0
PROVIDER REIMBURSEMENT
STRATEGIES FOR 2014
Michael P. James, J.D., M.B.A., CSSGB
Phone: (517) 377-0823
(313) 965-9038
Emai...
Shifting Landscapes Under
Health Care Reform
Physician Landscape

Accenture predictive modeling. Accessed
12/3/13.
http://www.accenture.com/usen/outlook/Pages/outlook-...
Reimbursement Landscape

2011

2000
National Health Expenditures

National Health Expenditures

Government

Government
64....
Reimbursement Landscape
Evolving Reimbursement Models under HCR






Fee-for-Service
Bundled Payments/Episode of Car...
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 prom...
What Are ACOs?


ACOs are the vehicles through which
providers/suppliers participate in the MSSP.
 A legal

entity desig...
What Are ACOs?
Fundamental Principles of ACOs
Reduce
Growth of
Beneficiary
Expenditur
es

Improve
Care for
Beneficiari
es
...
Types of ACOs
Integrated Delivery System Model ACO
CMS

Health System ACO

Hospital

Physicians

Skilled
Nursing
Facility
...
Types of ACOs
PHO Model ACO
CMS

PHO
ACO
Hospital

Independent
Practice
Assn.
Types of ACOs
Independent Practice Association Model ACO
CMS

IPA
ACO

Physician

Physician

Physician

Physician
Types of ACOs
Group Practice Model ACO
CMS

Group
Practice
ACO

Hospital

Specialists
ACO Membership

5% of Members
= 45% of costs
15% of Members =
35% of costs

80% of Members = 20% of
costs
Utilization Management


Predictive Modeling for Last 2 Years of Life:









Medical homes
Home Calls
Care Plan...
Utilization Management


Chronic Disease:







Medical Home
Care Plans
Team Care
ER / Hospital

All Others:



...
Payment Evolution








Insurance License.
Claims Processing.
Alignment of Fee Structures.
Incentive to Move from V...
Risk Sharing
Culture of Restructuring

More
Patients in
System

Reduce
Capacity of
System
Michael P. James, JD, MBA, CSSGB

Fraser Trebilcock
Health Care Reform
www.mihealthcarelaws.com
Fraser Trebilcock Davis & ...
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Provider Reimbursement Strategies for 2014

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Understanding reimbursement models for 2014, including Accountable Care Organizations (ACO's), Private Payer Models, and Health Care Reform Initiatives.

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Transcript of "Provider Reimbursement Strategies for 2014 "

  1. 1. PROVIDER REIMBURSEMENT STRATEGIES FOR 2014 Michael P. James, J.D., M.B.A., CSSGB Phone: (517) 377-0823 (313) 965-9038 Email: mjames@fraserlawfirm.com www.linkedin.com/in/MichaelJamesLaw Fraser Trebilcock Davis & Dunlap, P.C. One Woodward Avenue, Suite 1550 Detroit, Michigan 48226 www.fraserlawfirm.com Phone: (313) 237-7300 Fax: (313) 961-1651 Fraser Trebilcock Davis & Dunlap, P.C. 124 W. Allegan Street, Suite 1000 Lansing, Michigan 48933 www.fraserlawfirm.com Phone: (517) 482-5800 Fax: (517) 482-0887 © 2013 Fraser Trebilcock Davis & Dunlap, P.C.
  2. 2. Shifting Landscapes Under Health Care Reform
  3. 3. Physician Landscape Accenture predictive modeling. Accessed 12/3/13. http://www.accenture.com/usen/outlook/Pages/outlook-online-2011adapting-new-model-physicianemployment.aspx
  4. 4. Reimbursement Landscape 2011 2000 National Health Expenditures National Health Expenditures Government Government 64.5% 35.5% 55% Private 45% Private 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.pdf Accessed 12/3/13. (see Historical; NHE Web tables, Table 5).
  5. 5. Reimbursement Landscape 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
  6. 6. Riding the Wave of Change How do you address these shifting landscapes to continue to drive profits?
  7. 7. 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.
  8. 8. What Are ACOs?  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.
  9. 9. What Are ACOs? Fundamental Principles of ACOs Reduce Growth of Beneficiary Expenditur es Improve Care for Beneficiari es Enhance Health in its Population
  10. 10. Types of ACOs Integrated Delivery System Model ACO CMS Health System ACO Hospital Physicians Skilled Nursing Facility Etc.
  11. 11. Types of ACOs PHO Model ACO CMS PHO ACO Hospital Independent Practice Assn.
  12. 12. Types of ACOs Independent Practice Association Model ACO CMS IPA ACO Physician Physician Physician Physician
  13. 13. Types of ACOs Group Practice Model ACO CMS Group Practice ACO Hospital Specialists
  14. 14. ACO Membership 5% of Members = 45% of costs 15% of Members = 35% of costs 80% of Members = 20% of costs
  15. 15. Utilization Management  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
  16. 16. Utilization Management  Chronic Disease:      Medical Home Care Plans Team Care ER / Hospital All Others:     Medical Contact & Education Care Plans ER / Hospital
  17. 17. Payment Evolution      Insurance License. Claims Processing. Alignment of Fee Structures. Incentive to Move from Volume to Value. Quality Monitoring Systems.
  18. 18. Risk Sharing Culture of Restructuring More Patients in System Reduce Capacity of System
  19. 19. Michael P. James, JD, MBA, CSSGB Fraser Trebilcock Health Care Reform www.mihealthcarelaws.com Fraser Trebilcock Davis & Dunlap, P.C. One Woodward Avenue, Suite 1550 Detroit, Michigan 48226 www.fraserlawfirm.com Phone: (313) 237-7300 Fax: (313) 961-1651 Phone: (517) 377-0823 (313) 237-7300 Email: mjames@fraserlawfirm.com www.linkedin.com/in/MichaelJamesLaw Fraser Trebilcock Davis & Dunlap, P.C. 124 W. Allegan Street, Suite 1000 Lansing, Michigan 48933 www.fraserlawfirm.com Phone: (517) 482-5800 Fax: (517) 482-0887 © 2013 Fraser Trebilcock Davis & Dunlap, P.C.
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