july 28, 2016 navigating new payment models

Navigating New Payment Models

James English, Florida Hospital, Vice President

Angelia Ewing, Cerner, Sr. Director

July 28, 2016

AGENDA

• Overview of the Regulatory Environment related to Alternative Payment Models

• Overview of Florida Hospital• Example: Medicare Bundled Payment• Example: Organ Transplants• Analytics and Tools

Fee-for-servicePay-for-

performanceEpisodic bundling

Partial risk /

shared savings

Full-risk:

% of premium

HMO

Episodic Cost Total Cost

Provider Accountability

Patient Centered Medical Home Accountable Care Organization

201630%

201850%

201685%

201890%

Bundled and ACO

Payments

Medicare w. Quality Measures

Latest CMS Announcements

Next Gen ACO

50%-100%

From Volume to Value– Continuum of Payment Models

MIPS – APM – CJR – DSRIP-CCM

A Model for Classifying Alternative Payment Models

PAYMENT MODEL FRAMEWORK

Alternative Payment Models Framework

HCP LAN Alternative Payment Model (APM) Framework White Paperhttps://hcp-lan.org/workproducts/apm-whitepaper-total.pdf?utm_source=LAN+Newsletter&utm_campaign=05cb367423-LAN_eNewsletter_January_12_2016&utm_medium=email&utm_term=0_1b87e2051f-05cb367423-105704389

Source: Audacious Inquiry, ONC 2016 Annual Meeting

FLORIDA HOSPITAL

• 2300+ beds• 149k admissions• 687k+ patient days• 530k+ ED Visits• 76k+ surgeries• 8 satellite locations (one provider number)• $3 Billion+ annual revenues• Currently experiencing rapid growth

• Currently building a replacement hospital for a legacy campus.

• Just completed and ED and OP facility that will become our 9th satellite in the coming years.

• Just completed a 12 story Women’s Tower.• Currently building one free standing ED set to

open in May and another scheduled to open in 2017.

OBJECTIVE

• To provide a Revenue Cycle solution that can address various value-based payment methodologies (i.e. bundles, global payments, package and capitation) while administering the complex claim submission process, respective to the at-risk provider for payment and the reporting necessary to respond to this payment shift from volume to value-based reimbursement.

PROGRAMS

• Medicare BPCI Model Initiatives

• Transplant Bundles

• Self Pay Package Pricing

SOLUTION

• An Integrated solution which eliminates manual manipulation, removes multiple interfaces, reduces costs, delivers greater accuracy, and provides consistent workflow.

• Provide an intuitive platform to manage loading and maintenance of complex payment arrangements.

• Track and reprice both Hospital and Professional claims in one consistent view for a given episode.

Cerner/Florida Hospital Partnership

Example: Medicare Bundled Payment

Acute Care IP Admissions Select DRGs

Medicare Services and Readmissions

(Hospital & Physician)

Prospective Payment

BPCI MODEL 4

THE PROCESS (Manual)

Surgery Scheduled (CVI)

Notification of Patient Qualification (email)

Medicare Notice of Admission

(60 Days)

NOA Initiated (DDE)

Daily Tracking (Spreadsheets)

Eligibility Updates (Spreadsheets)

Claims Submission (DDE)

Monitor for Discharge Status

Post Discharge

Coding/DRG Review

Additional Eligibility Review

Monitor for Payment

TPA Updates/Payment Distribution

Example: Transplant Services

Bone

Marrow Transplant

Solid Organ

Heart

Lung

KidneyPancreas

Liver

TRANSPLANT PROCESS

Global Team Creates Case

Physicians, Hospital, Ancillary Providers

Claims Submission

Bundles claimsTransplant Center

Notification

Funds DispersedPhysicians, Hospital, Ancillary Providers

Final Payment Received

Hospital bills patient (if applicable)

DRG

Quality FinancialClinical

FFS

Clinical

QualityFinancial

APM

DRG only connectionAll connected by patient’s

longitudinal care needs

SHIFTING FROM FFS TO APM

OPERATIONAL REQUIREMENTS

• Traditional Revenue Cycle Capabilities• Claims Analysis Tools• Predictive Capabilities for Assessing Risk of Service Population• Operational Analytics• Financial Benchmarking• Patient Attribution• Care Planning• Contract Management• Patient Panel Definition and Management• Referral Management • Patient Compliance Monitoring• Information Sharing• Network Participation and Shared Savings/Cost Administration

HealtheCare

analyticsCMS

Req

Care Management

Population Health Management

MS-DRGs

Length of StayPhysician

QUALITY REPORTING

STAR ratings

Medical Home

PreadmitPredictive Modeling Transition Post-AcuteAdmission

CMS

Req

Procedure Inpatient

CMS

Req

CMS

Req

Data Monitoring

Data-driven Process Improvement

Readmission Prevention Worklist

Cerner EMR

PowerChart® PowerPlans

Access Management

Acute Case Management

eRx

eSignature

Transitions of Care

UM Worklist

PowerChart® Ambulatory

HealthePrograms

HomeWorks™

HealtheAnalytics

MANAGEMENT OF THE PROCESS

• EMR Based Analytics• AR Management

• Revenue and Adjustment

• Payment Analysis

• Denial Management

• Contract Performance Analysis

• Productivity Analysis

• Volume and Driver Analysis

• Payor Performance Analytics

• Physician Performance Analytics

• Dimensions / Data Drill-in• Financial Class, Payor, Inpatient/Outpatient, DRG, CPT, Facility,

Physician, Nursing Unit

Example Metrics AR Days DNFB Days Cash as % of Net Revenue POS Collections Adjustments as % of Gross Revenue Charity Care as % of Gross Revenue Case Mix Inpatient Days Average Length of Stay Patient Visits Denials

FINANCIAL MANAGEMENT ANALYSIS

Key Metrics

• Claims Analytics• PMPM / cost analysis

• Risk stratification (MARA)

• Utilization analysis

• In Network/out of Network analysis

• Member demographics analysis

• Generic drug dispense analysis

• Readmissions claims analytics

• Quality Performance Analytics

• Value-based Payer Reporting

• Dimensions / Data Drill-in• All Population, Payer/Plan, Region, Practice, Provider, CI-APCP, CI-

APP & Member

Example Metrics Attributed population Member Months Risk-adjusted PMPM – Total Risk-adjusted PMPM – Medical Risk-adjusted PMPM – Rx Risk-adjusted PMPM – Inpatient Risk-adjusted PMPM – Outpatient Risk scores – concurrent & prospective PMPM (Real) Generic Drug Utilization High-cost Imaging/1000 Admits/1000 ED/1000 Inpatient Days/1000 ED Unique Members/1000 # of Unique Members with Admit # of Unique Members with ED Visit OP Visit/1000 30-day readmits (no exclusions) ED/IP/OP Counts CT Scans/MRI Counts Registries 230 standard measures

COST & UTILIZATION ANALYSIS

18

Process

Disburse Bundleas Incurred

Segment to Service Providers

Submit

DisbursePayments

Cardiologist

PCP

Hospital

Claim Scrubbing

PayorHealth System – New Era

*Traditional EMR

**Value-Based Reimbursement

Remittance

Payor

Edit Claims

Reconcile Payments

Health + Care Integration

Delivery Network Management

Consumer* Traditional EMR is represented by the gray box

** Value-Based Reimbursement is represented by the white space within the purple box

Automated process

BUNDLE ADMINISTRATION

Q&A

• Thank you for your time!

• James English– James English@FLHosp.org

– 407-200-2307

• Angelia Ewing– Angelia.Ewing@Cerner.com

– 816-201-7257