retaining and gaining insured hiv+ patients in your medical practice: surviving the opportunities...
TRANSCRIPT
Retaining and Gaining Insured HIV+ Patients in Your Medical Practice:
Surviving the Opportunities and Challenges Presented by the ACA
Julia Hidalgo, ScD, MSW, MPH
About the AETCs
The AIDS Education and Training Centers (AETCs), a national network of leading HIV experts, provide locally based, tailored education and technical assistance to healthcare teams and systems to integrate comprehensive care for those living with or affected by HIV. The AETCs transform HIV care by building the capacity to provide accessible, high-quality treatment and services throughout the United States.
The AIDS Education and Training Centers are funded by the Health Resources and Services Administration, HIV/AIDS Bureau
Housekeeping & Announcements
• Audio is via the telephone• Session is being recorded• Please type questions for the presenter into the chat room
• Include state and your organization
Date Area
Retaining and Gaining Insured HIV+ Patients in Your Medical Practice: Surviving the Opportunities and Challenges Presented by the ACASeptember 23, 2013
Julia Hidalgo, ScD, MSW, MPHPositive Outcomes, Inc. &
George Washington [email protected]
Disclaimer
The information provided in this webinar does not necessarily represent the views of agencies funding George Washington University or Positive Outcomes, Inc.
Strategies provided in this webinar may vary by stateIt is important to maintain current knowledge about health care
reform in your state to ensure timely and well informed actionsFor Ryan White HIV/AIDS Program grantees, it is important that you
seek guidance from your project officer or grantee to ensure your programs’ strategies are consistent with HIV/AIDS Bureau (HAB) policies and grant requirements
Thanks to the American Academy of HIV Medicine, HIV Medicine Association, and HealthHIV for supporting the work reflected in this webinar
Presentation Focus
Today’s webinar focuses on helping HIV clinicians to retain and gain insured HIV+ patients in your practices byParticipating in commercial and public health insurance provider networks
While the ACA is our most immediate focus for provider participation, there are other opportunities for contracting with employer-based health plans, Medicare and Medicare+ Choice health plans, and other insurers
Effective contracting strategies Gaining access to newly insured patients
Expanding capacity to serve additional HIV+ patientsEnsuring that your practice receives sufficient third party reimbursement to
cover your costsEducating your patients about the insurers in which you participateScreening your patients for current or potential insurance enrollment
“I hope this will be very practical information from the beginning, and less about history of the reform. I need very practical information! “
Are you ready to participate in Marketplace Qualified Health Plans and Medicaid expansion?
Rationale for Readiness for the ACA: A Review
Continue to serve your current HIV+ insured patients and expand services to additional HIV+ insured patients
Diversify income sources to reduce dependency on grant funds
Fiscal solvency Generate discretionary income for capital
investment, administrative expenses, and services not supported by grant funders
Adhere to HAB policies
Rationale for Readiness of HIV Clinics in States That Have Chosen Not to Expand Medicaid Coverage
Health insurance coverage available to patients with pre-existing health conditions who were denied benefits or enrolled in Pre-Existing Condition Programs
Readiness for Medicaid participation, particularly managed care systems, can be a slow process You can gain important experience by
participating in commercial health insurance provider networks
Many HIV+ individuals may benefit from enrollment through Marketplaces
Key Domains of Readiness for Health Reform: A Review
Aligning with your organization’s visionBuilding infrastructureDefining your products and target
populationsComputing the cost of your productsRe-engineering your practice managementAssessing the health insurance marketContracting with health insurersEducating HIV+ patients about navigating
health insurance systems
Practice Management Readiness Activities
Expanding workforce capacity to deliver covered services to enrolled HIV+ beneficiaries
Designing telephone systems that promote patient communication rather than create barriers to access
Scheduling systems to optimize clinician productivity, reduce broken appointment rates, and promote retention in care Open access or same day appointment scheduling
Assessing and improving wait times for new and established patients Streamlining registration and intake process Assessing and improving patient flow to optimize efficiency and maximize resources Enhancing eligibility determination, e-verification, and enrollment assistance
systems Addressing factors resulting in HIV+ patient lost to care
Do you know your lost to care rate? Have you designed and implemented a strategy for improving retention in care?
Practice Management: A ReviewAdopt practice and panel management systems
Adopt patient empanelment processes (i.e., assigning each provider a set number of patients) to improve clinical processes and outcomes
Assess and address patient flow, opportunities for task shifting (ideally to billable personnel), continuity of care, time consuming activities (e.g., medication refills), impact of part-time clinical staff on productivity and quality
Automate patient process and outcome data, quality management systems, and capacity to improve clinic and provider performance
Team with CBOs and other community partners to undertake community-based linkage to care and retention activities
Become educated about the concepts and adopt tools to create accredited patient-centered medical homes
Update practice policies and procedures and mobilize your staff
Eight Steps for Contracting With Insurance Plans and MCOs
Eight Key Steps for Contracting
Check with your organization about their health plan contracting process
Identify opportunities in the health insurance markets
Gather information about insurers Assess insurers’ track records Understand how insurers will pay for
your services Evaluate the adequacy of payment
based on your actual costs Contract with insurers Assess payoffs and pitfalls
Resource: HIVMA, Strategies for HIV Medical Providers Contracting With Health Insurers
Check With Your Organization About Their Plan
Before moving forward with health reform readiness activities, it is critical to Ensure your HIV practice’s efforts are aligned with your organization’s
overarching readiness effortsAn important step for HIV practices in large integrated health
systems, hospital-based or university-affiliated health systems, city or county health departments, large FQHCs
Contracts may have been negotiated or are being negotiated now for 2014
Medicaid managed care contracts have probably been finalized for the current year
Engage organizational leadership, including corporate board supportIdentify organizational resources that can be applied to your
readiness activities
Identify Insurance Contracting Opportunities
The American Academy of HIV Medicine and Positive Outcomes, Inc. teamed to gather State-specific information about provider enrollment in Marketplace Qualified Health Plans and Medicaid (including fee for service and managed care): http://www.aahivm.org
Your State’s Health Insurance Commissioner has information about other licensed health insurance plans in your state: http://www.naic.org/state_web_map.htm
Gather Basic Information About Insurers’ Networks Research health insurers and managed care plans in your service area to
assess network participation bySpecialty care providers
Do the providers serve your patients? Are there gaps in specialties and subspecialties needed by your patients? Are the providers conveniently located?
Pharmacies Are you familiar with the pharmacies? Are they conveniently located? Do they routinely stock HIV medications? Is mail order delivery available?
Inpatient hospitals Are you familiar with these hospitals? Do you have admitting privileges with these hospitals? What is the hospital’s track record about notifying you about your patients’
admissions? What is their track record for coordinating inpatient discharges?
Gather Basic Information About Insurers’ Policies and Procedures
Payment RatesCan you negotiate with the plan?What are the payment mechanisms and rates?Are enhanced payments available for care coordination?What is the plan’s policy for timely payment?What is the plan’s rate of denied claims for primary care and ID visits?
Access to HIV Providers and Specialty CareAre referrals required for HIV+ patient to receive your services?Can HIV specialists serve as primary care providers?Is HIV recognized by the insurer as a specialty?What is the plan’s credentialing requirements?What are the plan’s access standards?For Marketplace Qualified Health Plans, what is the process for
contracting as an Essential Community Provider?
Gather Basic Information About Insurers’ Policies and Procedures
Coverage and Benefits Who determines medical necessity?What is the plan’s policy for coverage of HIV tests, antiretrovirals, CD4 tests, viral
load tests, and genotype and phenotype resistance test? Is prior authorization required?
Are disease managers or case managers routinely assigned to HIV+ patients? What is their role in care coordination? What are their training requirements
and expertise? What are their utilization management and review procedures?
Quality and ReportingDoes the plan have HIV-related quality measures?What are the provider reporting requirements?What is the plan’s quality track record?
Resource: The Harvard Law School Center for Health Law and Policy Innovation has developed a resource for assessing other aspect of health plans: http://www.hivhealthreform.org/assessment/
Assessing the Insurer’s Track Record Many health insurers operate in multiple statesReach out to your colleagues in other HIV clinics and ID practices to learn of
their perceptions of the insurer:The insurer’s willingness to negotiate contracts, including enhanced HIV
payment arrangementsAdequacy and timeliness of paymentsFinancial stabilityPropensity to deny claims due to “lack of evidence of medical necessity”Willing to allow standing referralsCoverage of HIV testing, ARVs and other HIV medications, and HIV-related
lab testsUse of disease managers to “manage” HIV, mental health, substance
abuse treatment utilization
Understand How Insurers Will Pay for Your Services
Fee-for-service (FFS) continues to be commonly used by commercial and public health insurers
Capitation payment modelsPrimary care coordination paymentsCondition-specific capitationShared savingsGlobal paymentsPay for performanceBudget-based payment systemsAccountable care organizationsCarve outs and carve ins
Ways to Limit Risk in Managed Care ContractingPayments models vary in the extent to which the provider assumes
financial riskAccept capitation only for services your practice directly provides or
controlsCarve out high-cost, low-frequency services more appropriately
reimbursed on a FFS basis Strive to retain FFS payment until a statistically valid enrollment level
has been achieved by health planPurchase stop-loss insurance coverageSeek risk adjustment in the payment systemDefine precise boundaries between your practices’ services and other
providers’ care to avoid “dumping”Gain experience with small-scale contractsEnsure that adequate termination options exist
Evaluating the Adequacy of Payment Systems Based on Your Costs
The AMA has developed tools to help medical practices calculate their costs: http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/claims-revenue-cycle/managed-care-contracting/evaluating-payment-options/establishing-baseline.page
HAB offers resources to calculate unit costs http://hab.hrsa.gov/deliverhivaidscare/tactoverview.html
It is important to include the actual components of cost for the contract period, including salary adjustments
The amount of grant funds awarded to your program by HAB or other funders is not your cost
Conduct break-even analysis comparing costs to likely third party insurance revenueConsider opportunity costs, such as the likely reduction in revenue from HAB
grants resulting from the payer of last resort policy and federal funding reductions
Credentialing and Contracting With Commercial and Public Insurers
CredentialingMany health insurers use the Universal
Provider Data Source maintained by the Council for Affordable Quality Healthcare for their credentialing process: http://www.caqh.org/overview.php
ContractingSeek legal advicePrepare to negotiateCarefully evaluate the contract
Contract terms Coverage and benefits Payment and claims
Assessing the Payoffs and Pitfalls of Contracting
In the first year of contracting with insurers, you may want to weigh the financial benefits of your contracts versus issues that arose with the insurer and their enrolled patients Small number of enrolled patients, resulting in administrative costs and
hassle but small revenue yieldInsufficient revenue to cover administrative costs
Staff time to research and resubmit rejected claimsUntimely payment Payment that does not cover labor and overheadRejection of claims due to lack of medical necessityLimits on the number of visits covered, burdensome cost controls, or
other utilization management policies Prior authorization or other requirements for specialty referrals
Marketing to Health Insurers
Considerations in Marketing to Health InsurersWhat are the products you are offering?How many plan members could benefit from your products?Will your products attract new members to the plan?How much does your product cost?Will the plan have to pay for your products (e.g., grant-funded
service)?What distinguishes your products from that of another provider?How will your products enhance the plan’s network?How will your products help meet health plans’ benefits, network,
access, or quality assurance standards?
Defining Your Products and Target Populations
Assess your current payer mixIdentify services commonly covered by public and commercial insurers
Parse non-billable services that may legitimately continue to be paid by the Ryan White Program
Identify services that may be covered by some insurers to help them to manage service utilization, prevent morbidity or mortality, promote positive health outcomes, and reduce unnecessary costsPrevention services, disease management, care coordination, linkage
and retention servicesHIV+ patients only, patients with communicable diseases (e.g., Hep C),
other patients HIV+ patients and provision of reimbursable HIV screening to insured
populations
Key Marketing Messages for HIV Providers
We are experienced inDelivering clinical services that reflect state-of-the art HIV careDelivering clinical and psychosocial services to hard-to-reach
populationsManaging behavior to achieve positive clinical and behavioral outcomesAvoiding or reducing psychosocial crises that impact adherence to
clinical regimensDelivering culturally sensitive and appropriate servicesWorking in an integrated network of clinical and support servicesProviding prevention services to reduce HIV infection among
beneficiaries, their sexual partners, and newbornsAssisting newly identified HIV+ to link to care, be retained in care, and
be located if lost to careDelivering cost-effective services through low overhead
Educating Patients About Your Participation in Health Insurance Networks
Gaining and Retaining HIV+ Patients Develop and implement a patient marketing strategy
If your website is part of the strategy, consider how it can be used strategically Ask your community advisory board and peer workers for strategies for gaining and
retaining HIV+ patients Educate HIV+ individuals about selecting an insurance plan in which you participate
and select an affiliated primary care provider Educate current patients about pathways to insurance enrollment through
Marketplaces, premium subsidies, ADAP assistance, current and expanded Medicaid programs, importance of selecting a Medicaid managed care plan to avoid auto-assignment
Educate insured HIV+ individuals that are unlikely to need to enroll through the MarketplaceReasons some insured patient should enroll in the Marketplace include that their
current plan does not meet ACA Essential Benefits requirements, lower cost premiums, provide better benefits for their family, or to join a plan in which you participate
Gaining and Retaining HIV+ PatientsActively facilitate the work of CMS and State-funded facilitators and
navigators, in-person assisters, and certified application counselorsArrange for on-site activities at your HIV clinic or practiceSponsor patient education sessions
Inform current and new patients about your policies if eligible individuals do not enroll in Marketplace or Medicaid health plans
For new and ongoing patients, provide linguistically and culturally appropriate patient education to empower patients to navigate your HIV clinic, the broader health care system, and the health insurance system
Adopt web-based patient tools to help them schedule appointments, request medication refills, and get information about their health, HIV care, and medications
Help patients to understand “health insurance basics” through group and individual training, including their roles and responsibilities
2013
Oct 2013
Nov 2013
Dec 2014
Jan 2014
Feb 2014
Mar
While it is important to educate your HIV+ patients about enrolling in the Marketplace during the Ryan White Program eligibility determination and recertification
cycle, some patients may enroll before their next determination appointment
Common Errors Found in Intake and AssessmentHousehold Size: assumption that the patient is a single adult, individuals
meeting EMA/TGA household definition are not identified during assessment (particularly spouses and dependent children)
Household Income: patients’ income poorly documented, family members’ income not assessed, patients claiming $0 income not probed for how they manage with no income, undercounting income from self-employment, and missed income from sources other than wages
Insurance Enrollment: inability to understand health insurance deductions documented on paystubs, not researching if an employer offers insurance benefits to full or part-time employees, not assessing enrollment of spouses in plans that could cover the HIV+ spouse, failing to query college students about enrollment through their college
General Errors: not updating key information when things change
Tips for Assessing Health Insurance Enrollment Check paystubs carefully Ask the patient directly if he/she or his/her spouse is insured Ask the patient if he/she can enroll in insurance through his/her employer
If the patient reports that he/she declined available health insurance, find out why, and help to address concerns (e.g., cost or disclosure)
If the patient reports his/her employer does not offer insurance, check the employer’s human resources website and/or ask for an employer letter
If the patient is less than 26 years of age, ask if his/her parents are insured and inquire if he/she can enroll in parents’ insurance
If the patient is a university or college student, verify available insurance, and counsel the patient to enroll in available insurance
Query the Medicaid electronic verification system and use commercial web-based query systems to identify current Medicare and commercial insurance enrollment Avality, Capario, Medifax POS, Passport Health Communications, WebMD Envoy
Ready, Set, Go
Develop a Readiness PlanRemain calmIdentify key members of your readiness team based on the
domains identified todayTeam members might include policy, practice management, finance, clinical,
information technology, human resources, and other staffIf feasible, designate an in-house expert on health reform
Honestly assess your readiness using the domains discussed today, identify barriers, and develop realistic strategies for overcoming them
Readiness planning and implementation are likely to be evolutionary, long-term, and improve with experienceEven highly experienced HIV clinics report new challenges
Develop a Readiness PlanThe readiness team should set priorities, create a schedule,
assign tasks, and meet routinelyAnticipate that some tasks are likely to be slowSet short-term achievable goals- start slow and then growIdentify interorganizational and outside resources and seek helpRoutinely update the HIV clinic staff to solicit their suggestions and buy-inAim for durable sustainability regardless of staff turnover
Evaluate infrastructure and other costs and compute the likely return on investment Identify and seek funds to cover costs
Identify strategies to collaborate with other HIV clinics to form formal or informal networks
Key Resources
Key Resources American Academy of HIV Medicine
http://www.aahivm.org/
American Medical Association Practice Management Center http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center.page?
Families USA Health Reform Central http://www.familiesusa.org/health-reform-central/
Harvard Law School Center for Health Law and Policy Innovation http://www.hivhealthreform.org/assessment/
CMS Medicaid Provider Payment Provisions Under the ACA http://www.medicaid.gov/AffordableCareAct/Provisions/Provider-Payments.html
CMS Documentation Guidelines for Evaluation and Management (E/M) Services http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html
Falcone AJ. Negotiating Contracts with Managed Care Organizations. A presentation at the HAB All Grantees Meeting. November 2012. https://careacttarget.org/library/negotiating-contracts-managed-care-organizations
HIV Medicine Association http://www.hivma.org/Home.aspx
HRSA Bureau of Primary Health Care http://bphc.hrsa.gov/technicalassistance/index.html
HRSA HIV/AIDS Bureau TARGET Center https://careacttarget.org/library/affordable-care-act-ryan-white-hivaids-program
Key Resources National Association of Community Health Centers
http://www.nachc.com/complete-list-of-trainings.cfm
National Academy for State Health Policy. Engaging Safety-net Providers in Expanded Coverage: Tips on Enhancing Billing Capacity. http://www.nashp.org/sites/default/files/SNP.tips.billing.capacities.pdf
National Association of State and Territorial AIDS Directors http://www.nastad.org/care_and_treatment/resources.aspx?category=health%20reform
National Conference of State Legislatures, Medical Homes and State Implementation of the ACA and Medicaid Expansion http://www.ncsl.org/issues-research/health/the-medical-home-model-of-care.aspx http://www.ncsl.org/issues-research/health/affordable-care-act-state-action-newsletter.aspx
National Committee for Quality Assurance Patient-Centered Medical Homes http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx
HIV Medical Homes Resource Center http://fxbcenter.org/mhrc.html
Substance Abuse and Mental Health Services Administration http://www.samhsa.gov/healthreform/
US Department of Health and Human Services ACA Resources http://www.healthcare.gov/
Download the slides: www.HIVHealthReform.org
Questions and Discussion
Maximizing HIV Care Reimbursement in 2014http://www.aidsetc.org/aidsetc?page=etres-display&resource=etres-703&
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9/23/13
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