How to Get Managed Care Companies to Pay For Your Practice's Improvements

managed care moneyBy: Valerie Shahriari

Florida’s providers are buzzing with questions about value based care, asking why now? Is it a fad? Will it really ever be a widespread form of payment? Why does Florida seem farther behind the value based curve than other markets?

While there are more aggressive markets in other parts of the country, the bottom line is this: CMS changes are coming and they will not be stopped.  The government has invested too much money to turn around at this point.  Here are just a few examples of why:

  • The CMS Value Based Program with hospitals is already implemented;
  • Center for Medicare and Medicaid Innovation is piloting NUMEROUS programs covering many physician specialties
  • CMS expanded the Medicare Shared Savings Program to 3 tracks.
  • A new Merit-Based Incentive Payment for Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists will be apply to payments for services furnished in 2019.

The train has left the station. Providers will now shift from fee for service to value based payments with CMS.  To be successful and still have a profitable business, clinical integration and quality improvements will need to be implemented to improve your practice whether you are hospital based or office based AND whether you are employed by a hospital or in private practice. These changes will be implemented for all of your patients as you will not distinguish in your level of service between patients with managed care as the payor rather than CMS.  This essentially means that managed care payors will reap the benefits of these improvements in your practice.  If you do not have a value based contract in place with the managed care payors they will not be sharing one dime with you.  They will reap the benefits of your improvements AND keep the money!  And by the time you get around to a managed care contract that is value based, the shared savings opportunities will be less than if you began those discussions now. Continue reading

How to Get Managed Care Companies to Pay for Your Practice’s Improvements

managed care moneyBy: Valerie Shahriari, via Healthcare Reimbursement Blog

Florida’s providers are buzzing with questions about value based care, asking why now? Is it a fad? Will it really ever be a widespread form of payment? Why does Florida seem farther behind the value based curve than other markets?

While there are more aggressive markets in other parts of the country, the bottom line is this: CMS changes are coming and they will not be stopped.  The government has invested too much money to turn around at this point.  Here are just a few examples of why:

  • The CMS Value Based Program with hospitals is already implemented;
  • Center for Medicare and Medicaid Innovation is piloting NUMEROUS programs covering many physician specialties
  • CMS expanded the Medicare Shared Savings Program to 3 tracks.
  • A new Merit-Based Incentive Payment for Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists will be apply to payments for services furnished in 2019.

The train has left the station. Providers will now shift from fee for service to value based payments with CMS.  To be successful and still have a profitable business, clinical integration and quality improvements will need to be implemented to improve your practice whether you are hospital based or office based AND whether you are employed by a hospital or in private practice. These changes will be implemented for all of your patients as you will not distinguish in your level of service between patients with managed care as the payor rather than CMS.  This essentially means that managed care payors will reap the benefits of these improvements in your practice.  If you do not have a value based contract in place with the managed care payors they will not be sharing one dime with you.  They will reap the benefits of your improvements AND keep the money!  And by the time you get around to a managed care contract that is value based, the shared savings opportunities will be less than if you began those discussions now. Continue reading

Provider Service Volume is No Longer King

By: Valerie Shahriari

As the shift from fee for service to value based payment develops, one thing is crystal clear:  volume is no longer king.  Prior to 2010, medical providers were being paid on the amount of services that they rendered. The more patients that they treated, the more money they made. That certainty has disappeared with value based compensation and outcomes are now driving the compensation.  To be successful, a provider must learn to bend both the quality and cost curve.  In short, providers must increase quality while decreasing costs.

When contemplating negotiating or entering into a value based contract, the first thing to consider is the amount of financial risk that your practice or healthcare business can take on.  The four main types of financial payments are:

Payment Structures

The best way to determine which payment model best suits your needs is to hire a qualified financial healthcare analyst who will be able to generate financial risk modeling.  A provider will then have a common starting point to negotiate as well as a better understanding of the issues, risks, and potential cost savings involved. Continue reading

Value Based Payments Gaining Traction – CMMI Oncology Care Model

443 Providers sign up for the CMMI Oncology Care Model including numerous providers in Florida.  The Oncology Care Model is a new payment model for physician practices administering chemotherapy.  Practices receive reimbursement via an episode based payment model that incentivizes high quality coordinated care.  Letters of Intent from payers (several of which are Florida payers) wishing to participate in the new model were submitted and Letters of Intent from providers wishing to participate were also submitted.  A list of those payers and providers who submitted LOIs can be found at http://innovation.cms.gov/initiatives/Oncology-Care/ .

If you would like to learn more about value based payments for your practice, Attorney Valerie Shahriari is offering a free webinar on June 24, 2015.  Registration is now open: “Preparing Your Practice for an Incentive Based Payment Structure”

 

Hospitals Respond to Governor’s Challenge…Are Hospitals Like Baseball?

By: Valerie Shahriari

Like a scene from the popular Netflix series, House of Cards, Governor Scott has requested that State agencies list critical services in light of a possible government shutdown over a battle of the budget.  It is important to note that Floridians relying on Medicaid could be impacted and shifting their care from the Primary Care Doctors back to the Emergency Departments.  Lawmakers will have a special session from June 1-20 with the goal of passing a budget.

In the meantime, hospitals have responded to Governor Scott’s challenge for profit sharing and likening healthcare to baseball.  The Florida Hospital Association responded equating the profit sharing to an additional tax on hospitals.  The Florida Hospital Association stated that hospitals already contribute roughly $1.3 billion to Medicaid as supported by a report commissioned by the State.  Governor Scott also drew criticism from State Senator Don Gaetz in a talk radio interview where he likened the Governor’s profit sharing to government price controls.

Value Based Payments for Physicians

A3124Color300By: Valerie Shahriari

H.R.2 – Medicare Access and CHIP Reauthorization Act of 2015 was passed by the House on March 26, 2015 and the Senate on April 14, 2015.  While the title of the law indicates one of the topics of the bill (removing the sustainable growth rate (SGR) methodology from the determination of annual conversion factors in the formula for payment for physician services), the title is not representative of a major change that could affect all physicians.  Under the Medicare Access and CHIP Reauthorization Act of 2015, the Secretary of Health and Human Services is directed to consolidate components of the three specified existing performance incentive programs into a new Merit-based Incentive Payment (MIP) system under which physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists, would receive annual payment increases or decreases based upon their performance as measured by standards the Secretary shall establish according to specified criteria. Continue reading