PPACA: IMPACT ON MEDICAL PRACTICES AND CARE DELIVERY ROSA FINI, M.D. APRIL 2013

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1 PPACA: IMPACT ON MEDICAL PRACTICES AND CARE DELIVERY ROSA FINI, M.D. APRIL

2 A SYSTEMS ORGANIZATION CHANGE COMPREHENSIVE SYSTEM REFORM IMPACTS: REIMBURSEMENT MECHANISMS MEDICAL CARE DELIVERY MODEL STANDARDS OF PATIENT CARE EXPANSION REGULATORY REACH 2

3 ROLE OF GOVERNMENT HEALTHCARE BECOMES GOVERNMENT CENTRIC INCLUDING PRIVATE INSURANCE REGULATION SECRETARY OF HEALTH EMPOWERED TO ISSUE REGULATIONS AND DELEGATE RESPONSIBILITY TO PPACA AGENCIES CONGRESS DELEGATES RULEMAKING AUTHORITY TO FEDERAL AGENCIES UNDER AUSPICES OF SECRETARY OF HEALTH CONGRESSIONAL REVIEW SERVICE REPORT: REGULATIONS PURSUANT TO THE PATIENT PROTECTION AND AFFORDABLE CARE ACT(PL ), CURTIS W. COPELAND, APRIL 13, 2010, p.1,10, 17

4 ROLE OF GOVERNMENT 4

5 DELIVERY MODEL REFORMS REFORMS PROMULGATED BY REIMBURSEMNT MECHANISMS CMI (Section 3021) Established within CMS to promote care delivery models that improve the coordination, quality, and efficiency of health care services. ICD-10 IN LINE WITH PPACA PPACA FAVORS CONSOLIDATION TO FACILITATE COST REDUCTIONS TO INTEGRATE PATIENT CARE TO DRIVE IMPROVED QUALITY OF CARE 5

6 REIMBURSEMENT MODALITIES MOVEMENT FROM VOLUME TO VALUE FFS REWARDS NON-INTEGRATED CARE VALUE BASED PAYMENTS ARE REALLY BUDGET BASED PAYMENTS BASIS FOR PAYMENT: VARIATION OF COST OF CARE FROM ACTUAL to PROJECTED "Evaluating and Negotiating Emerging Payment Options," AMA Practice Management Center,

7 REIMBURSEMENT MODALITIES BUDGET BASED PAYMENT METHODOLGIES DRIVE EFFICIENT QUALITY COORDINATED CARE NEED LARGE PATIENT POPULATIONS NEED TO DIFFUSE ADDITIONAL COSTS FOR ANALYTICS EXAMPLE: CAPITATED PAYMENTS "Evaluating and Negotiating Emerging Payment Options," AMA Practice Management Center,

8 REIMBURSEMENT MODALITIES INCENTIVES & BONUSES PERFORMANCE PAY (SECTION 3002, 10327) VALUE BASED MODIFIERS (SECTION 3007) WITHHOLD AND BONUS-ONLY MODELS BUDGET BASED BONUS SHARED SAVINGS PROPOSALS (SECTION 3022) GLOBAL PAYMENT FOR TOTAL CARE BUNDLED PAYMENTS (SECTION 3023, 10308) 8

9 INTEGRATED DELIVERY MODEL PREFERRED CARE MODELS UNDER PPACA INCLUDE ACO (SECTION 2706) A LEGAL ENTITY PATIENT CENTERED MEDICAL HOME (SECTION 2703) A MODEL OF CARE, ESP FOR HIGH-RISK PATIENTS GOLD STANDARD IS ACCREDITATION BY THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE (NCQA) 9

10 INTEGRATED DELIVERY MODEL EXISTING MODELS WHICH CAN ASSUME ACO ROLE ALLIANCE ORGANIZATIONS IPA, PPO LEGAL ENTITIES, SHARE RISK BUT NOT OVERHEAD JOINT CONTRACTING/COLLECTIVE BARGAINING PHYSICIAN & HOSPITAL/ HEALTH PLANS PSA: PHYSICIAN MAINTAINS AUTONOMY & GETS HOSPITAL COMPENSATION IN EXCHANGE FOR PROVIDING CLINICAL SERVICES 10

11 INTEGRATED DELIVERY MODEL POSSIBLE FORMS OF ACO ORGANIZATIONS GROUP PRACTICE WITH PHYSICIANS & OTHER PROFESSIONALS NETWORKS OF PRACTICES WITH PHYSICIANS & OTHER PROFESSIONALS PARTNERSHIPS OR JOINT VENTURES WITH HOSPITAL & PHYSICIAN/PROFESSIONALS HOSPITALS EMPLOYING PHYSICIANS/PROFESSIONALS OTHER FORMS DEEMED APPROPRIATE BY THE Secretary of Health and Human Services 11

12 BUSINESS ANALYTICS TO NEGOTIATE FOR SUCCESS SUCCESSFUL PRACTICE MUST ANALYZE PATIENTS MEDICAL DATA ANALYZE INTEGRITY OF THIRD PARTY PLANS FOR ACTUARIAL INTEGRITY ADEQUATE RISK ADJUSTMENTED RATES o/w MDs unfairly forced to take on too much risk "Evaluating and Negotiating Emerging Payment Options," AMA Practice Management Center,

13 BUSINESS ANALYTICS The SUCCESSFUL PRACTITIONER UNDERSTANDS INSURANCE CONTRACTS FROM A NEW ACTUARIAL VIEWPOINT: Understand actuarial third payor payment predictors and risk adjustment methods Track detailed pt and demographic and health status data Track incurred and not yet reported claims Compare Actual utilization against budgets 13

14 BUSINESS ANALYTICS SUCCESSFUL PRACTICE DEVELOPS CAPACITY TO HAVE: CONTRACTING ANALYTICS PRACTICE ANALYTICS PATIENT OUTCOME TRACKING MD or GROUP PERFORMANCE METRICS QUALITY AND UTILIZATION REVIEW "Evaluating and Negotiating Emerging Payment Options, AMA Practice Management Center,

15 BUSINESS ANALYTICS APPLY ANALYTICS TO THIRD PARTY NEGOTIATIONS ASSESS PRIVATE INSURER RISK ADJUSTMENT METHODS FOR PATIENT POPULATION ESTABLISH PRACTICE BASELINE COSTS ASSESS PRACTICE PAYOR MIX EVALUATE FEE SCHEDULES "Evaluating and Negotiating Emerging Payment Options, AMA Practice Management Center,

16 NEW & IMPROVED BOARDS BOARDS FOR COST CONTAINMENT IMPACT CARE DELIVERY PATIENT CENTERED OUTCOMES RESEARCH INSTITUTE (SECTION 1181, 6301) INDEPENDENT PREVENTIVE SERVICES TASK FORCE (SECTION 4003) COMMISSION ON KEY NATIONAL INDICATORS (Section 5605) INDEPENDENT PATIENT ADVISORY BOARD (SECTION 3403) 16

17 NEW & IMPROVED BOARDS IPAB (Independent Patient Advisory Board) No bipartisan requirement, all members appointed Funded by PPACA in perpetuity Mandate to control Medicare costs may lead to decrease care Blocking an IPAB proposal requires a minimum of a 3/5 agreement by the House and the Senate and the approval of the president AND production of a substitute PPACA forbids Congress from repealing IPAB outside of a seven-month window in the year 2017 with a 3/5 majority vote in both houses 17

18 EXPANDED REGULATIONS INCREASED ENFORCEMENT & PENALTIES FALSE CLAIMS ACT (SECTION 6408) ANTI-KICKBACK LAWS (SECTION 6402) STARK LAWS (SECTION 6409) NEW RIGHTS TO SUE BASED ON EMR (SECTION 3512) SHERMAN ANTI-TRUST ACT & ACO s February 13, FTC cleared Norman Physician Hospital Organization (Norman PHO) in Oklahoma Physicians Post-PPACA: Not Going Bust at the Healthcare Buffet," Hilgers and Welch, American Bar Association, Vol. 24, No. 3, February

19 PHYSICIANS AS CONSUMERS CAN YOU KEEP YOUR PLAN? (SECTION 1302) QUALIFICATIONS GRANDFATHERED PLANS INCREASE IN PREMIUMS (SECTION 9010) HSA/ HIGH DEDUCTABLE PENALTIES CHANGES: CAPS AND TAXES

20 PHYSICIANS AS EMPLOYERS AS EMPLOYERS OFFERING INSURANCE COVERAGE PENALTIES FOR BUSINESSES with 50+EMPLOYEES CAN BE DEFINED AS ALL EMPLYEES OF COMBINED BUSINESSES OF ONE EMPLOYER SHARED RESPONSIBILITY TAX W-2 REPORTING 20

21 FUTURE PATHWAYS AMEND ASPECTS OF PPACA ADDRESS SGR & IPAB ADDRESS PRACTICE BUSINESS MANAGEMENT OUTSOURCE TRANSITIONS TO OFFICE MANAGEMENT FIRM WORK AROUND INSURANCE ISSUES CONCIERGE CARE MEDIBID ALTERNATIVE PHYSICIANS PROVIDER ROLES INCREASE ADMINISTRATIVE OR SUPERVISORY ROLES LEGISLATION TO EXPAND NP/PA DUTIES BECOME SALARIED EMPLOYEES 21

22 THE END MAMA MIA!

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