Transcript Accountable Care Organizations

HFMA Florida Chapter Fall Conference
September 16, 2010
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Accountable Care – Approach or “Thing”
Physician/Hospital Integration Journey
Concepts of Bundling Payments
The Payer/Buyer Perspective
Roles and Accountabilities of an ACO
Potential ACO Models
The ACO Revenue Cycle Infrastructure
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Genesis from “HillaryCare” in 1993
◦ Managed Competition and the PHO
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Quality Payment for Services – CMS 2003
◦ Process – Evidence Based Medicine Guidelines
◦ Outcomes – Improvement in Quality Measures
◦ Treatment of Chronic Diseases
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Shared Savings for Cost Containment
◦ Emerging Payer/CMS Pilots in Episodes of Care
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Integrated Care = Good Non-Integrated = Bad
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New Name with Newly Anticipated Functionality
Entity Will Need to be Able to do the Following:
◦ Assemble and Manage a Broad-based Group of
Providers including Acute Hospitals, Primary Care
Physicians, Sub-Specialists, and Ancillary Providers.
◦ Provide Services in a Seamless Business Infrastructure
◦ Accept and Administer Bundled Payments from Payers
◦ Identify Enrollment and Pay Providers
◦ Report on Quality, Costs, and Patient Outcomes
◦ Manage Risk and Gain-Sharing Methodologies
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Medical Staff Delegated Responsibilities
◦ Credentialing, Privileging, Quality Assurance
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Creation of PHOs for Managed Care
Service Line Development
◦ Specialty Partnering with Hospital
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Employment of Primary Care & Sub-Specialists
IT Connectivity and Meaningful Use
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Other than Employment – Not Much
Regulatory Constraints
◦ Stark, F&A, IRS, etc.
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Cultural Issues
◦ Professional Independence
◦ Entrepreneurial Interests
◦ Control vs. Security
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Financial IT Platform Differences
◦ Hospital Legacy & Practice Management Systems
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Management of Chronic Care Patients
– Screening and Lifestyle Management
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Medical Home Approach – Primary Care
Population-based Semi-Capitation
Episode of Care Fixed Payment
Performance-based Payment
Combinations of Those Above
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Slow the Rate of Cost Growth
Public Health Approach – Lifestyle/Prevention
◦ Obesity, Smoking Cessation, Screening, etc.
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Reduce Fee-For-Service Exposure
◦ Bundling Acute Care Episodes for Elderly
◦ Medical Home Fixed Payments for M&M
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Shift Risk to Provider Community
◦ Move toward “Partial Capitation”
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Four Clinical Areas Represent 61% of Spend
◦ Cardio-Vascular, Orthopedic, Neuro, Cancer
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Difficulty Predicting Unit Cost and Utilization
Hospital and Physician Combined
◦ Bundled Payment Minimizes Risk of Outliers
◦ Pharma and Medical Device Usage Included
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Pay For Performance / Enter “the Ratchet”
“They” Won’t be Able to Contract for This
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Clinically and Financially Integrated Provider
Network
Capability to Underwrite Risk
Broad Scope of Clinical Services
◦ Acute Care, Primary Care, Out-Patient Care,
Rehabilitation Services, Home Care, etc.
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Information Technology Infrastructure
◦ Internal and External Transaction Capabilities
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Ability to Engage with Consumers/Patients/Payers
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Health Plan as ACO
Independent Practice Association as ACO
Multi-Specialty Group Practice as ACO
Hospital as ACO
Hospital and Medical Staff as ACO
Other Entrepreneurial Models???
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Management of Provider Networks
Administrative IT Platform - Eligibility
Financial IT Platform - Claims
Utilization Management Reporting
Patient Engagement and Incentives
Strong Capital Position
Experienced in P4P/Payment Bundling
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Strong Clinical and Financial Infrastructure
Durable Provider Relationships
Case Management Expertise
Leverage on Acute Care Costs
Managed Care Contracting Expertise
Focus on Patient Retention/Engagement
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Solid Administrative Infrastructure
Comprehensive Clinical Coverage
Integrated Clinical Platform
Integrated Financial Platform
Out-Patient Services
Built-in Referral Network
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Comprehensive Acute Care Services
Relationships with Ancillary Providers
Large Medical Staff Footprint
Local Brand Awareness
Solid Capital Structure
Administrative and Financial IT Infrastructure
Managed Care Relationships
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Full Spectrum of Patient Services
Superior Local Brand Awareness
Clinical Integration
Ability to Retain Risk
Contracting Leverage with Payers
Administrative/Financial Infrastructure
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Shared Governance Among Constituents
Community Benefit Organization/Co-Op
Medical Staff Roster Development
Invitation to Ancillary Providers
Participation Agreements
Information Technology Requirements
Health System Capitalization
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Choose Scope of Clinical Services
Establish EBM Guidelines for Services
Model Historical Financial Performance
Determine Professional Fee schedules
Establish Hospital Revenue Code Charges
Create Combined Charge Structures
Determine P4P Gain Sharing Rules
Determine Risk Retention Rules
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Patient Enrollment and Eligibility
Contract Modeling and Management
Maintenance of CDM/Fee Schedules
Case Management/Referral Services
Claim Re-Pricing/Clearing/Payment
Dispute Resolution/Collections
Performance and Dashboard Reporting
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Receive Enrollment Data from Payers to ACO
Identifying Patient Enrollees
Develop Patient Roster for Physician Offices and
Hospital Registration
Perform Eligibility Checking using HIPAA
Transactions and Portal Interfaces
Transmit Authorizations to Practices and Hospital
Accounting Operations
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Based on ACO Developed EBM Rules:
Track Utilization among Providers
Identify Variances from ACO Guidelines
Manage and Track Provider Referrals
Create Worklists for ACO Reviewers
Develop Internal Clinical Authorizations
Accommodate External Clinical Authorizations
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Model Bundled Contracts using Historical Claims
Data and ACO Charge Master
Load Executed Contract Terms and Rules into
ACO Master Contract Library
Disseminate Relevant Terms to Providers for
Verification and Reconciliation
Identify Payer Variance Record
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Create Charge Master Indexes
◦ Chronic Care Bundles/Medical Home
◦ Acute Episodes/Procedure Package Pricing
◦ Bundled Charges for Episode of Care – 30 Days
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Imbed Charge Master into ACO Platform
Maintain and Update
Disseminate to Providers
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ACO Platform Receives Un-scrubbed Claims from
Physicians and Hospital – UBs & HCFAs
ACO Re-Prices Claims According to Contract
Terms or CMS Methodology
ACO Bundles Individual Claims Into Bundled
Claim Edited Format
ACO Clears Bundled Claim to Payer/CMS
ACO Receives Payments/Pays Providers
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There WILL BE Incorrect Payments within a
Bundled Payment Environment
Administrative Denials/Underpayments
◦ Clinical Denials/Reduction of P4P Payments
◦ Financial Reconciliation Denials/Outliers
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ACO Platform Re-Adjudicates Disputed Claims
with Denial Management Tools
Patient Receivables – Co-Pays, etc.
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Care Management/Utilization Management
◦ Flash Reporting on Active Patients
◦ Concurrent Clinical Variance Reporting
◦ Summary Reporting On Process/Outcomes
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Administrative Reporting – Process Costs
Financial Reporting
◦ Charge/Cost, Payer Variances, Gain-Sharing,
Risk/Retention, Receivables, Distributions
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The New ACO Technology Platform is not simply
the Traditional PHO Platform
The Buyer Market will Change its Approach
The ACO must have a Nimble Platform
Physicians will need Assurances that the
Operating System is Accurate and Transparent
The Current Revenue Cycle Systems and
Applications are Inadequate for the Future
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The Accountable Care Organization Concept and
Construct is a MUST for Health Systems
As an ACO, Health Systems will be positioned as
an Integrated Delivery Network
As an Integrated Delivery Network, the Health
System can effectively deal with changing
Reimbursement Methodologies from Payers
And, as an ACO, Health Systems can become a
Participant in the planned State Exchanges
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Nick Hilger
JDA eHealth Systems
1717 Park Street, Suite 250
Naperville, IL 60562
[email protected]
(630)355-5220 ext. 3279 (Office)
(651)324-2943 (Mobile)
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