[PPT] - Practice Managers Meeting March 19, 2015 2 Accountable Care PowerPoint Presentation

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Practice Managers Meeting March 19, 2015

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Accountable Care Network 101

Aligning hospitals, their staffs, and community physicians into clinically integrated networks

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Accountable Health Partners Vision

To bring together community and faculty physicians, hospitals and other affiliated providers to develop a clinically integrated care network with aligned financial incentives, to improve population health, to provide patient-centered care and to promote efficient use of resources.

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Adult PCPs

PCP Pediatricians

Specialists CNMs Total Community 145 111 249

505

URMFG 174 16 993 13 1196 Total 319 127 1242 13 1701

The Growing AHP Network

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Network: Ten-County Region

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Network: Hospitals

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Intro to AHP Gain Sharing Contracts

Sits on top of existing fee-for-service contracts
For 2014, upside only
Payer sets a budget and quality goals for the

attributed population

Network performs under the budget and meets

quality goals

The dollars saved (the “gain”) are shared

between payer and network

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MVP TAG Contract

Term: 2014-2016
30,000 attributed members
Upfront clinical integration payments to PCPs
HEDIS-based quality measures
Opportunities for gainsharing if quality goals

are met

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Excellus ACQA Contract

Term: 2014 (2015-2018 contract still being

negotiated)

128,000 attributed members
Commercial only (including self insured)
Upfront clinical integration payments to PCPs
Opportunities for gainsharing if quality goals are

met

ARCADIA!!

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2014-2015 Arcadia Analytics Connection & Validation Work plan

Jul June May Mar Feb Jan ’15 Apr Sept Aug

Wave #1 Wave #2 Wave #3 Wave#4 Wave#5

UR Primary Care (EPIC)

Wave #1 (1/30-3/27)

Wave#6 Wave#7

Wave #3 (3/13-5/8) Wave #4 (4/3-5/29) Wave #5 (4/24-6/19) Wave #6 (5/15-7/10) Wave #7 (6/5-7/31) Wave #8 (6/26-8/21)

Office of Drs. Cahn-Hidalgo, Minnella,

Plain, Tan, Yoon (Chartmaker)

UR Thompson (Medent)
Elmwood Ped (Medent)
Letchworth Family (Medent)
Alexander Medical (Medent)
Finger Lakes Family(Amazing Charts)
Honeoye Valley Family (HST)
Tri-County Family (ECW)
Lewis Ped (Medent)
Keuka Family (Medent)
Naples Valley (Medent)
Canandaigua Medical (Vitera)
Brighton Family(HST)
Zoneci Medical (HST)
Jefferson Family (HST)
Goodman Peds(Medent)
Pathway Peds (Medent)
Office of Dr. Qureshi (Chartmaker)
Bayoumi Medical (Chartmaker)
Abbasey Medical (Chartmaker)
Hope Internal (Amazing Charts)
Northern Allegany (Amazing Charts)
Lake Country Family (Amazing

Charts)

Sheikh (CureMD)
His Branches Health (Medent)
Twelve Corners Ped(Medent)
Office of Dr. Tinkelman (Medent)
Office of Drs. Mahoney, Horohoe &

Garneau (HST)

Shifa Medical (eCW)
Noyes Health

Employed(eCW)

Wayland Family(eCW)
James Three Seventeen

Medical (Practice Fusion)

Depner(Medent)
Eastside Peds (Medent)

As of: 2/6/15

DRAFT

Oct

Breen and Assoc (HST)
Sunrise Ped (Medent)
Valley View Family (Medent)
Pinnacle Family (Vitera)
Jones Memorial (LSS)
Family Medical Alfred

(Practice Fusion)

University Health Services

(Pyramed)

Office of Dr.Akowuah (HST)
Bloomfield Family

(Medent)

Wave #9 (7/17-9/11) Wave #10 (8/7-10/2) Wave #11 (8/28-10/23) Wave #12 (9/18-11/13)

Arnot Medical (eCW)
Legacy Peds (TBD)
Brighton Peds (Soapware)
Blossom Rd Internal (Practice

Fusion)

Wave #8 Wave#9 Wave#10 Wave#11

Wave #2 (2/20-4/17)

Victor Health (Medent)
Stonybrook Ped (eCW)

Wave#12

Nov

Office of Dr. Kerper (EPIC)

Wave #1b (2/27-3/29)

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UR Health Plan Contract

Term: 2015-2017
30,000 covered lives
Tier One Network
Employees pay lowest copay/deductible when
btaining services from AHP providers
Quality measures and integration measures

TBD

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Patient Population

Employees and their dependents covered under

the University of Rochester Employee Benefit Plans

Excludes:
Affiliates
Medicare-eligible retirees
Members of 1199 SEIU
30,000 individuals are covered by the UR employee

benefit plan

Approximately 10,000 are seeing an out-of-network

PCP

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Benefits Basics

Two TPAs: Excellus BCBS and Aetna
Two plans:
PPO Plan
HSA-Eligible Plan
Both plans:
Three tiers of benefits
No PCP required
Preventive care covered at 100% whether AHP or

Aetna/Excellus network

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PPO Plan Deductibles: Single

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AHP

Aetna/ Excellus

OON Deductible $400 $800 $1600 Coinsurance 90% 80% 60% RC OOP Max $2000 $2500 $2500 $3000 $4000 $4000 Deductible applies to all health care expenses except

ffice visits.

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PPO Plan Deductibles: Family

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AHP

Aetna/ Excellus

OON Deductible $1000 $2000 $4800 Coinsurance 90% 80% 60% RC OOP Max $4000 $5000 $5000 $6000 $8000 $8000 Deductible applies to all health care expenses except

ffice visits.

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PPO Plan Coverage: Office Visits

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AHP

Aetna/ Excellus

OON PCP $15 $30 60% of RC Specialist $30 $60 60% of RC

PCP visit

$150 $150 $1300 $1800

Chest X-Ray

$650 $650

Specialist Visit

$250 $250 $250 $250

Specialist Visit

90% covered

AHP Specialist Visit Non AHP PCP visit

$150

Non AHP Labs

$350 Tier One-AHP Tier Two

Non AHP Specialist

80% covered

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HSA Plan Coverage: Office Visits

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AHP

Aetna/ Excellus

OON PCP 90% 80% 60% of RC Specialist 90% 80% 60% of RC

Preventive Care

100% (no copay or deductible ) Not covered

Chiropractor

90% 60% of RC PT/ST/OT 90% 60% of RC Optometrist 90% 60% of RC

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HSA Plan Coverage: Maternity

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AHP

Aetna/ Excellus

OON Prenatal 100% 100% 60% of RC Postnatal 100% 100% 60% of RC Hospital 90% 80% 60% of RC

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HSA Plan Coverage: Hospital

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AHP

Aetna/ Excellus

OON Inpatient 90% 80% 60% of RC Outpatient

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Two Tiered Services/Providers

AHP does not include all of the providers that

deliver health care services (e.g., optometrists, podiatrists)

For these specialties, the UR employee claims will

process at the highest benefit level (Tier One) if the provider is in the Aetna/Excellus networks.

If the provider is not in the Aetna/Excellus

networks, the claim will process at the Tier Three benefit level.

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Examples of Non-AHP Provider Services Covered at the Tier 1 Benefit Level

Acupuncture
Ambulatory Surgery Center
Audiology
Chest and respiratory

therapy

Chiropractic
Dialysis
DME
Dentistry
Infusion (facility and home)
Oral Surgery/Endodontics

(covered under medical)

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Optometry (routine)/Eyewear
Inpatient/outpatient Mental

Health

Inpatient/Outpatient Substance

Abuse

Midwifery
Podiatry
PT/OT/ST
SNF
Speech Pathology
Urgent Care

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Important!! Anesthesia in ASCs

ASCs are not tiered
UR health plan patients will have tier one benefits for

their AHP surgeon and the ASC

Not all ASCs have AHP-par anesthesiologists
Example: Unity Linden Oaks

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Facility Untiered Surgeon AHP par Anesthesiologist not AHP Par Tier One Benefits Tier One Benefits Tier Two Benefits

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Exclusive Benefits: BHP

Behavioral Health Partners
Comprehensive mental health services for UR employees

and dependents (18+) enrolled in a UR benefit plan.

A team of therapists, NPs, psychiatrists and RNs.
Covered dx: depression, anxiety, stress
Services: diagnostic assessments, psychotherapy,

medication management, consults with PCPs

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Referrals or consults: 585-276-6900

http://www.urmc.rochester.edu/behavioral-health-partners.aspx

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Exclusive Benefits: BHP continued

PPO: no out-of-pocket costs
HSA: no out-of-pocket costs after deductible is met
Free parking
One week timeframe for initial consults
Day and evening appointments available

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Referrals or consults: 585-276-6900

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Condition Management

No cost to employee or employee’s spouse/partner
Programs to help employees with a chronic disease

manage the condition.

Programs include lifestyle modification and behavior

change counseling

Referral by screening results or PCP
Seamless communications with PCPs to ensure

effective, coordinated care

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Condition Management

Comprehensive Programs for:

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Asthma
COPD
DM
CAD
A-fib
CHF
Hypertension
High cholesterol • Lower back pain
Stroke

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Lifestyle/Wellness Programs

Evidence-based lifestyle programs
No cost to employee or employee’s

spouse/partner

Programs delivered in individual and group

settings

Patients can self-refer

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Lifestyle/Wellness Programs

Programs for:

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Tobacco Cessation
Cholesterol Control
Blood Pressure Control
Weight Loss
Weight Loss for Life
Stress Reduction

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Contact the Center for Employee Wellness

Phone: 585-275-6810
Email: Healthy_Living_Center@urmc.rochester.edu
Fax Referral Form to 585-461-4488

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Identifying AHP Providers

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http://ahpnetwork.com/search-provider/

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Helping UR Patients Save $$

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Remember to send UR patients to AHP-par:

Labs
Imaging
Hospitals
Specialists

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Helping Patients Know You’re in AHP

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Web site info is correct
Window clings
Phone staff
Front end staff
Check-out staff
Billing Staff

Don’t forget your Front End Fast Facts document and card images

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The Most Important Thing to Learn Today

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Yes! We are an

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Accepting apps for consultant funding soon
Eligible to apply:
PCP office with EMR
Eligible to participate in ALL AHP payer

contracts

No NCQA recognition or existing 2011

recognition with fewer than 12 months before re-attestation is due.

PCMH Consulting

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Physician Practice Eligibility

PCP specialty
EMR fully implemented or go-live planned

imminently

Eligible to participate in all AHP payer contracts
No NCQA recognition or existing 2011

recognition with fewer than 12 months before re-attestation is due.

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Care Management Program

Develop clinically integrated model
Achieve quality and cost goals
Manage chronic disease
Improve health
Avoid unnecessary re-hospitalizations
Improve safety & decrease medical errors
Meet payer contract requirements to provide

care management

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Internal/Family Med Team: LMSW - BHS - Pharmacist Pediatric Team: LCSW - Care Manager

AHP

Embedded Care Managers

Comm. Practices with CM Hospital

Employed

Comm. Practices w/out CM

39 CMs

9 CMs

10 CMs (9 CMMI) 2014 2020

Care Management Model

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Surprise Bills Law

Effective March 31, 2015
Holds patient harmless from OON bills if status of OON

provider is not disclosed prior to visit

Disclosure Requirements

– Participating status of healthcare providers – Participation status with carriers – Must be able to provide OON costs upon request – Must provide name, address, phone # of OON provider(s)

Biggest Impact: Surgical Assists, Anesthesiology,

Pathology, Radiology

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Surprise Bills Law (cont’d)

Surprise Bills Law is separate from the tiered structure

that applies to UR Employee Benefits Plan

Tier 1= In Network for AHP, In Network for Excellus &

Aetna

Tier 2= Out of Network for AHP, In Network for Aetna &

Excellus

Tier 3= Out of Network for AHP, Aetna, and Excellus
Surprise Bills Law applies to UR patients in Tier 3

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Chronic Care Management Code Program

Patient must be enrolled in Medicare FFS program
2 or more chronic conditions that are expected to last at

least 12 months, or until the death of the patient

Chronic conditions place the patient at significant risk of

death, acute exacerbation/decompensation because of that condition, or functional decline

20 minutes of non-face-to-face care management and/or

care coordination to a patient who has agreed to receive CCM services

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CCM Code Program (cont’d)

CPT Code for Medicare CCM services is 99490 @ $42.60

per patient per month (average)

Patient pays $8.40 copayment (average)
Beneficiary may only be attached to one CMS claim from
ne provider per month
Exclusions: ESRD, Home Health Supervision, Hospice

Care Supervision, TCM

Must be able to track minutes and document in certified

EHR

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Potential Reimbursement for CCM Services

600 Patients w/2 Chronic Conditions
600 X $42.90 X 12months = $308,880 Annually

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Save the Date! Next Practice Managers Meeting will take place

n

Thursday, June 18th 8:00am – 9:30am

Advancement Center Seminar Room

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Thank You for Attending Today’s Meeting!

Renee A. Sutton, Director, Physician Relations

Renee.Sutton@ahpnetwork.com

Jeanine M. Wilder, Sr. Physician Relations Liaison

Jeanine.Wilder@ahpnetwork.com