annual Meeting
FLORIDA HOSPITAL
• 2300+ beds• 149k admissions• 687k+ patient days• 530k+ ED Visits• 76k+ surgeries• 8 satellite locations (one provider number)• $3 Billion+ annual revenues• Currently experiencing rapid growth
• Currently building a replacement hospital for a legacy campus.
• Just completed and ED and OP facility that will become our 9th satellite in the coming years.
• Just completed a 12 story Women’s Tower.• Currently building one free standing ED set to
open in May and another scheduled to open in 2017.
OBJECTIVE
• To provide a Revenue Cycle solution that can address various value-based payment methodologies (i.e. bundles, global payments, package and capitation) while administering the complex claim submission process, respective to the at-risk provider for payment and the reporting necessary to respond to this payment shift from volume to value-based reimbursement.
PROGRAMS
• Medicare BPCI Model Initiatives
• Transplant Bundles
• Self Pay Package Pricing
SOLUTION
• An Integrated solution which eliminates manual manipulation, removes multiple interfaces, reduces costs, delivers greater accuracy, and provides consistent workflow.
• Provide an intuitive platform to manage loading and maintenance of complex payment arrangements.
• Track and reprice both Hospital and Professional claims in one consistent view for a given episode.
Cerner/Florida Hospital Partnership
Example: Medicare Bundled Payment
Acute Care IP Admissions Select DRGs
Medicare Services and Readmissions
(Hospital & Physician)
Prospective Payment
BPCI MODEL 4
THE PROCESS (Manual)
Surgery Scheduled (CVI)
Notification of Patient Qualification (email)
Medicare Notice of Admission
(60 Days)
NOA Initiated (DDE)
Daily Tracking (Spreadsheets)
Eligibility Updates (Spreadsheets)
Claims Submission (DDE)
Monitor for Discharge Status
Post Discharge
Coding/DRG Review
Additional Eligibility Review
Monitor for Payment
TPA Updates/Payment Distribution
Example: Transplant Services
Bone
Marrow Transplant
Solid Organ
Heart
Lung
KidneyPancreas
Liver
TRANSPLANT PROCESS
Global Team Creates Case
Physicians, Hospital, Ancillary Providers
Claims Submission
Bundles claimsTransplant Center
Notification
Funds DispersedPhysicians, Hospital, Ancillary Providers
Final Payment Received
Hospital bills patient (if applicable)
DRG
Quality FinancialClinical
FFS
Clinical
QualityFinancial
APM
DRG only connectionAll connected by patient’s
longitudinal care needs
SHIFTING FROM FFS TO APM
OPERATIONAL REQUIREMENTS
• Traditional Revenue Cycle Capabilities• Claims Analysis Tools• Predictive Capabilities for Assessing Risk of Service Population• Operational Analytics• Financial Benchmarking• Patient Attribution• Care Planning• Contract Management• Patient Panel Definition and Management• Referral Management • Patient Compliance Monitoring• Information Sharing• Network Participation and Shared Savings/Cost Administration
HealtheCare
analyticsCMS
Req
Care Management
Population Health Management
MS-DRGs
Length of StayPhysician
QUALITY REPORTING
STAR ratings
Medical Home
PreadmitPredictive Modeling Transition Post-AcuteAdmission
CMS
Req
Procedure Inpatient
CMS
Req
CMS
Req
Data Monitoring
Data-driven Process Improvement
Readmission Prevention Worklist
Cerner EMR
PowerChart® PowerPlans
Access Management
Acute Case Management
eRx
eSignature
Transitions of Care
UM Worklist
PowerChart® Ambulatory
HealthePrograms
HomeWorks™
HealtheAnalytics
MANAGEMENT OF THE PROCESS
• EMR Based Analytics• AR Management
• Revenue and Adjustment
• Payment Analysis
• Denial Management
• Contract Performance Analysis
• Productivity Analysis
• Volume and Driver Analysis
• Payor Performance Analytics
• Physician Performance Analytics
• Dimensions / Data Drill-in• Financial Class, Payor, Inpatient/Outpatient, DRG, CPT, Facility,
Physician, Nursing Unit
Example Metrics AR Days DNFB Days Cash as % of Net Revenue POS Collections Adjustments as % of Gross Revenue Charity Care as % of Gross Revenue Case Mix Inpatient Days Average Length of Stay Patient Visits Denials
FINANCIAL MANAGEMENT ANALYSIS
Key Metrics
• Claims Analytics• PMPM / cost analysis
• Risk stratification (MARA)
• Utilization analysis
• In Network/out of Network analysis
• Member demographics analysis
• Generic drug dispense analysis
• Readmissions claims analytics
• Quality Performance Analytics
• Value-based Payer Reporting
• Dimensions / Data Drill-in• All Population, Payer/Plan, Region, Practice, Provider, CI-APCP, CI-
APP & Member
Example Metrics Attributed population Member Months Risk-adjusted PMPM – Total Risk-adjusted PMPM – Medical Risk-adjusted PMPM – Rx Risk-adjusted PMPM – Inpatient Risk-adjusted PMPM – Outpatient Risk scores – concurrent & prospective PMPM (Real) Generic Drug Utilization High-cost Imaging/1000 Admits/1000 ED/1000 Inpatient Days/1000 ED Unique Members/1000 # of Unique Members with Admit # of Unique Members with ED Visit OP Visit/1000 30-day readmits (no exclusions) ED/IP/OP Counts CT Scans/MRI Counts Registries 230 standard measures
COST & UTILIZATION ANALYSIS
18
Process
Disburse Bundleas Incurred
Segment to Service Providers
Submit
DisbursePayments
Cardiologist
PCP
Hospital
Claim Scrubbing
PayorHealth System – New Era
*Traditional EMR
**Value-Based Reimbursement
Remittance
Payor
Edit Claims
Reconcile Payments
Health + Care Integration
Delivery Network Management
Consumer* Traditional EMR is represented by the gray box
** Value-Based Reimbursement is represented by the white space within the purple box
Automated process
BUNDLE ADMINISTRATION
Q&A
• Thank you for your time!
• James English– James [email protected]
– 407-200-2307
• Angelia Ewing– [email protected]
– 816-201-7257