Shaping Healthy Communities

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1 Lone Star Circle of Care A Patient-Centered Health Home Shaping Healthy Communities Shaping Healthy Communities. Denise Esper, Chief Operating Officer, Chief Revenue Officer Amy Peacock, Senior Billing Manager 0

2 Session Summary Highlight the success and work of LSCC as a PCMH Discuss FQHC revenue streams in a PCMH Contract renegotiations w/pcmh Status Future of reimbursement in an ACO 1

3 Who We Are A non-profit, federally qualified health center network Currently 25 locations spanning three Central Texas counties Opportunity to expand access into additional cities and add additional sites in FY2012 to FY2013 Committed to the pursuit of community-wide access to a behaviorally enhanced, patient-centered health care home that provides accountable care for all patients, focusing on the underserved A Joint Commission-Accredited and National Committee for Quality Assurance Level 3-Designated Patient Centered Medical Home Only a fraction of designated PCMHs have Level 3 recognition the highest level awarded Proud health care home to over 90,000 Central Texans 2

4 Our Philosophy As a non-profit, we are responsible for maximizing the assets and benefits afforded to us to provide quality health care to those who otherwise would not receive it Treat nonprofit status as a tax designation, not a business model Be as creative, innovative and collaborative as possible to increase access and streamline care delivery to improve outcomes and reduce costs Be ambassadors for the model we ve created so other communities can benefit from our lessons learned Serve as a virtual Accountable Care Organization (ACO) with stakeholders the way health care reform will happen 3

5 Our Vision LSCC s patient-centered health care home model provides unique and innovative assets that provide differentiation and value in an Accountable Care Organization Strong clinician leadership in defining and executing health care home strategies Utilize technology to drive health innovation and intervention Promote wellness and chronic disease maintenance to manage costs and improve outcomes Differentiate based on availability and quality of services and customer service 4

6 Services In Our Health Care Home Family Practice Pediatrics and Adolescent Health OB/GYN, including prenatal, labor & delivery, post-partum Senior care, including nursing home services Integrated Psychiatry and Psychotherapy General Dentistry Vision Pharmacy Over 145,000 prescriptions filled in FY2011 Wellness Classes and Programs Coordinated and comprehensive access to specialty care for LSCC patients through our ACO stakeholder network 5

7 Increasing Access Lone Star Circle of Care Visits FY FY2012 (Projected) 400, , , , , , , , , ,000 50,000 24,895 35,348 74,224 96, , Conservative Projection FY2012 6

8 Uninsured Patients Services, Approach and Benefits to the Uninsured 7

9 Uncompensated Care Uncompensated Care 14,000,000 12,000,000 10,000,000 $10,591,671 $13,332,346 $13,501,175 $12,236,462 8,000,000 6,000,000 4,000,000 2,000,000 $2,759,441 $1,180,000 $1,802,417 $4,691, Projected 2011 Budget

10 Payments for Services Uninsured patients at LSCC are screened to determine their eligibility for public and local insurance programs Those who qualify are assisted with enrollment We find eligible and directly assist over 200 uninsured patients per month with Medicaid enrollment Those who do not qualify for a program pay for services on a sliding fee scale based on the Federal Poverty Level (FPL) guidelines ACO model is universally applied to all segments Uninsured patients present the most compelling outcome-based returns Reducing cost of care delivery while improving outcomes is then replicable to other demographics with captive audiences* 9

11 CHASSIS Software and Medicaider CHASSIS Software is a suite of software tools designed by Network Sciences Used for eligibility case management and program management Medicaider is a CHASSIS tool that provides a fast and accurate way to screen for a large set of programs Both are web-based tools used by both providers and payers to efficiently and successfully connect the uninsured to benefit programs 10

12 CHASSIS Software and Medicaider Providers use Medicaider to quickly and accurately screen patients for multiple benefit programs, and then to assist the patient through the entire process of completing applications, collecting required proof documentation, and filing to the correct agency Agencies can use Medicaider to electronically receive applications, determine eligibility consistently and accurately, and manage their program Medicaider is a paperless solution that can be used independently or to connect organizations online and includes reporting capabilities 11

13 Network Sciences Vision Transform the Eligibility Process Change the process of applying for and enrolling in financial assistance programs to become Efficient Less costly and much faster Transparent Manageable Compliant with policy Integrated process between client, provider, and agency 12

14 Network Sciences Regional Vision Pre-Qualified (through Medicaider ) Applications could be filled out and filed electronically to any participating agency/program No Wrong Door for document collection Documents are filed electronically with application Providers see a real-time status update for all application packets filed Any clarification or pended activity could be communicated and resolved through the software Integrated eligibility determination and certification Common data system for verification 13

15 What is Medicaider to the PCMH? In most cases Medicaider is a tool utilized to identify program funding when/where applicable Expanded utilization goes beyond program identification Program Application (Interview) and Assistance Electronic Application Submission Program Certification/Enrollment New Program Enrollment (TMHP) History of applications/screenings within ICC* Repository for Screening Documents within ICC* Shared Documents within ICC* Interface with EHR (Practice Management)* 14

16 Uninsured Inpatient Outpatient EMR Clinics Patient interviewed Patient not interviewed Screening was Accurate Inaccurate Screening Each Program has different criteria Eligibility is complicated Eligibility is inter-related Measure? Manage? Improve? Interview considered all programs Notify CIHCP of Service Limited Programs Missed 72 hr window Assignment/Strategic Follow-up No Follow-up Errors File Application and Documents Mail/Fax Wrong Docs Lost Docs Eligibility Determination, Certification, Verification Training Excel Access Phone??

17 2010 Q4 Enrollment Data 16

18 Financial Gain of Uninsured Converted to Payer Spreadsheet represents 780 patients in Q Equates to 3,120 in one full year Calculated at 3.8 visits/year per patient 11,856 encounters Paid at $170/enc (average pps) $2,000,

19 Benefits Go Far Beyond Financial Preventive Care Quicker response when acute issues arise Fewer ER visits Controlled Chronic Disease, Increased Compliance Healthier patient Healthier community Fewer sick days for students and employees and so on 18

20 Health Care Home (Value Add of PCMH) Examples of Services, Outcomes and Cost Savings 19

21 Value of Services Access to affordable care regardless of payor helps curb unnecessary ER visits and reduces avoidable hospital admissions Evening and weekend hours, after hours coverage Access to free or low cost medications promotes health maintenance, working to lower downstream costs of noncompliance Early access to care in OB and pediatrics helps eliminate/curb downstream costs associated with poor birth outcomes and/or lack of access to pediatric care 20

22 Integrated Behavioral Health LSCC-employed behavioral health providers work collaboratively with primary care providers to address patients' overlapping physical and behavioral health needs EHR is shared between medical and behavioral health providers to improve continuity and outcomes while reducing costs LSCC employs over 30 integrated behavioral health professionals Child/Adolescent psychiatrists Adult psychiatrists Geriatric psychiatrists Addictions/Substance Use psychiatrists Licensed Clinical Social Workers and Licensed Professional Counselors Psychologist Insured and Medicare patients have serious access issues for behavioral health services, as well as reimbursement challenges 21

23 Behavioral Health Visits Lone Star Circle of Care BH Visits FY FY2012 (Projected) 51,417 37,219 23, ,119 3,937 5,023 10, Projected FY

24 Revenue Codes for BH Services The Medicare manual states and are diagnostic codes and could be billed as Revenue Codes 0521, 0524 and 0525 therefore not being subject to the psychiatric reduction billed to Medicare as 0900 revenue code would be reimbursed around $12-$30 because it is subject to the psychiatric reduction The same being billed as a 0521, 0524 and 0525 would be reimbursed as our current Medicare PPS Rate According to the Medicare Mental Health Treatment Limitation FQHC Additional Information Decision Guide, you would proceed as follows: Is the primary DX in the ICD9-CM ? If yes, is the purpose of the visits for diagnostic services (90801/90862)? If yes, then you are NOT subject to the limitation and should bill as Revenue Code 0521,0524, and

25 24

26 Medicare Psychiatric Reduction Phase Out January 1, 2010 : The limitation percentage is percent (Medicare pays 55 percent and the patient pays 45 percent) January 1, 2012: The limitation percentage is 75 percent (Medicare pays 60 percent and the patient pays 40 percent) January 1, 2013: The limitation percentage is percent (Medicare pays 65 percent and the patient pays 35 percent) Beginning January 1, 2014: The limitation percentage is 100 percent (Medicare pays 80 percent and the patient pays 20 percent) Source: Section 102 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) 25

27 Pediatrics In 2005, LSCC developed a pediatric model focused on serving uninsured and publicly insured children The model is so successful, Dell Children s Medical Center wants LSCC to serve as its primary care network The goal of the program is to provide early intervention and wellness education to children and their families in an effort to improve health outcomes and reduce costs, both today and throughout the child s life LSCC also has a distinct Adolescent Clinic located at the Setonsponsored Texas A&M Health Science Center 26

28 Childhood Immunization Status 100.0% Lone Star Circle of Care Childhood Immunization Status December November % 79.3% 75.0% 74.1% 50.0% 25.0% 0.0% Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov HEDIS Medicaid Mean LSCC National Quality Forum Measure 0038: Childhood Immunization Status. Percentage of children 2 years of age who had four DtaP/DT, three IPV, one MMR, three H influenza type B, three hepatitis B, one chicken pox vaccine (VZV) and four pneumococcal conjugate vaccines by their second birthday. HEDIS Medicaid Mean is based on the 2010 National HMO Medicaid Mean. Source: The State of Health Care Quality: Continuous Improvement and the Expansion of Quality Measurement available from: 27

29 Obstetrics and Gynecology In Texas, Medicaid and CHIP coverage typically extends to otherwise uninsured women during their pregnancy Private providers were not accepting these payors Many women going without prenatal care, presenting to ER for delivery $$$...Costly Results in higher incidence of low birth weight, pre-term births, high risk pregnancies, and poor birth outcomes $$$...Costly LSCC s obstetrics program was created in 2006 to provide a complete health care home to underserved women who did not have access to consistent, patient-centered care during their pregnancies or to ongoing care for themselves and their babies after delivery Currently operate two OB/GYN clinics Delivered 1,200 babies in

30 OB/GYN Outcomes Lone Star Circle of Care (LSCC), Texas, and United States Live Births by Birth Outcome Outcome LSCC 1 Texas 2 United States 3 Preterm births 4 (<37 completed weeks gestation) 7.2% 13.3% 12.3% Low Birth Weight (<2,500 grams) 3.6% 8.4% 8.2% 1. Source: Lone Star Circle of Care births occurring in FY2010 (December 1, November 30, 2010). 2. Source: Texas Department of State Health Services, 2008 Vital Statistics Birth Dataset, Unpublished data. Analysis conducted internally. 3. Source: Martin JA et al. Births: Final Data for National Center for Health Statistics, Vol. 59, No.1, December

31 OB/GYN Outcomes and Cost Savings Creation of ACOG template in EHR system to ensure best practices No inductions before 39 weeks of pregnancy Lone Star Circle of Care (LSCC) and Texas Low Birth Weight (LBW) Outcomes and Total Savings LBW Percent Savings Achieved by LSCC Savings Achieved if Texas Rates Equaled LSCC Financial Class LSCC 1 Texas Total Per Baby Total Per Baby Medicaid/CHIP 3.3% 8.9% $1,009,884 $11,178 $118M $11,178 30

32 Coordination of Services within the PCMH The Role of HIT & Innovation 31

33 Patient Navigation Center Far beyond a traditional call center, LSCC s Patient Navigation Center (PNC) proactively manages LSCC patients using state-of-the-art technology, connecting them to every service they need throughout the continuum Goal is to provide patient-centered, responsive care that focuses on improving quality and reducing costs Over 660,000 calls answered in FY2011 The PNC s contact management system and functionality is maximized via LSCC s EHR, as PNC staff can access data across LSCC s entire network versus a single clinic site There is significant, community-wide interest in leveraging LSCC s Patient Navigation infrastructure and services to be used in ACOs and MCOs Potential to provide services beyond Texas 32

34 Patient Navigation Center Staff PNC is staffed with Patient Service Representatives, Clinical Interventionist RNs, LVNs, Medical Assistants, Behavioral Health Service Representatives, and Specialty Referral Representatives Patient Navigators uber case managers Ensure patient s appointment is scheduled correctly and at a location/time convenient for the patient Ensures patient attends appointment (Contacts no shows ) Ensures successful program enrollment Ensures lab/medication/notes are populated in the chart before&after the visit Ensures referrals are authorized, scheduled and attended Proactively follow up to determine patient experience, answer outstanding questions and provide further education when needed Ensures coordination of patient s healthcare 33

35 Clinical Interventionist LSCC Clinical Interventionists are experienced Registered Nurses Identifies risks and proactively manages patient Increases compliance Fills in the space between episodic visits with preventive contacts Work in tandem with LSCC clinicians All documented in the EHR for continuity of care 34

36 Clinical Interventionist Proactive Care Post Surgery Follow Up (clinic and out-patient) Hospitalization Follow Up (in-patient and ER) Records Medication Update Orders Medication management THSteps compliance and periodicity Chronic Disease Management Asthma Diabetes Hypertension Obesity Others as needed or targeted depending on provider request, seasonality, and trends 35

37 Clinical Interventionist Examples of Clinical Interventionist Programs: Diabetes patients with an A1C of 7+ automatically triggers a recall to be performed by the RN who will provide diabetes awareness and education, including use of medication Elevated BMI Patients identified as being within the 30 th percentile range are targeted for an RN recall to provide weight management education High Blood Pressure - Patients identified based on recent diagnosis of hypertension will automatically trigger a recall performed by an RN to provide education and support The PNC also follows up with patients identified as having a chronic illness but who are non-compliant with their PCP follow-up appointments 36

38 Clinical Interventionist RN Care Management Intervention Results Improves health outcomes Prevents emergency visits Reduces hospitalizations (number and length of stay) Reduces cost in an ACO by substituting face to face visits with telephonic coordinated care A CNI operating at a volume of 700 patient interactions per month can save over $750k per year in avoided face to face encounters with providers 37

39 Pediatric Outcomes 85.0% Well Child Check Kept Rate (Aug 2008 to Sept 2011) 80.0% 75.0% 70.0% 65.0% Paneling Start Scheduler Continuity Tracking Start Notifications Start 60.0% Training Start Confirmation Calls Start (Call Center) Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep

40 Pediatric Well Child Check Compliance Lone Star Circle of Care (LSCC) 1 and Texas 2 Medicaid and CHIP Patients Well Child Care (WCC) Visits by Age Group Total, Age 1-5 Age Group 1-2 Age Group 3-5 Did Child Receive at Least One WCC Visit? LSCC Texas LSCC Texas LSCC Texas Yes Number 2, ,602 1, ,176 1, ,426 Percent No Number , , ,936 Percent Total 2, ,761 1, ,399 1, , Source: Lone Star Circle of Care encounters occurring in FY2010 (December 1, November 30, 2010). 2. Source: Texas Form CMS-416: Annual EPSDT Participation Report for encounters occurring in FY2009 data (October 1, September 30, 2009). 39

41 Hemoglobin A1c Testing 100.0% Lone Star Circle of Care Hemoglobin A1C Management December November % 50.0% 44.0% 25.0% 0.0% 24.5% 25.7% Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov HEDIS Medicaid Mean LSCC National Quality Forum Measure 0059: Hemoglobin A1c Management. Percentage of adult patients with diabetes aged years with most recent A1c level greater than 9.0% (poor control). (NOTE: This measure assesses the percentage of patients in poor control, thus a lower percentage is desired.) HEDIS Medicaid Mean is based on the 2010 National HMO Medicaid Mean. Source: The State of Health Care Quality: Continuous Improvement and the Expansion of Quality Measurement available from: 40

42 Summary LSCC s Patient Navigation Center is an optimal solution for patient/member contact services for any healthcare system with a wide variety of services including, but not limited to: Utilization of state of the art contact center software and EHR/HIE solutions High quality customer service Delivery of healthcare beyond the visit Clinical Interventionist offerings (proactive education, triage, medication refills) Proven results with timely response to needs and redirection Overall care coordination Member navigation 41

43 Payment Reform Future of Reimbursement in a PCMH and ACO 42

44 43

45 PCMH Value Add Improves health outcomes Prevents emergency visits Reduces hospitalizations (number and length of stay) Reduces cost in an ACO by substituting provider-patient face to face visits with other methods of coordinated care 44

46 Contract Negotiations with PCMH Designation Raised, gold seal next to listing in provider directory Higher reimbursement for certification Based on higher Medicare Region Higher % of standard (1-5%) Higher % of Medicare (114%) Pay for Performance Options, PM/PM 45

47 Patient Navigation and ACO Forecast Short Term Long Term Office Visits Emergency Department Visits Phone, Telemedicine, and Visits Hospitalizations Cost labs, diagnostic tests, referrals, medications Readmissions Care team works at highest level of licensure Length of Stay 46

48 LSCC s View of Healthcare Evolution (Payment Reform) Current Model ACO Model Financial Sustainability # of Encounters Evidence Based Practice Incentives Encounter Numbers Health Outcomes Highest Leverage Provider Face-to-Face Team-Based Care Payment Patient Experience Data Regardless of Patient Outcome Does not affect Reimbursement Only Share Good Outcomes Depends on Patient Outcomes Impacts Reimbursement Transparency 47

49 Options PM/PM reimbursement in addition to standard claims payment Offset the initial loss of claims reimbursement Incentivized to encourage compliance and improve outcomes Access Education Open dialogue with payers (MCOs) on Monthly Loss Ratios (MLR) ER Visits Hospital Admissions Length of Stay Re-admissions Introducing concept of shared risk 48

50 MCO Site Visit (2 Day Audit) PCMH practices that provide high-quality, relatively low-cost primary care are the foundation of the Accountable Care Organization (ACO) model. While it is true that resolving the future of health care reform and writing the regulations for ACO will take years, some studies suggest that accountable care can be provided through a contractual arrangement based on sound business principles. Provider Quality Incentive Program 49

51 PQI Program Introduction Managed Care Medicaid organization has developed a pilot Provider Quality Incentive Program for the Medicaid (CHIP/STAR/STAR+PLUS) population. The Program will reward eligible Primary Care Physicians who meet quality benchmarks and improvement targets as well as medical cost management targets. 50

52 PQI Program Program Objectives Improve targeted clinical quality results Promote quality, safe and effective patient care across the health care delivery system Improve provider operational efficiency Improve medical cost management by providing incentives for improving quality care and tools for providers to reduce medically unnecessary utilization and costs 51

53 Options Member Concept in an Accountable Care Organization Risk and Reward for ACO or ACO-Like Entities Incentivized to encourage compliance (participation) to improve overall wellness and health of member therefore lowering the cost of avoidable, controllable healthcare crisis Requires coordinated effort beyond the 4 walls of a primary care clinic 52

54 Future of Healthcare 53

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