The Top Five Healthcare Leadership Challenges in the Industry for 2017 JEOPARDY Lyman Sornberger Chief Healthcare Strategy Officer Capio Partners LLC Bethesda Hospital March 31, 2017 1
Presented by: Lyman G. Sornberger Hea Chief Healthcare Strategy Officer - Capio Partners President & CEO - LGS Healthcare Consulting For over 33 years Mr. Sornberger lead revenue cycle activities for The Cleveland Clinic and UPMC and has consulted with the largest health systems in the country. Those healthcare organizations have revenues that exceed $12 billion. He has authored over 2,200 articles for HFMA, AAHAM, and other leading healthcare publications and has been a featured speaker at over 125 healthcare revenue cycle industry events. 2
Agenda Overview of Healthcare Topics: Obamacare, New President s Impact to Health Care, Bundled Payments, Revenue Cycle Tips, and Increased Patient Responsibility Potential Impact to Patient, Provider, and Industry and why self pay is growing Test Your Knowledge - Play Jeopardy 3
Obamacare Exchanges Overview 1 Improve Quality 2 Increase Access 3 Improve Price 4
Fact 2014 Final Numbers 11 million adults +2.6 million under the age of 26 -.0.8 million non-payment (assumes 90% will pay) +1.5 million children +0.95 million early expansion TOTAL: 15.25 MILLION GAINED INSURANCE DUE TO OBAMACARE AS OF DECEMBER 2015 assumes a 6 % drop on a population of 240M adults in the USA 5
Fact 2017 Current Annual Marketplace re-enrollment rate is 56.2% Annual Cost for Subsidized Enrollee is $3,500 Number of Uninsured Before Obamacare was 47,000,000 Number of Young Adults (Ages 19-25) Who Were Able to Gain Coverage on a Parent s Plan Until Age 26 is 3.4 Million Drop in Underinsured Rate from 2013 to Current is 6.1% Percent of Adults Currently Without Health Care is 12.3% or 10.5 Million 6
Fact 2017 Percent of people who say ObamaCare has helped them or their families Percent of people who say ObamaCare has hurt them or their families Percent of people who say Obama Care has had no direct impact on them Percent of Americans who say they have an unfavorable view of ObamaCare 19 % 22 % 57 % 43 % 7
Fact 2017 Individual shared responsibility payment-aka penalty, fine, or individual mandate The fee is owed for every month that the patient and/or family members do not have insurance The fee is paid when the federal tax return is filed The calculated as a percentage of household income and family size 2.5% of household income Per Adult, $695.00, $347.50 child under 18, Maximum is $2085.00 Whichever is higher! I 8
Fact 2017 Exchanges -----Bronze, Silver, Gold, and Platinum---plus catastrophic Subsidies are based on Silver Plan Only difference is lower premiums with higher out of pocket and deductibles-up to $7150 and then the insurer kicks in at 100% All five plans have seventeen (17) co-ordination of care benefit designs. Free Preventative Care is included and no preexisting conditions I 9
Obamacare Impact to Self Pay Estimated 2M as of 2016 that did not pay their premium Payers and provider denial processes are inconsistent and engage the patient Providers closing the door on Marketplace Back to the Out of Network denial world and the ED as a Dr s office 10
Obamacare Impact to Self Pay 75% of healthcare exchanges are in high deductible plans Silver plan has 30% out of pocket, bronze 40% Gone are the days of the peak in collections with tax returns 11
President Donald Repeal Trump To be or not to be? Basis to repeal budget reconciliation A minimum of one year to those that just enrolled and its estimated that it could be as much as three years It will be difficult to reverse the pre-existing clause, twenty six year old student coverage, or the subsidies; and therefore it will require a transitional period No alternative plan exists today note Paul Ryan has a document that shares his concerns but no concrete solutions 12
President Donald Repeal Trump To be or not to be? Highlights Remove the individual mandate Create high risk pools Tax deduction for the purchase of individual health coverage Insurers to sell across state lines Health Savings Accounts (HSA): Tax-free transfer of HAS to heirs Price Transparency for all hospitals, doctors, clinics; etc. 13
President Donald Repeal Trump To be or not to be? Medicaid and Medicare Highlights 70 million Americans are covered under Medical Assistance today Highlights Medicaid to the state level through a Medicaid per capita allotment or block grand 57 million Americans are covered under Medicare Modernize Medicare -improved preventive care, drug benefits, raising the age of Medicare eligibility, and prescription drugs from other countries 14
Revenue Cycle Healthcare Tips 2017 Highlights Working smarter not harder with patient scoring and generating work flows Patient Experience: Price Transparency, self service technology, a component to all financial and clinical decisions Value Based Reimbursement will require two charge masters: shift from volume to value. Include denials management and denials prevention 15
Revenue Cycle Healthcare Tips 2017 Highlights Promote Physician Documentation Clinical Spokesperson at the table to be a Physician champion. CDI, Denial Management etc. Value based care and clinical participation: leverage a complete view of patient population data: utilization, cost, care management, high risk patients, readmissions, care intervention and the return on investments Data Analytics to insure proper payments-contracting etc 16
Revenue Cycle Healthcare Tips 2017 Highlights Company leadership buy-in with diverse groups participating with various vested interests Self Pay strategy: increased premiums, increased out of pocket, and patient responsibility is NOT going away Outsource when appropriate bad debt, out of state Medicaid, Medical Assistance enrollment, early out, statement management, provider enrollment, --Supply Chain-no unless the decision maker is RCM leadership 17
Bundled Payments in Health Care IPPS published in the Federal Register, April 20, 2015 Comment Period Ended June,16 2015 Final Rule and Responses August 1,2015 18
CMS Releases Comprehensive Care Payment Model Joint Replacement Payment Model-Final Rule Fact Sheet January 2016 aka CCJR Episodic Care with Exclusions Methodology for Pricing Wage Adjustment Variations Data Collections for Outcome Measures Trending 19
CMS Releases Comprehensive Care Payment Model Claims Submission Beneficiary Incentives Gainsharing Audits Appeal Process Overlap with Care Improvement Episodes (BPCI) CMS is discussing the expansion of the Bundled Payment for Care Initiative (BCPI) 20
Bundled Payment Provider and Patient Impact Providers are responding differently to medically necessary services and claims denied for readmission Patients are receiving billings for HAC denials Providers are stressing the bundled payments are too difficult to manage operationally and a bundled payment does not mean a full payment 21
Health Care Consumerism and the Patients Role is Changing 22
Health Care Consumerism and the Impact to Health Care Patients have multiple sources to measure healthcare quality and is it too confusing Patients have to pay more for their healthcare-increased cost of care and higher out of pocket Therefore: Patients will utilize the existing quality and procedural information to optimize their outcomes Patients will become more prudent users of healthcare - when? 23
Health Care Consumerism and the Impact Legally, Financially, and Provider Brand Payment Plans, Loans, 501R, Collection Agencies, Debt Buyers all have Legal, Financial, and Patient Relations Risk CFPB Director Richard Cordray stated The Consumer Financial Protection Bureau is taking action to improve credit reporting. Getting medical care should not make your credit report sick 24
Health Care Consumerism Options for Providers and Patients Payment Plans-Traditional but Higher Out of Pocket Loans- New Concept-Financial Risk Prompt Pay Discounts-Legal Challenges Interest- Patient Relations Concerns Patient Advocacy-Education Debt Buying-New Millennium Concept 25
Self-pay Not Going Away! Three definitions: 1. True self-pay 2. Underinsured- Balance after insurance 3. Underinsured & True self-pay combined are: Patient Responsibility Patient responsibility outcomes: Paid, Charity, and/or Bad Debt 26
Self-pay Not Going Away! American Hospital Association reported in 2011 that uncompensated care was at 41.1 billion on average it has continued to increase by 8% and expected to double by 2016: 2011--- 41 BILLION TO 72 BILLION IN 2016 OR A 16% INCREASE! 90% of providers note the growth of high-deductible plans among their patients and 75% of them are in healthcare exchanges 27
Self-pay Not Going Away! Regulators in the industry are: Federal Trade Commission (FTC) Fair Debt Collections Act Consumer Financial Protection Bureau (CFPB) Self Pay Management Best Practices: Loan Programs- recourse Early Out Programs- 501R Letter Series-extended business offices Collection Agency shared risk model Debt/Asset Buyers- unfound cash 28
Self-pay Not Going Away! FACT FACT FACT 81% of true self pay responsibilities are never recovered 55% of the patients financial responsibilities are never recovered It cost 3X to pursue the patient vs. the payer FACT Historically hospitals have written off about 3-5% to bad debt and today that number is 7-9% with the majority of it related to the underinsured 29
Self-pay Not Going Away! Patient Responsibility or Self Pay # Three Payer Behind Medicare and Medicaid! 30
Lyman Sornberger Chief Healthcare Strategy Officer Capio Partners LLC Southern Illinois Chapter HFMA August 20, 2015 31
Questions? Feedback! 32
Contact Lyman Sornberger Chief Healthcare Strategy Officer lyman.sornberger@capiopartners.com c: 216.337.4472 o. 440.546.0947 www.capiopartners.com 33