provider reimbursement strategies for 2014
DESCRIPTION
Understanding reimbursement models for 2014, including Accountable Care Organizations (ACO's), Private Payer Models, and Health Care Reform Initiatives.TRANSCRIPT
PROVIDER REIMBURSEMENT STRATEGIES FOR 2014 Michael P. James, J.D., M.B.A., CSSGB
Phone: (517) 377-0823 (313) 965-9038
Email: [email protected]
www.linkedin.com/in/MichaelJamesLaw
Fraser Trebilcock Davis & Dunlap, P.C.One Woodward Avenue, Suite 1550Detroit, Michigan 48226www.fraserlawfirm.comPhone: (313) 237-7300Fax: (313) 961-1651
Fraser Trebilcock Davis & Dunlap, P.C.124 W. Allegan Street, Suite 1000Lansing, Michigan 48933www.fraserlawfirm.comPhone: (517) 482-5800Fax: (517) 482-0887
© 2013 Fraser Trebilcock Davis & Dunlap, P.C.
Shifting Landscapes Under Health Care Reform
Physician Landscape
Accenture predictive modeling. Accessed 12/3/13.http://www.accenture.com/us-en/outlook/Pages/outlook-online-2011-adapting-new-model-physician-employment.aspx
Reimbursement Landscape
National Health Expen-ditures
Gov-ern-mentPrivate
National Health Expen-ditures
Gov-ern-mentPrivate
64.5% 35.5% 55% 45%
2000 2011
Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/tables.pdfAccessed 12/3/13. (see Historical; NHE Web tables, Table 5).
Evolving Reimbursement Models under HCR Fee-for-Service Bundled Payments/Episode of Care Payments Partial or Full Capitation Care Management Fees Shared Savings
One-Sided Two-Sided
Reimbursement Landscape
Riding the Wave of Change
How do you address these shifting landscapes to continue to drive profits?
Medicare Shared Savings Program (MSSP)
MSSP designed to improve beneficiary outcomes and increase value of care by promoting: Accountability for patient population; Coordination of care for services; Investment in infrastructure; and Redesign of care processes.
ACOs are the vehicles through which providers/suppliers participate in the MSSP. A legal entity designed to manage and coordinate care
for Medicare fee-for-service beneficiaries under the MSSP.
What Are ACOs?
Fundamental Principles of ACOs
Improve Care for Beneficia
ries
Enhance Health in its Population
Reduce Growth of Beneficia
ry Expendit
ures
What Are ACOs?
Types of ACOs
Integrated Delivery System Model ACO
CMS
Health System ACO
Hospital Physicians
Skilled Nursing Facility
Etc.
PHO Model ACO
PHO ACOHospital
Independent
Practice Assn.
CMS
Types of ACOs
Independent Practice Association Model ACO
IPA ACO
CMS
Physician
Physician
Physician
Physician
Types of ACOs
Group Practice Model ACO
Group Practi
ce ACO
CMS
Specialists
Hospital
Types of ACOs
5% of Members = 45% of costs15% of Members = 35% of costs
80% of Members = 20% of costs
ACO Membership
Predictive Modeling for Last 2 Years of Life: Medical homes Home Calls Care Plans Navigators ER / Hospital Hospice
Multiple Chronic Diseases: Medical Home Care Plans Team Care Navigator ER / Hospital
Utilization Management
Chronic Disease: Medical Home Care Plans Team Care ER / Hospital
All Others: Medical Contact & Education Care Plans ER / Hospital
Utilization Management
Insurance License. Claims Processing. Alignment of Fee Structures. Incentive to Move from Volume to Value. Quality Monitoring Systems.
Payment Evolution
Culture of Restructuring
More Patients in
System
Reduce
Capacity of
System
Risk Sharing
Fraser Trebilcock Davis & Dunlap, P.C.124 W. Allegan Street, Suite 1000Lansing, Michigan 48933www.fraserlawfirm.comPhone: (517) 482-5800Fax: (517) 482-0887
Fraser Trebilcock Davis & Dunlap, P.C.One Woodward Avenue, Suite 1550Detroit, Michigan 48226www.fraserlawfirm.comPhone: (313) 237-7300Fax: (313) 961-1651
Michael P. James, JD, MBA, CSSGB
Phone: (517) 377-0823 (313) 237-7300
Email: [email protected]
www.linkedin.com/in/MichaelJamesLaw
© 2013 Fraser Trebilcock Davis & Dunlap, P.C.
Fraser Trebilcock Health Care Reform
www.mihealthcarelaws.com