10/16/2019 1 Supporting Care Transformation Through Payment Reform Iowa Primary Care Association Annual Conference October 22 nd , 2019 Why is VBP & VBC Gaining Traction? Curt Degenfelder Consulting, Inc. The Triple Aim 3 Total Cost of Care Improving Health of Populations Improving Patient Experience
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10/16/2019
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Supporting Care Transformation Through Payment Reform
Iowa Primary Care AssociationAnnual ConferenceOctober 22nd, 2019
Why is VBP & VBC Gaining Traction?
Curt Degenfelder Consulting, Inc.
The Triple Aim
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Total Cost of Care
Improving Health of
Populations
Improving Patient
Experience
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Fee-For-Service is Flawed
• Rewards volume without accountability to quality
• Focuses work on the billable provider instead of the work of the team
• Doesn’t reward continuity between the patient and provider
Patient Protection and Affordable Care Act passed in 2010. This legislation benefitted health centers by:
Expanding the Medicaid program to include most citizens at or under 138 of the Federal Poverty Guideline (previously the program covered mostly moms & kids).
New Access Point funding, which allowed for New Starts (receiving 330 funding for the first time) and NAPs (additional grant funding for new sites for existing 330 grantees)
Expanded services funding to add providers/services
The net financial impact of these changes should have been very positive for the health center’s bottom line (profit) and top line (revenue and growth).
Curt Degenfelder Consulting, Inc.
Current CHC Financial PerformanceThe Virtuous Cycle
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Positive Cash Flow through Productivity & Payor Mix
Investments in Infrastructure to Improve Quality & Efficiency
Increased Coverage of Base Administrative Costs
Working Capital to Fund Expansion
More Sites, More Patients, More Revenue
Curt Degenfelder Consulting, Inc.
Health Center Trend Summary It is hard to recruit providers, and not enough providers lowers
revenue from visits
Visits per provider per day and per year are declining, and lower
provider productivity lowers revenue from visits
Medicare & Medicaid rate increases of approximately 1.2% per
year are not enough to keep up with provider compensation
increases (10%), staff raises (3%), and inflation (2.2 %)
Not enough pay for performance revenue to offset the decline in
patient service revenue
330 grant is a constant dollar amount
The financial benefit of Medicaid expansion has already occurred
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Curt Degenfelder Consulting, Inc.
Health Center Trend Summary
Our electronic health record (EHR) specifically, and technology
generally, keeps eating up a greater portion of our budget
New staff (health coaches, referral coordinators) for better patient
management are not billable
Loan repayment program more difficult to qualify for
SO WHAT DO WE DO?
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Curt Degenfelder Consulting, Inc.
Potential Shift In CHC Revenue
At least in the short/medium term, VBP is not sufficient to cover these trends20
Phase I: Grants‐ Establish systems: Team formation, co‐location, data systems, Training, Meaningful Use, PCPCH
Phase II: Coding to reimburse for elements of model. Review of possible CPT codes aligned with model (Example: Behavioral Health Assessment Codes)
Phase III: Change in Scope Application (Adjust PPS rate to support new model)
Phase IV: Development of Alternative Payment Methodologywith payers to support model (baseline indicators, pay for process)
Phase V: Payment for Outcomes/ Value-Based Pay (VBP)
Policy Change
BUILDING THE FINANCIAL FOUNDATION FOR
PATIENT-CENTERED PRIMARY CARE
FQHC Capitated APM
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What is a Capitated APM?
• Converts FQHC Medicaid per-visit rates and utilization to a capitated rate
• The point of the capitated APM is to take the majority of FQHC Medicaid revenue off the visit, so clinics have the flexibility to transform their care model
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Medicaid Capitated APMs
• Difference between capitated and cost-based APMs
• Common purposes of capitated APMs
Remove the incentive to produce billable visits
Provide flexibility to implement robust team-based care, including SDoH interventions
• Started in Oregon (first statewide), then WA, then CO
• NACHC APM academy – IA, LA, MT, TN, NY
• Several other states are actively pursuing or have actively pursued: CA, CT, HI, IL, IN, MI, MO, NV, OK, Wash DC
• That’s 18 total, I’m sure there are others I’ve missed
Curt Degenfelder Consulting, Inc.
Thoughts on Utilizing Providers In 20191973
1974
1972 Chevy Impala
1982 Ford Escort
In 2019, what is expensive and in short supply in the future?
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Curt Degenfelder Consulting, Inc.
Cost of Workers
Physician - $170,000 – $240,000
PA & NP - $120,000 - $150,000
RN - $70,000 - $85,000
Integrated behavioral health provider - $65,000
Medical assistant 1 - $12/hr
Medical assistant 2 - $14/hr
Medical assistant 3 - $20/hr
Care/referral coordinator - $20/hr
Front desk - $13/hr
Scribe - $20/hr
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Curt Degenfelder Consulting, Inc.
Actual – Visits to Touches
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BUT YOU SAID WE DON’T GET PAID FOR THIS!!!
Care Model Changes Under a Capitated APM – Oregon Example
WHAT GOT US HERE
Infographic from bipartisanpolicy.orghttp://bipartisanpolicy.org/sites/default/files/5023_BPC_NutritionReport_FNL_Web.pdfData from: McGinnis et al 2002. The Case for More Active Policy Attention to Health Promotion. HealthAffairs
PATIENT CENTERED MEDICAL HOME
NECESSARY BUT NOT SUFFICIENT
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• Whole person and family care• New team roles, including response to social factors• Team members work at top of license• Integrated and trauma‐informed approach • New workflows and clinical processes that integrate new
team members
• Care management infrastructure for complex care needs
• Community and public health partnerships
• Trauma‐informed approaches that integrate behavioral, medical and social services
• Partner with patients to educate on PCPCH access and services
• Therapeutic alliance to understand whole person priorities
• Motivational interviewing to empower and support patients
• Human‐centered design to create patient‐driven care transformation
• Focus on and document patient medical, behavioral and social priorities and strengths, as well as needs
• Team‐level• Population health management that
reflects whole person priorities• Identify disparities and use QI to
improve equity• Trauma‐informed and patient‐centered
approach to social determinants of health data collection and use
• Organizational data analytics strategy and capacity
• Access to wellness care, not just sick care• New models for group and technology
supported interactions• Care and services offered outside of clinic walls• Team‐based approach to providing continuity• Reportable documentation of all access and
enabling services• Co‐design new access models with patients