Discover Your Leverage: A Value-Based Contracting Case Study

Transcription

1 Discover Your Leverage: A Value-Based Contracting Case Study Doral Jacobsen, MBA, FACMPE, Chief Executive Officer Amanda Pritchett, MHA, Chief Executive Officer Prosper Beyond Inc., Asheville, N.C. Coastal Pediatric Associates, Charleston, S.C.

2 Learning Objectives 1. Analyze the steps to prepare and execute a value-based contracting strategy. 2. Illustrate key elements of alternative payment models and utilize in payer contract negotiations. 3. Determine how to utilize a value proposition in payer contract negotiations. 2

3 Agenda 1.Introductions and Partner Selection 2.Next Generation Payer Contracting Landscape 3.Case Study: Coastal Pediatric Associates 4.Tips and Tricks Activities Goal Setting / Partner Discussion *postcard drawing 3

4 Live Content Slide When playing as a slideshow, this slide will display live content Poll: Who s in the house?

5 Next Generation Payer Contracting Landscape

6 Next Generation Contracting Landscape Source: Alternative Payment Model Framework and Progress Tracking (APM FPT) Work Group. Alternative Payment Model (APM) Framework Final White Paper. Health Care Payment Learning and Action Network. 12 Jan

7 Next Generation Contracting Landscape May feel like Different routes emerging 7

8 Where Does the Rubber Meet the Road? 8

9 Next Generation Contracting Landscape 9

10 Live Content Slide When playing as a slideshow, this slide will display live content Poll: What next generation payment models does your practice participate in today?

11 Activity #1 5 mins 1) Goal #1 - what is one stretch payment model to explore? What s your 1 st step? 2) Say it out loud to your partner 3) Group share two 11

12 Case Study

13 Coastal Pediatric Associates MD providers providers (MD, DO, PNP, FNP, PA) 1 location 7 locations (PCMH Level 3) 12,380 patient encounters 135,377 patient encounters Additional entities: 13

14 81% of CPA Payer Mix 14

15 Gather Data Define Targets 15

16 Gather Data Assess Performance Payer Gross Collections Adjusted Collections AR Days AR 120+ % Payer Mix Prior Period P4P Comments Hassle Factor (A-F) Payer 1 38% 115% 42 10% 17% Payer 2 36% 69% 79 35% 1% Reporting challenges Communication issues C D Payer 3 29% 97% 56 22% 2% NA D Payer 4 51% 85% 51 18% 13% No Issues C Payer 5 32% 84% 40 9% 3% NA C Payer 6 18% 105% 63 8% 61% NA B 16

17 The Math 17

18 Developing Your Value Proposition Know your organization. Know why you stand out in your market. Know your payer. Pull it together. 18

19 Value Proposition Step 1 Know your organization. Know why you stand out in your market. Know your payer. Pull it together. Your practice s history and purpose Vital stats about your practice (team members, locations, hours) Vital stats about your patients (active patients, patient visits last year, average LOS) Goals for the next 1-2 years Have stories ready to tell outside stakeholders about how your team improved quality, improved patient access or dramatically improved the health of a patient. Make sure it is memorable and easily repeatable. 19

20 Value Proposition Step 2 Know your organization. Know why you stand out in your market. Know your payer. Pull it together. What does your practice do differently? How do you serve patients better, faster, more efficiently? Have you received quality designations from other payers? Have you earned awards/designations from independent organizations? Do you have high social media rankings? Do you have low staff turnover? What does your practice do to reduce health care costs? 20

21 Value Proposition Step 3 Know your organization. Know why you stand out in your market. Know your payer. Pull it together. Get to know the people you are talking to they are human too. Understand which of your competitors are in their network. Ask what the payer s goals and focus are for the year. Ask what information you can provide to allow that person to be your internal advocate. Thank you for being our champion in your internal discussions. What other information can I provide you? 21

22 Value Proposition Step 4 Know your organization. Know why you stand out in your market. Know your payer. Pull it together. Align your ask with the practice needs and the payer s goals. Anticipate questions the payer may have about your proposition. Provide facts, figures and data that demonstrates your value. Ask what other information they may need when making decisions. Be flexible with contracting options. 22

23 Alternative Payment Model Key Elements Alternative Payment Models APM Alternative Payment Model Innovation Center Models Demonstration programs Medicare Shared Savings Programs Advanced APMs Physician- Focused Payment Models AAPM Advanced Alternative Payment Model Requires participants to use Certified EHR technology Employs quality measure similar to MIPS Participants must bear more than nominal risk or expanded medical home model PFPM Physician-Focused Payment Model Include Medicare as a payer Physicians play a core role in implementing Targets quality/costs of services providers influence FFS Barriers to APM adoption inadequate payment for services that would help reduce avoidable spending, financial penalties for delivering different service mix, provider readiness, and lack of adequate technology.

24 Alternative Payment Model Breastfeeding 24

25 Alternative Payment Model The Ask Payers approached: Medicaid MCO Largest Private Payor in SC Distribution of risk First ask Monthly Fee to support BFC activities regardless of visits by members. Second ask Per member per BFC visit. If no member visit occurs, no APM fee is paid. Third ask BFC is responsible for showing quality outcomes at Year One and payor will retrospectively pay per member per visit APM fee. 25

26 Relationship Building

27 Live Content Slide When playing as a slideshow, this slide will display live content Poll: How do you rate your current payer relationships overall?

28 Relationship Building A Checklist Build trust. Be personal. Communicate often. Pick up the phone. Invite for a tour. Give swag. Remember small details. Take feedback well. 28

29 Activity #2 5 mins 1) Goal #2 - what is one payer relationship you want to work on? What s your 1 st step? 2) Say it out load to your partner 3) Group share two 29

30 Tips and Tricks

31 Understand Their Position Key questions Do you need this relationship? What is their position in the marketplace? What is their current strategy? Any new products? Retiring products? Alternative payment models? Do your peers participate? 31

32 Understand Your Position 32

33 Live Content Slide When playing as a slideshow, this slide will display live content Poll: Do you have a feel for how your practice stacks up to peers?

34 CIGNA CIGNA care designation = Top 3 rd of network Take a look at cost efficiency reports 34

35 Traditional Medicare Value modifier - quality and resource use reports Take a look at provider level details 35

36 Tell Your Story Our practice treated 184 Payer A members for top five procedures at ASCs and other cost- effective facilities and saved Payer A an estimated $1.8 million (annual). 36

37 Tell Your Story Our practice interprets CT scans in half the time of our peers. We are part of a care team that improves outcomes for patients presenting with stroke symptoms saving Payer A an estimated $2.5 million (annual). 37

38 Most Common Barriers to Success 1. Not enough hours in the day 2. Bottom of the priority list 3. Don t know where to start 4. Lack of understanding of the process 5. Exhausting lack of responsiveness from payer 6. Adversarial relationship payer 7. Lack of contract monitoring 8. No long term strategy 9. Lack of necessary skill set(s) 38

39 Value Proposition Exercise Practice Information Goals & Ratings Key Questions for Payer Discussion Describe your practice succinctly? (4 5 bullets) How many MDs? Midlevels? Pharmacists? What specialties? How would you briefly describe your service mix? What ancillary services do you provide? Do you participate in any alternative payment models? If so, which ones? What are your affiliations with hospital systems, IPAs, ACOs, etc.? Future plans in this area? How would you describe your organizational mission in one sentence? How would you state your organizational goal(s) succinctly? How does your practice rate relative to payer profiles? Medicare Physician Compare BCBS/Anthem? CIGNA? UHC? Aetna? Healthgrades? Narrow network participation? Transparency cost information? Do you understand where you stand relative to costs compared to your peers? How do you compare in terms of quality to peers? Identify a few key questions that you would like to focus on during your discussion. How can we work together? What kinds of value based contracts should we explore together? How can we facilitate improved communications? What types of models would be worth investigating? What timelines are we working within? What kinds of arrangements are being explored with our peers? What does your practice offer that differentiates the practice from the competition? Same day appointments? Technology? Affiliations of interest (e.g., sports teams, schools)? Accolades? Participation in alternative payment models? Special Programs? Where are your office locations? Plot them on a map Indicate expansion plans as applicable What do you know about practice outcomes compared to peers? Infection rates? Length of Stay? ED utilization? Readmissions? Costs compared to peer groups? What are patient satisfaction scores? Quality Initiatives PQRS? MIPS? APM? MU? Other? Referring Provider satisfaction scores? Employee satisfaction scores? Patient engagement initiatives? Specific to the payer, what common ground can you identify relative to practice goals and payer goals? What statement can you make that defines how you wish to collaborate with this payer? Where is your practice in terms of demonstrating how you are working toward achieving the Quadruple Aim? Where do you want to be on the managed care contracting continuum and how are you going to get there? Practice Differentiators Outcomes Payer Common Ground 39

40 Activity #3 5 mins 1) Exchange partner contact info 2) Goal #3 what are two high value attributes you could envision on your Value Prop? What s your 1 st step? 3) Say it out load to your partner 4) Group share two 40

41 Execute Your Strategy Keys to success Develop your personal sales pitch value proposition. Understand they need you Ask to meet and roll out the red carpet. Involve the team. It s all about building relationships. Draft your communication and include reimbursement goal. Do it all in writing. Keep at it Quantify success. You re not ever really done conclude by planning your renegotiation next start date. 41

42 Thank You. Doral Jacobsen Prosper Beyond Inc. 60 N Market Street C200 Asheville, NC Amanda Pritchett pritchett@cpakids.com Coastal Pediatric Associates 2051 Charlie Hall Blvd. Charleston, SC

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