Cutting Edge Issues Related to Payments to Physicians Under P4P Compensation Models April 16, 2014 2515 McKinney Avenue, Suite 1500 Dallas, Texas 75201 Telephone: 214.369.4888 Fax: 214.369.0541 3100 West End Avenue, Suite 940 Nashville, Tennessee 37203 Telephone: 615.777.7300 Fax: 615.777.7301
Jen Johnson, CFA Partner at VMG Health. VMG Health solely provides transaction advisory and valuation services in the healthcare industry. Since 1995, offices in Dallas and Nashville. 90 professionals, over 1,200 valuation per year. Third party role: business valuations, real estate, fixed assets, fair value Leads Professional Service Agreements Division. Previously in KPMG s litigation department & finance professor, University of North Texas. Published and presented over fifty times related to physician compensation and fair market value. April 2014 HFM Magazine Evaluating The Fair Market Value of Pay for Performance Finance Committee Attendance on major P4P initiatives
P4P Background
Why the Growth in Integration & P4P? Affordable Care Act Physicians and hospitals need to collaborate more than ever Security healthcare reform, changing reimbursement Increased compensation: post employment or contracted arrangement Better hospital-based reimbursement Replace potential loss of ancillary earnings Investment requirements for information technology Participate in risk-based contracting, ACOs, quality initiatives 4
Evolution of P4P payments Hospitals critical success factors shifting from production towards quality of clinical performance and efficiencies 1. Payments for Reporting (ie: PQRI) 2. Pay for Process 3. Pay for Outcomes Standard process leading up to P4P payments 1. Recognized organization identifies quality metrics or average costs 2. Reporting measures is required, or costs are tracked 3. Benchmarking data is gathered 4. Payments for outcomes or savings is observed in market FMV can now be established Common factors included in P4P arrangements Lowering costs without sacrificing quality Quality outcomes payments individual, services line level, entire population Use of technology
History and Results of P4P In late 2003, CMS and Premier Inc. launched the Hospital Quality Incentive Demonstration (HQID) for over 250 hospitals Average composite quality score (CQS), an aggregate of all process and outcomes measures within each clinical area, improved project-wide by 18.6% over the project's six years (October 2003 through September 2009) In 2008, the Robert Wood Johnson Foundation and California HealthCare Foundation reported results of a national program that tested the use of financial incentives to improve the quality of health care. Tested seven projects across the nation that adjusted compensation based on performance scores hospitals and physicians. Notable findings: Financial incentives motivate change Alignment with physicians is a critical activity for quality outcomes Public reporting is a strong catalyst for providers to improve care
History and Results of P4P - examples SAVINGS: 13 Gainsharing Opinions (2001-2008) QUALITY: February 2012 Committee on Ways and Means 1 example UnitedHealth Group discusses results of its Premium Designation Program (PD) Results show over 50% decrease in some complication rates SAVINGS & QUALITY 2013 Results 114 ACOs in the program - 54 of the ACOs saved money - of $126 million 2013 Greater New York Hospital Association - 100 hospitals desired to work with participating physicians to account for the use of hospital resources. Physicians that met hospital quality targets while lowering costs could be compensated a portion of the savings. There is a P4P market, but how much can be paid to physicians? It depends.
Market Comparables for P4P Payments Third party payors UnitedHealth Group largest US health insurer by sales 2013 paid 21 different specialties based on quality WellPoint largest US health insurer by membership Will increase primary care physician pay by 10% - coordinated care Additional cost savings bonus of 20% to 30% of savings achieved BCBS and Aetna Growing P4P programs Including payments for both cost savings and quality Governmental Programs growing State and Federal MSSP, ACOs and bundled payments
ACA Provisions & P4P CMS to play major role in developing P4P programs VBP quality and cost goals simultaneously Section 3001: Hospital Value Based Purchasing 2012 Quality Outcomes payments Efficiency measures in 2014 Must be reporting on Hospital Compare website for at least 1 year DRG reductions nationwide will fund UP to 2% can be earned Section 3006: Value Based Purchasing Skilled Nursing Facilities and Home Health Section 3007: Value Based Payment Modifier under the Physician Fee Schedule Payment modifier for cost and quality 2015 for larger groups 2017 for all Size of incentive not specified
ACA provisions continued Section 3008: Payment reduction for Hospital Acquired Conditions Section 3021: Establishment of Center for Medicare and Medicaid Innovation within CMS, 3 of 18 models are P4P Appropriate criteria for diagnostic imaging orders Payments for using patient decision support tools Payments for using evidence based guidelines for cancer care Section 3022: Medicare Shared Savings Program Promotes ACO development Cost savings and quality must be met Governmental programs great roadmap for how much is acceptable to distribute to physicians. Consider 3 rd party payors as well when defining the P4P market.
P4P Arrangements
Physician Service Agreements P4P May be a result of joint ventures, acquisitions, employment or independent contractor arrangements Committee Meetings Call Coverage Co-management (fixed + variable) PSA Model ACOs & IDNs Bundled Payment models Medical Directorships Employment We will be stuck between FFS and P4P for a while 12
Physician Risk & Arrangement Types with P4P Less risk for physicians Traditional deals with P4P component Clinical (% of base add-on) Medical directorships (hourly rate differential) Call coverage (portion at risk for outcomes) Co-management of service line More risk for physicians ACO type models Upside based on actual savings -> possibly downside ->Quality initiatives provide gate or extra upside ->Share gains/losses Bundled Payments
Quality Metrics & P4P Arrangements Common metrics Patient satisfaction Infection Rates Readmission Core Measures Challenges with certain service lines, less data: oncology, imaging Look to current reporting measures Track what credible organizations are measuring Identify metrics third party payors are measuring CMS metrics
Co-Management - The Basics Fixed Fee + Variable Fee = Co-Management Fee Structure Hospital and physicians enter into an agreement where physicians are jointly responsible with hospital for managing a defined service line Various arrangement types exist in the market Joint Ventures Contractual arrangements Payments contained in the agreement Will vary based on services outlined Should be linked to actual services and/or outcomes
Co-Management - Fixed Fee Overview Physician service related payments are justified by need for clinical expertise Time dedicated to meetings designed to improve the overall quality of care for a specific service line. May also include Medical Directorship Non-physician services Billing Management/administration Call coverage The duties must not overlap with hospital staff Probably not a typical management fee
Co-Management - Variable Fee Overview Quality outcomes drive payments - create payment tiers for incentives based on various outcomes Improvement and superior outcomes may warrant incentive payment Obtain industry-recognized benchmark data for the quality metrics, (average or median and top or 90th percentile) Understand historical performance and who is responsible for developing and implementing the strategy Cost savings metrics Administrative oversight to protect quality is essential Measurement must be tied to physician s input
Clinical Integration payments - ACO/IDN models The following payment allocations may be included within a clinical integration model Bundled payment splits understand who is providing what service Quality and Shared Savings splits among ACO entity and hospital and physicians FMV process - balanced approach for overall model should be assessed Third party funded or from hospital Infrastructure cost recovery Buy-in or participation Fee Time spent/effort hourly rate paid Split of savings existence of minimum savings threshold Split of quality - benchmarks utilized Upside and downside risk Care coordinator payments ie: Nurse care manager PMPM fee for management consider acuity and NCQA
Fair Market Valuation Guidance and Regulatory Tips
Case Law Growth and Take-Aways Hospital is at risk for relying on unsupportable valuations Valuation methodology is as important as total compensation No opinion shopping, carefully choose your valuation firm Logic Test Tuomey examples: Do not pay fulltime benefits/malpractice premiums for part-time services Physicians paid above the 75th percentile of market data should demonstrate productivity consistent with other physicians in this percentile Understand arrangements where the provider is not making money Compensation for administrative duties should be based on significant duties P4P watch out for low hanging fruit and rebase annually
Valuation Starting Point 1. Agreement terms must be understood and are sometimes unclear at valuation stage, define: What services will be provided? How will parties be compensated? 2. Commercially Reasonable gaining importance Facility needs check for overlap of services (numerous medical directors needed) Operational assessment (quality metrics relevant for patient population) 3. There are no published standards for physician compensation valuations, P4P new Appraisal firm should understand Healthcare regulations Valuation principles Fair Market Value Data considerations competing hospital, extra caution
Fair Market Value Definition Based on the anti kickback statute, and other healthcare regulations and guidelines, any transaction between hospitals and physicians must be at Fair Market Value. IRS definition - the amount at which property would change hands between a willing seller and a willing buyer when the former is not under any compulsion to buy and the latter is not under any compulsion to sell and when both have reasonable knowledge of the relevant facts. Provides a conclusion which should not reflect consideration for value or volume of referrals. Offer equal P4P opportunities to all providers Do not tie P4P compensation to expected referrals P4P comparables Stick to regulatory guidance when it comes to paying for quality or shared savings Governmental programs and third party payors are good market comparables
Regulatory Guidance - Quality Quality measures should be clearly and separately identified Quality measures should utilize an objective methodology verifiable by credible medical evidence Quality measures should be reasonably related to the hospital s practice and consider patient population Do not consider the value or volume of referrals. Consider an incentive program offered to all applicable providers Incentive payments should consider the hospital s historical baseline data and target levels developed by national benchmarks Thresholds should exist where no payment will accrue and should be updated annually based on new baseline data. Hospitals should monitor the incentive program to protect against the increase in patient fees and the reduction in patient care Incentive payments should be set at FMV
Regulatory Guidance Shared Savings Gainsharing Guidance Favorable OIG Opinions Each member of the physician group should have medical staff privileges The arrangement should be administered by a program administrator, whose compensation was not tied in any way to the incentive compensation. A program administrator should identify cost-savings metrics after reviewing historical practices and understanding its medical appropriateness. The savings targets should be re-based at the end of each year in multi-year arrangements. The hospital should calculate the cost savings separately for each group and for each cost savings recommendation. The arrangement should include objective measures to monitor quality (i.e., CMS Specification Manual for National Hospital Quality Measures). Incentive payments should be set at FMV ------------------------------------------------------------------------------------------------------- More complex factors should be considered for allocating savings associated with patient population and bundled payments Responsibility for outcomes and savings Risk adjustment for patient population Responsibility for infrastructure costs (if applicable) Caps are prudent and seen in demonstration projects
Common Challenges with P4P Evolutionary Process, Seen one, seen one Reported Data for making P4P decisions provider and payor concerns Inaccurate Inconsistent, outlier treatment Expensive/timely to aggregate and report IT Infrastructure other issues Sharing and access New software options Connectivity of information among integrated parties
Common Topics in the Boardroom with P4P Allocation of payment methodologies Primary care versus specialists Primary care PMPM and allocation of shared savings Specialists - service line co-management and bundled payments Year 1 versus Year 2+ Care coordinators needed? Risk taking Choosing Metrics - inconsistent among P4P programs
P4P Program Starting Tips Modest set of metrics perhaps consistent with those found in both commercial ACOs and Medicare ACOs Start small Have a written agreement Update and rebase metrics annually Understand who is driving cost savings and quality Have safeguards which prevent cherry picking and lemon dropping Identify flow of funds allocation early on in process Compliant P4P payment formula = Good Data + Logic + FMV guidance
Questions? Jen Johnson, CFA Partner jenj@vmghealth.com 214.369.4888