Eyes Wide Shut - Texas Optometric Associationtexas.aoa.org/Documents/TX/2016 PCS/HANDOUT - Morning Session.pdf · Eyes WIDE Shut The Independent Practice In The World Of Health Care
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Eyes WIDE ShutThe Independent Practice In The World Of Health Care Reform
J. Rumpakis, OD, MBAPractice Resource Management, Inc. – [email protected]
• Most OD’s get into practice to have some semblance of control over their professional lives
• Today, 95% of OD’s participate in MVCP• Today, 90% of OD’s participate in Medical plans• The current model of optometric practice is highly dependent on optical revenue (65% of average practice revenues)
• Optometry practices utilize high levels of technology and test to a higher degree than other medical professionals
• The model of health care delivery is in unprecedented territory• Fee for service model is under attack
Trends Affecting Practices•Downward pressure on refractive reimbursements•Increasing costs•Increasing demand for care (baby boomers)•Contracting supply of ophthalmologists•More patient pay (deductibles, diagnostics, treatments)•More savvy patients•EMR and other technology•Need for better‐trained staff•Practice consolidation•Continual changes in the healthcare delivery system
Service Revenue Analysis Calculator Input Column ResultsTotal Gross Revenues (Collections) $983,515.81Total Gross Revenues From Material Sales 0% $0.00Total Gross Revenues From Services $983,515.81Service Revenue Breakdown (enter percent as decimal)Percent of Patients With Private Pay Vision (PPVS) 0%Average Fee For PPVS Exam & Refraction -$ Percent of Patients With Covered Vision (CVS) 0%Average Reimbursement For CVS Exam & Refraction -$
0%Percent of Patients With Private Pay Medical (PPMS) 0%Average Fee For PPMS Examination Services -$ Percent of Patients With Covered Medical (CMS) 0%Average Reimbursement For CMS Examination Services -$
0%Percent of Revenues From Vision Related Services 0%Percent of Revenues From Medically Related Services 0%Total Patient Services Composition (Must Equal 100%) 0%
Analysis Section OneTotal Income From PPVS $0.00Total Income From CVS $0.00Total Income From PPMS $0.00Total Income From CMS $0.00 Result From Above
Validity Check $0.00 $983,515.81Total Number of Annual Patient Encounters Per Office -
Resultant Patient Mix Total Of PPVS Encounters #DIV/0! - Resultant Patient Mix Total Of CVS Encounters #DIV/0! -
Resultant Patient Mix Total Of PPMS Encounters #DIV/0! - Resultant Patient Mix Total Of CMS Encounters #DIV/0! -
Input AreaDesired Total Pre-Tax Net Income From Services $0Current Pre-Tax Net Income From Services $0Total Number of physician production hours - Current Practice Chair Cost #DIV/0!Current Pre-Tax Gross Revenue/Hour From Services #DIV/0!Current Pre-Tax Net Revenue/Hour From Services #DIV/0!Desired Total Pre-Tax Net Income/Hour From Services #DIV/0!Projected Total Gross Income of Entire Practice #DIV/0!
Cost Per Minute Calculation•It’s Easy To Calculate!•Calculate chair cost per hour•Divide chair cost per hour by 60•That equals your chair cost by minute
•Think I’m too detailed?oEvery minute you are in your practice is either a drainon cash flow or a builder of cash flow
Affordable Care ActTHE PATIENT PROTECTION AND AFFORDABLE CARE ACT WAS S IGNED INTO LAW BY PRESIDENT OBAMA IN MARCH 2010. ITS MAJOR PROVIS IONS GO INTO EFFECT IN JAN. 1 , 2014, ALTHOUGH SIGNIF ICANT CHANGES WENT INTO EFFECT BEFORE THAT DATE AND WILL CONTINUE IN YEARS TO COME.
Affordable Care ActTHE PATIENT PROTECTION AND AFFORDABLE CARE ACT WAS S IGNED INTO LAW BY PRESIDENT OBAMA IN MARCH 2010. ITS MAJOR PROVIS IONS GO INTO EFFECT IN JAN. 1 , 2014, ALTHOUGH SIGNIF ICANT CHANGES WENT INTO EFFECT BEFORE THAT DATE AND WILL CONTINUE IN YEARS TO COME.
• Minimum Essential Coverage – 10 Essential Health • Ambulatory patient services• Emergency services• Hospitalization• Maternity and newborn care• Mental health and substance use disorder services, including behavioral health treatment
• Prescription drugs• Rehabilitative and habilitative services and devices• Laboratory services• Preventive and wellness services and chronic disease management• Pediatric services, including oral and vision care.
Control Supply & Demand The Employer Mandate / Employer Penalty• Originally set to begin in 2014, was delayed until 2015 / 2016. The “employer mandate” is a requirement that all businesses with 50 or more full‐time equivalent employees (FTE) provide health insurance to at least 95% of their full‐time employees and dependents up to age 26, or pay a fee.
The Individual Mandate• The individual mandate requires that most Americans obtained health insurance by 2014 or pay a tax penalty. The individual mandate went into effect January 1st, 2014 and continues each year. The penalty for not having coverage will be paid on your Federal Income Tax Returns, based on yourModified Adjusted Gross Income (MAGI), for each full month you or a family member doesn’t have health insurance or an exemption.
The Individual Mandate• The individual mandate tax forces households to purchase an expensive product or to pay a tax in lieu of that purchase. The law softens this blow for some households by providing subsidies, called “health insurance premium tax credits.” To be eligible for the subsidies, a household must meet two conditions:
1. Household income must be less than 400% of the Federal Poverty Level (FPL), which varies with family size. For a family of four in 2015, 400% FPL = $97,000.
2. The household’s portion of the employer‐sponsored health insurance premium must exceed 9.5% of household income.
•Six million to pay penalties – WSJ, Jan 28, 2015•ACA creates trickier tax season – WSJ, Jan 1, 2015•IRS Budget Cuts Reduce Assistance – NYT, Jan 7, 2015
Reduce Utilization• By shifting costs to the consumer of the health care, utilization of services has shown a demonstrable decrease in the first year of the ACA.
Outcome Based Care• Three federal initiatives — the HITECH Act, the Health Data Initiative (HDI) and the Affordable Care Act (ACA) — are designed to improve clinical quality and the patient experience, and make health care more affordable. As a result of these changes, several trends are emerging, including movement toward outcome‐based payments, higher labor productivity, decreased demand for hospital‐based care and better, more efficient consumer markets.
• The Affordable Care Act was supposed to make insurance, well, more affordable. But now hard results are starting to emerge: premium surges that often average 10% to 20% and spikes that sometimes run as high as 50% or 60% or more from coast to coast.
• In a study across 45 states, the research outfit Health Pocket reports that mid‐level Exclusive Provider Organization plans are 20% more expensive in 2016 on average. HMOs are 19% more expensive, and for all plan types the average is 14%.
• President Obama dropped by Nashville last week to claim Tennessee as a state where “the law has worked better than we expected” and “actually ended up costing less than people expected,” so let’s test the reality of those claims. As a baseline, in 2015 premium increases for Tennessee plans ranged from 7.5% to 19.1%.
• For 2016 BlueCross BlueShield of Tennessee—one of the state’s two major insurers—is requesting a 36.3% increase. One product line from Community Health Alliance Mutual is rising 32.8%, while another from Time Insurance Co. hits 46.9%. Offerings from Cigna,Humana and UnitedHealthcare range from 11% to 18%.
• In a rational market, premiums wouldn’t be soaring in a single year by 49.1%‐65% (Blue Cross Blue Shield of New Mexico) or 40.6%‐58.4% (Geisinger Health Plans of Pennsylvania).
• After the first two years of ObamaCare in 2014 and 2015, insurers have more experience with the demographics and expenses of the new enrollees. They seem to be older and have more chronic conditions like diabetes or congestive heart failure than predicted. There are also fewer than expected.
• Some 76% of eligible individuals at 100 – 150% above the poverty line are enrolled, report the consultants at AvalereHealth. But enrollment drops:• to 41% between 151% and 200% of poverty,• and then to 30% at 201%‐250%. • and 251%‐300%, the share is 20%,• and 16% for 301%‐400%.
Physician Quality Reporting InitiativeIN 2007 , THE CENTERS FOR MEDICARE AND MEDICA ID SERV ICES (CMS ) ESTABL ISHED THE PHYS IC IAN QUAL ITY REPORT ING IN IT IAT IVE (PQR I ) AS REQUIRED BY THE 2006 TAX REL IEF AND HEALTH CARE ACT (TRHCA) . THE 2007 PQRI WAS A PAY ‐FOR‐REPORT ING PROGRAM THAT INCLUDED CLA IMS ‐BASED REPORT ING OF DATA ON 74 IND IV IDUAL QUAL ITY MEASURES .
The Quality Composite Score in the QRUR is based in part on the PQRS quality measures you report. Additionally, CMS will also calculate your performance on three outcome measures. The outcomes measures include two composite measures of hospital admissions for ambulatory care‐sensitive conditions (one for acute conditions and one for chronic conditions) and one measure of all‐cause hospital readmissions. Your PQRS performance in addition to your performance on the outcomes measures will determine your quality score.
Meaningful UseMEANINGFUL USE I S US ING CERT IF IED ELECTRONIC HEALTH RECORD (EHR) TECHNOLOGY TO IMPROVE QUAL ITY, SAFETY, EFF IC IENCY, AND REDUCE HEALTH D ISPAR IT IES , ENGAGE PAT IENTS AND FAMILY, IMPROVE CARE COORDINAT ION, AND POPULAT ION AND PUBL IC HEALTH , AND MAINTA IN PR IVACY AND SECUR ITY OF PAT IENT HEALTH INFORMAT ION
• The penalty increases by 1 percent per year until the adjustment reaches 97% in CY 2017.
• If the Secretary of HHS finds that fewer than 75% of eligible professionals are meaningful EHR users, the penalty will continue its annual 100 basis point climb until the adjustment reaches 95% of the PFS in 2019.
Narrow NetworksAN ACCOUNTABLE CARE ORGANIZAT ION (ACO) I S A HEALTHCARE ORGANIZAT ION CHARACTER IZED BY A PAYMENT AND CARE DEL IVERY MODEL THAT SEEKS TO T IE PROV IDER RE IMBURSEMENTS TO QUAL ITY METR ICS AND REDUCT IONS IN THE TOTAL COST OF CARE FOR AN ASS IGNED POPULAT ION OF PAT IENTS . A GROUP OF COORDINATED HEALTH CARE PROV IDERS FORMS AN ACO, WHICH THEN PROV IDES CARE TO A GROUP OF PAT IENTS .
•A healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
•A healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
•A healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
•A healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
Accountable Care Organizations•The definition of “ACO” bears a striking resemblance to the definition and history of “HMO,” a term coined in 1970. As was the case with the HMO, the ACO has been promoted primarily for its alleged value as a cost‐cutting tool. Like the HMO concept, the ACO concept is vague and has multiple definitions which vary depending on who you ask. Like the HMO, the ACO is defined as an entity that will be “held accountable” for providing comprehensive health services to a defined population.
Accountable Care Organizations•As was the case with the HMO, “accountability” for cost will allegedly be achieved by shifting some or all of the insurance risk now born by insurance companies and public programs like Medicare to providers, and “accountability” for quality will allegedly be achieved by subjecting providers to report cards.
•As was the case with the HMO, Kaiser Permanente is often held up as an example of what an ACO might look like. The HMO and ACO are both said to have “enrollees.”
•A healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients.
• Entering These Relationships On An Individual Basis Can Be A Slippery Slope
• Experience & Knowledge Of This Sophisticated Marketplace Is Critical
• Having Network Wide Representation Is Extremely Attractive To ACO’s
• Having Practices That Are Technologically Advanced Is Critical
ICD‐10•The International Classification of Diseases (ICD) is the standard diagnostic tool for epidemiology, health management and clinical purposes. This includes the analysis of the general health situation of population groups. It is used to monitor the incidence and prevalence of diseases and other health problems, proving a picture of the general health situation of countries and populations.
•Quality Measurement ‐ data captured by the code sets could be used in more meaningful ways to better understand complications, design clinically robust algorithms, and track care outcomes.
•Public Health•Research•Organizational Monitoring & Performance ‐ ICD‐10’s increased specificity offers payers and providers the potential for considerable cost savings through more accurate trend and cost analysis.
Diagnosis Related GroupsDIAGNOSIS RELATED GROUPS (DRG) ARE A PATIENT CLASSIFICATION SYSTEM ADOPTED ON THE BASIS OF DIAGNOSIS CONSISTING OF DISTINCT GROUPINGS.
Diagnosis Related Groups•The DRG method assigns a numeric value to an acute care inpatient hospital episode of care, which serves as a relative weighting factor intended to represent the resource intensity of hospital care of the clinical group that is classified to that specific DRG. As a reimbursement system the DRG assignment determines the payment level the hospital will receive.
Hierarchical Condition Categories (HCC)•The basis of CMS’s Risk Adjustment Model
oRisk adjustment is a predictive model introduced by the ACAoGauges the risk a healthcare plan member will incur medical expenses above or below an average, over a period of time
•Risk adjustment assists in financial modeling/forecasting of future medical needs
•More information ‐https://www.cms.gov/Medicare/Health‐Plans/MedicareAdvtgSpecRateStats/Risk‐Adjustors.html
The Comparative Billing Report‐The Beginning Of The End For Independence?• Comparative Billing Reports (CBR’s) are but one of four current initiatives being conducted by the Centers for Medicare & Medicaid Services (CMS) under the Division of Compliance, Projects and Demonstrations.
• According to the CMS site, “A Comparative Billing Report (CBR) provides comparative billing data to an individual health care provider.
• CBR's contain actual data‐driven tables and graphs with an explanation of findings that compare provider's billing and payment patterns to those of their peers on both a national and state level.
• CBR study topic(s) are selected because they are prone to improper payments.
What Is The Value Based Modifier?• The Value Modifier provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule (PFS) based upon the quality of care furnished compared to the cost of care during a performance period.
• The Value Modifier is an adjustment made on a per claim basis to Medicare payments for items and services under the Medicare PFS. It is applied at the Taxpayer Identification Number (TIN) level to physicians (and beginning in 2018, to non‐physician EPs) billing under the TIN.
• Use this resource to download a current fact sheet: https://www.cms.gov/Medicare/Medicare‐Fee‐for‐Service‐Payment/PhysicianFeedbackProgram/Downloads/CY2015ValueModifierPolicies.pdf
• The recently passed Medicare Access and CHIP Reauthorization Act (MACRA) mandates that three major Medicare programs for physicians‐the Physician Quality Reporting System (PQRS), the Electronic Health Record (EHR) Meaningful Use Program and the Value Based Modifier (VBM) Program be combined. Currently, these programs reward or penalize physicians based on measures of quality and the ability to demonstrate certain capacities within a practice. Starting in 2019, these three CMS programs will be consolidated into a single program called the Merit‐Based Incentive Payment System (MIPS).
Better, Smarter, Healthier: In historic announcement, HHS setsclear goals and timeline for shifting Medicare reimbursements fromvolume to value
In a meeting with nearly two dozen leaders representing consumers, insurers, providers, and business leaders, Health and Human Services Secretary Sylvia M. Burwell today announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.
The Clock Is TickingHHS has set a goal of tying 30 percent of traditional, or fee‐for‐service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018. HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018.
This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value‐based payments.
•The only way to deliver care to a growing public demand is for us to realize that to fit into a new healthcare system, we must adapt ‐ the INDEPENDENT ECP MUST ADAPT. It is not a choice – It is a mandate.
•Maintaining the traditional “optometric model” of delivering care will not be an effective strategy for prosperity in the health care model of the future… but it can’t be done alone.
The Comparative Billing Report‐The Beginning Of The End?• Comparative Billing Reports (CBR’s) are but one of four current initiatives being conducted by the Centers for Medicare & Medicaid Services (CMS) under the Division of Compliance, Projects and Demonstrations.
• According to the CMS site, “A Comparative Billing Report (CBR) provides comparative billing data to an individual health care provider.
• CBR's contain actual data‐driven tables and graphs with an explanation of findings that compare provider's billing and payment patterns to those of their peers on both a national and state level.
• CBR study topic(s) are selected because they are prone to improper payments.
• Does Not Use EMR Successfully – Attested – but…???• Has Not Participated In PQRS/ERx – No Outcomes• Doesn’t Believe That QRUR Would Qualify As A Scrabble Word• Does Not Fulfill MU Requirements – No Data• Does Not Understand & Use ICD‐10 Properly• What The Heck Is MIPS??? • Is Not Asked To Participate In ACO At All• Figures That Everything Will Be OK Because They Still Have The MVCP Participation & Sell Optical
• Understands & Uses ICD‐10 Properly• Uses EMR successfully – Certified for MU• Participates In PQRS/ERx – Good Outcomes• Tracks his QRUR religiously• Fulfills MU requirements – Unified Health Record• Understands the value of his MIPS score• Is Asked To Participate In ACO As Tier One Provider
So What Can You Do NOW?• Collect data about your practice• PQRS, MU
• Analyze your practice data• Product/Service Mix, Chair Cost
• Define your practice• Form your goals• Prioritize your goals
•Execute Your PlanoKnow your numbero Learn the ICD‐10oKnow your outcomesoBe technology savvyoEngage with ACO’soDevelop your own DRG’s for your practice
Figure Out How Effective Training & Delegation Can Reduce Overhead Cost Per Patient & Continue To Drive Higher Quality Outcomes & A Better Patient Experience
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Influence & ActionWHEN CHOOSING A TEAM – DEPTH MEANS EVERYTHING