Payment Strategies That Enhance Payer Equity, Charge Position, and Yield. Jamie Cleverley, MHA William Cleverley, PhD

Transcription

1 Payment Strategies That Enhance Payer Equity, Charge Position, and Yield Jamie Cleverley, MHA William Cleverley, PhD

2 Today s Objectives 1) Evaluate internal and external payer equity to determine if payment differences are warranted 2) Examine payment differences among US hospitals to understand relationships to demographic factors and pricing 3) Develop an ideal strategy to enhance equity/defensibility and yield in charge-based and non-charge based areas 2

3 MARGIN US High/Low Margin Differences How Much Related to Cost? COST Source: State of the Hospital Industry, 2012 Edition Cleverley + Associates 3

4 US High/Low Margin Differences How Much Related to Revenue? REVENUE GROSS CHARGES Source: State of the Hospital Industry, 2012 Edition Cleverley + Associates 4

5 PAYMENT EQUITY

6 Equitable Payment Adequacy of payment: a level of payment necessary to ensure the financial viability of the healthcare provider Equity of payment: similar payments for identical services by a payer across multiple providers 6

7 Challenging national policy questions Should one payer be responsible to provide additional payment to ensure viability because another payer is deficient? Should payer equity exist between similar hospitals for similar services? 7

8 Payment adequacy is directly tied to sustainable growth 8

9 Payment adequacy is directly tied to sustainable growth Consolidated US Acute-care Hospital Industry Growth Rates 9

10 Payment adequacy is directly tied to sustainable growth Net income Equity Change in equity = Equity X Change in equity Net income Return on Equity is key to sustainable growth 10

11 Assessing payment equity differences between hospitals Hypothetical Payer Comparison (for same service) Hospital A Hospital B # of Payment Total # of Payment Total Cases Per Case Payment Cases Per Case Payment Government 9 $4,000 $36,000 1 $4,000 $4,000 Private Payer 1 $14,000 $14,000 9 $5,111 $46,000 Total 10 $5,000 $50, $5,000 $50,000 All-Payer Equity (average payment, in total, is the same across hospitals) Specific-Payer Equity (payment from the same payer is the same across hospitals) 11

12 Determining all-payer equity among hospitals FORMULA REQUIREMENTS NUMERATOR Total Patient DENOMINATOR Total Patient $ Revenue Volume Challenges to pull for you and others? 12

13 Determining all-payer equity among hospitals: Measuring payment per encounter Issues with traditional adjusted metrics to evaluate volume Patient Days Gross OP Rev (000) Gross IP Rev (000) Adj Pt Days Data prior to rate increase 10% OP rate increase 12,000 70,000 60,000 26,000 12,000 77,000 60,000 27,400 Adjusted Patient Days Formula: IP Patient Days X [1+(Gross OP Rev/Gross IP Rev)] 13

14 Determining all-payer equity among hospitals: Measuring payment per encounter Using equivalent discharge metric to measure volume Equivalent Discharge (Equivalent Patient Unit ) Inpatient Volume Formula: Total Gross Inpatient Charges Hospital Average Medicare Charge per Discharge (CMI adj) Outpatient Volume Formula: Total Gross Outpatient Charges Hospital Average Medicare Charge per Visit (RW adj) = = # OF EQUIVALENT IP DISCHARGES # OF EQUIVALENT OP VISITS + # OF EQUIVALENT OP DISCHARGES = # EQUIVALENT DISCHARGES Multiply by Medicare payment conversion factor 14

15 Determining all-payer equity among hospitals: Net patient revenue per equivalent discharge Net Patient Revenue per Equivalent Discharge Case Hospital Local Peer Hospital Market Average 18 Hospitals $7,888 $8,367 $8,819 15

16 Determining all-payer equity among hospitals: Reasons for all-payer inequity Poor Payer Mix Specific Payer Inequity Two Reasons for Payer Inequity 16

17 Determining all-payer equity among hospitals: Reasons for payer inequity Net Patient Revenue per Equivalent Discharge Case Hospital Local Peer Hospital Market Average 18 Hospitals $7,888 $8,367 $8,819 Medicare Gross Revenue % Medicaid Gross Revenue % Total Medicare & Medicaid Gross Revenue %

18 PAYMENT DIFFERENCES AMONG US HOSPITALS

19 Who is getting paid more? Framework of the high/low payment national study To examine the characteristics of high and low payment facilities, we created three groups for the study: 1) High net patient revenue per equivalent discharge hospitals: Composed of the top twenty-five percent of hospitals with the highest payment per equivalent discharge (adjusted for wage index differences) among all US shortterm acute-care hospitals that are prospectively-paid (non-critical access) 2) Low net patient revenue per equivalent discharge hospitals: Composed of the bottom twenty-five percent of hospitals with the lowest payment per equivalent discharge (adjusted for wage index differences) among all US short-term acute-care hospitals that are prospectively-paid (non-critical access) 3) All US hospitals: Composed of all US short-term acute-care hospitals that are prospectively-paid (non-critical access) 19

20 Who is getting paid more? Median net patient revenue per equivalent discharge by group 20

21 Who is getting paid more? Alaska Arizona California Colorado Hawaii Idaho Montana Regional Divisions Used by the United States Census Bureau WEST Nevada New Mexico Oregon Utah Washington Wyoming MIDWEST Illinois Missouri Indiana Nebraska Iowa North Dakota Kansas Ohio Michigan South Dakota Minnesota Wisconsin NORTHEAST Connecticut Maine Massachusetts New Hampshire New Jersey New York Pennsylvania Rhode Island Vermont What influences hospital pricing? SOUTH Alabama Georgia North Carolina Texas Arkansas Kentucky Oklahoma Virginia Delaware Louisiana South Carolina West Virginia Dist of Columbia Maryland Tennessee Florida Mississippi 21

22 Who is getting paid more? Distribution of US hospitals by group and region % of US Hospitals % High Payment % Low Payment 19% 19% 18% % of US Hospitals % High Payment % Low Payment 26% 27% 14% % of US Hospitals % High Payment % Low Payment 14% 7% 29% What influences hospital pricing? % of US Hospitals % High Payment % Low Payment 28% 44% 38% 22

23 Who is getting paid more? Median net patient revenue per equivalent discharge by group 23

24 Who is getting paid more? Median net patient revenue per equivalent discharge by group 24

25 Who is getting paid more? Median net patient revenue per equivalent discharge by group 25

26 Who is getting paid more? Median net patient revenue per equivalent discharge by group 26

27 Who is getting paid more? Payer mix metrics by group 27

28 Who is getting paid more? Median market share percentage by group 28

29 Financial impact of higher payment Key financial metrics by group High Net Patient Revenue per Equivalent Discharge Group Low Net Patient Revenue per Equivalent Discharge Group All U.S. Group Operating Margin Average Age of Plant (AAP) Long Term Debt/Equity % Total Liabilities/Assets %

30 Financial impact and mechanics of higher payment Hospital Cost Index and Hospital Charge Index by group 30

31 Mechanics of higher payment Median deductions percentage by group 31

32 Practical take-aways from the study 1) If you are currently a high payment hospital: you are likely to have a significantly higher cost structure and need to focus efforts to contain costs in future periods. Payment is likely to be reduced in coming periods and your position is most vulnerable if/when those reductions take place. 2) If you are currently a low payment hospital: you are likely to have lower costs and lower charges elements that equate to high value. This position could be significantly leveraged with your payers to drive additional volume. Further, evaluating payment equity among your peers using this construct could help leverage additional payment from commercial payers. 3) If you are an average payment hospital: the average might be a relatively safe place to be for now. However, if you find yourself in this position, it likely means you have neither high payment nor low cost. Without a strong hand in one of these dimensions the future could be challenging to navigate. 32

33 DEVELOPING A STRATEGY TO IMPROVE YIELD

34 Steps to realize increased yields 1 Determine current payer equity differences 2 Assess specific payer equity across area providers 3 4 Model impact of contract changes Assess existing contract compliance 34

35 Assessing Specific Payer Inequity Understand payment within the hospital Does payment inequity exist? Charges (000) Payment (000) Payment to Charge % Payer Government Medicare 137,500 44, % Medicaid 27,500 7, % Commercial Payer 1 15,500 9, % Payer 2 38,900 19, % Payer 3 12,500 7, % Payer 4 6,000 3, % TOTALS $237,900 $90, % 35

36 Assessing Specific Payer Inequity Understand payment within the hospital Does payment inequity exist? Payer Payer 1 Payer 2 Payer 3 Payer 4 Charges (000) Payment (000) Payment to Charge % Inpatient 2,459 1, % Outpatient 13,126 7, % Inpatient 7,339 3, % Outpatient 31,567 16, % Inpatient 2,845 1, % Outpatient 9,585 5, % Inpatient % Outpatient 5,098 2, % 36

37 Assessing Specific Payer Inequity Recognizing product mix differences Equivalent Inpatient Discharges Equivalent Outpatient Visits Inpatient Payment per Inpatient Equivalent Discharge Outpatient Payment per Outpatient Equivalent Visit Payer ,959 $13,927 $246 Payer ,451 $10,638 $222 Payer ,607 $11,230 $248 Payer ,024 $8,061 $246 37

38 Assessing Specific Payer Inequity Contract comparisons Payer Payer 1 Payer 2 Payer 3 Payer 4 INPATIENT SERVICES Per Diem Rates Medical-per diem $3,906 $3,610 $3,587 $2,338 Surgical-per diem $3,906 $3,610 $3,587 $2,338 CCU $3,906 $3,851 $2,338 ICU $3,906 $3,610 $3,851 $2,581 Step Down $3,906 $3,610 $3,851 $2,442 OB/Nursery OB Contract Designation 1-Mother Only 3-Unspecified 1-Mother Only 1-Mother Only C-Section 4 day stay-case rate $9,752 $9,495 $5,723 C-Section Addt'l Days-per diem $1,299 $1,292 $1,223 C-Section-per diem $2,279 Normal vag. Del. case rate (or 2 day stay) $5,671 $5,064 $4,327 Normal vag. Del. Addt'l Days-per diem $1,299 $1,292 $1,223 Normal Vaginal Delivery-per diem $2,279 Nursery Level 1- Boarder-per diem $1,007 $718 $950 $698 Drugs/Prosthetics High Cost Drugs Threshold $3,000 $3,388 $2,100 High Cost Drugs (%BC) w/ Threshold 70.00% 22.40% 47.00% IP Prosthetics/Implants/Devices Threshold $3,000 $3,388 $2,100 IP Prosthetics/Implants/Devices (%BC) w/ Threshold 42.40% 38.40% 47.00% Stoploss Stop Loss 1: Threshold $107, $105, Stop Loss 1: Total Charges paid at %: 47.54% 50.00% 38

39 Assessing Specific Payer Inequity Contract comparisons Payer Payer 1 Payer 2 Payer 3 Payer 4 OUTPATIENT SERVICES OP Surgery OP Surgery (% BC) 62.00% 44.24% 65.40% ED Emergency Department (% BC) 62.00% 57.92% 65.40% 79.00% Imaging Positron Emission Tomography (%BC) 47.70% Radiology (% BC) 47.70% 53.48% Radiology Fee Schedule Submitted? Yes Lab/Path Laboratory (% BC) 53.48% Lab Fee Schedule Submitted? Yes Yes Laboratory Fee Schedule FIXED FIXED Observation Observation (% BC) 62.00% 56.88% 63.30% 79.00% Therapies Occupational Therapy (% BC) 68.90% 56.88% 79.00% Physical Therapy (% BC) 79.00% PT Fee Schedule FIXED Respiratory Services/Therapy (%BC) 56.88% 79.00% Speech Therapy (% BC) 56.88% 79.00% 39

40 Assessing Specific Payer Inequity Across Area Providers High level metrics Case Hospital Competitor Hospital Operating margin -0.5% 3.1% Government payer % 66.3% 73.2% Net patient revenue per equivalent discharge $10,016 $11,534 Cost per equivalent discharge $10,023 $10,874 Hospital Charge Index

41 Assessing Specific Payer Inequity Across Area Providers Understand payment outside the hospital Does payment inequity exist for a common payer? Case Hospital Area Average Payer Payer 3 Payer 3 General MSDRG Base Rate FIXED Per Diem Rates Medical-per diem $3, $4, Surgical-per diem $3, $4, CCU $3, $5, Normal vag. Del. case rate (or 2 day stay) $5, $8, Normal vag. Del. Addt'l Days-per diem $1, $3, Normal Vaginal Delivery-per diem $1, OUTPATIENT SERVICES Multiple Procedure Discount OP Surgery OP Surgery (% BC) 65.40% 55.00% ED Emergency Department (% BC) 65.40% 67.50% 41

42 Model impact of contract changes Where are the greatest opportunities? Problems 1) Without specific contract terms you will use averages 2) Pricing differences 3) Patient mix differences 42

43 Assessing Specific Payer Inequity Across Area Providers Impact Existing Contracts Contract Original Charges Final Payment Payment % Payer 1 15,585,490 9,133, % Payer 2 38,906,555 20,051, % Payer 3 12,431,057 7,029, % Payer 4 5,802,218 3,256, % 72,725,320 39,471, % 43

44 Assessing Specific Payer Inequity Across Area Providers Impact Area Average Contracts Contract Original Charges Final Payment Payment % Dollar Change Payer 1 15,585,490 8,802, % (331,468) Payer 2 38,906,555 23,377, % 3,326,190 Payer 3 12,749,915 8,562, % 1,532,802 Payer 4 5,802,218 3,439, % 183,081 73,044,177 44,181, % 4,710,605 44

45 Assess Existing Contract Compliance Areas of special concern: 1) Implementation of price increase limits a) Overall CDM b) Payer specific c) Payer/service specific 2) Disallowance of specific charges (e.g. supplies) 3) Lesser than provisions 4) Application of vague and undefined group algorithms a) Inpatient b) Outpatient 45

46 PAYMENT EQUITY Contract Adequacy & Equity Commercial contracts/payments can be categorized, as follows: YES NO Closure Government Payer Closure Competition Payer Growth of Worst Payer NO YES PAYMENT ADEQUACY 46

47 Summary The payment environment continues to change for hospital providers and payers. As these changes take place, there must be mutual understanding of payment adequacy and equity. Hospitals need to carefully consider required profit levels given growth rates in assets and equity to ensure sustainability. Longterm projections are essential as payment terms typically have longer-term commitments. Payment equity should be evaluated to determine areas of higher/lower performance. Underpayment can put the hospital at financial risk and overpayment can jeopardize certain payers, as well as, the business community. 47

48 Thank you. Questions? Jamie Cleverley Principal Cleverley + Associates jcleverley@cleverleyassociates.com Phone: (614) William Cleverley President Cleverley + Associates bcleverley@cleverleyassociates.com Phone: (614)