Today s Payers and Providers Strategies for Success Emad Rizk, MD President and Chief Executive Officer Accretive Health
Session Objectives Description of value based models in the market Data elements and capabilities required to thrive in a value based reimbursement world How payers and providers can collaborate together for successful implementation of these models
ACA Includes Fee For Service Reimbursement Cuts
The Shift from Volume to Value
Impact on Providers
Health System Increasingly the Norm
The Changing Landscape
Integration of Clinical and Financial competencies is critical
Evolution of Reimbursement The model for payer reimbursement is changing dramatically Fee For Service Straightforward claims processing and direct reimbursement between providers and payers Fee For Value Billing and reimbursement processes require integration and coordination across the care continuum
Current Value-Based Models Payment model incentives provide logical building blocks and roadmap to take on risk Payment Mechanism Transition to Risk-Based Models Current Market Step I Step 2 Step 3 Step 4 Incentivize Structural Changes Incentivize Specific Activities Incentivize Outcomes Risk-Based / Total Cost of Care Models E.M.R P.Q.R.S. Value Modifier Episode Bundling MU Stage I Gaps-in-Care MU Stage II Shared Savings PCMH Core Measures Value Based Purchasing Capitation Varying Payment Models with Consistent Objectives: Lower Costs & Improve Outcomes
Clear Operational Requirements Payment Mechanisms vary; however the core operational capability requirements are consistent Payment Models Necessary Capabilities Activity-Based Incentives Outcome-Based Incentives Risk-Sharing/ Total Cost of Care 1 Patient Outreach / Engagement / Care Facilitation X X X 2 Transitional Care Management X X X 3 Chronic Condition Management X X X 4 Conversion of Dual-Eligibles - X X 5 Capture and Coding of HCC's - X X 6 Capture and Coding of Quality Measures X X X 7 Claims & Registry Reporting X X X 8 Ambulatory Care Management X X X 9 Provider Alerts / Notifications X X X 10 Population Analytics X X X
Financial Leakage Due To Operational Gaps Significant financial opportunity exists in today s market and will continue to grow over time Operations Support $ Leakage by Source 8% Patient Outreach ~50% Effectively contacting and managing patient care requirements between service encounters Well Visits RAF Recapture Preventative Services Transitional Care Mgmt. HEDIS / PQRS Chronic Care Management 12% 50% Coding ~30% Capture of all ICD- 9(10) codes associated with acuity and risks of patient population HCC Capture Historical Conditions Risk Based Coding HAC / POA / Readmits Compliant Documentation ROM / SOI / Mortality 30% Source: Accretive Health Data Warehouse Other = 8% Quality Measures Reporting ~12% Requires all captured and coded measures be reported / billed ICD-9(10) Quality Modifier CPT / HCPCS HAC / POA HEDIS / PQRS ROM / SOI / Mortality
Revenue Cycle Operations Must Transform FEE-FOR-SERVICE VALUE BASED ADD-ONS PRE-SERVICE: Focused on pre-service financial clearance & post-service collection of patient balances PATIENT ACCESS: Focused on insurance eligibility verification and co-pays CODING: Focused on reason for encounter and medical necessity PROCEDURE CODING: Focused on CPT s and E/M Levels ANALYTICS: Focused on A/R, Denials, FFS Collection Rate, profit & loss PRE-SERVICE: Pro-Actively engaging patients for well visits and Care Gaps remediation PATIENT ACCESS: Attribution Reconciliation and Care Gaps Screening CODING: Comprehensive health conditions and Risk Scores (HCC s) PROCEDURE CODING: Quality Measures; claims and registry reporting ANALYTICS: Utilization, Care Gaps, Value-Based Collection Rates and KPI Performance
Evolution of the Revenue Cycle Conventional View of Revenue Cycle Management o Silos restrict feedback across the revenue cycle o Defect resolution is reactive o Lack of integration limits root cause analysis, counteracts change management
Evolution of the Revenue Cycle Integrated View of Revenue Cycle Management Approach is clinically and financially integrated Business intelligence and over a decade of experience informs the Accretive Health methodology Proactively prevent defects by implementing sustainable process improvements Supports framework for managing valuebased reimbursement
Payer-Provider Collaboration: Data Payers Providers Retrospective and comprehensive patient data; stratification of high risk patients Analysis and proactive communication for variance or potential penalties Leverage Payer Data Integrating clinical and financial insights to support efficient gap resolution, patient engagement and coordinated care
Payer-Provider Collaboration: Transparency Payers Providers Contracts with clearly defined performance requirements Transparent payment bundles with tactical details related to scope and volume of services Financial & operational infrastructure to: Analyze Detect gaps Navigate Prioritize Exceptions Capture Updates Validate and reconcile
Payer-Provider Collaboration: Alignment Payers Benefit Design aligning reimbursement with value-based incentives for activity and outcomes (Misalignment example: incentives for decreasing readmission while reimbursing per admission) Providers Organizational Organizational infrastructure to support communication and cultural change management Engaging physician leadership Aligning physician compensation with payer reimbursement models
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