PROVIDER REIMBURSEMENT STRATEGIES FOR 2014 Michael P. James, J.D., M.B.A., CSSGB

Phone: (517) 377-0823 (313) 965-9038

Email: mjames@fraserlawfirm.com

www.linkedin.com/in/MichaelJamesLaw

Fraser Trebilcock Davis & Dunlap, P.C.One Woodward Avenue, Suite 1550Detroit, Michigan 48226www.fraserlawfirm.comPhone: (313) 237-7300Fax: (313) 961-1651

Fraser Trebilcock Davis & Dunlap, P.C.124 W. Allegan Street, Suite 1000Lansing, Michigan 48933www.fraserlawfirm.comPhone: (517) 482-5800Fax: (517) 482-0887

© 2013 Fraser Trebilcock Davis & Dunlap, P.C.

Shifting Landscapes Under Health Care Reform

Physician Landscape

Accenture predictive modeling. Accessed 12/3/13.http://www.accenture.com/us-en/outlook/Pages/outlook-online-2011-adapting-new-model-physician-employment.aspx

Reimbursement Landscape

National Health Expen-ditures

Gov-ern-mentPrivate

National Health Expen-ditures

Gov-ern-mentPrivate

64.5% 35.5% 55% 45%

2000 2011

Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/tables.pdfAccessed 12/3/13. (see Historical; NHE Web tables, Table 5).

Evolving Reimbursement Models under HCR Fee-for-Service Bundled Payments/Episode of Care Payments Partial or Full Capitation Care Management Fees Shared Savings

One-Sided Two-Sided

Reimbursement Landscape

Riding the Wave of Change

How do you address these shifting landscapes to continue to drive profits?

Medicare Shared Savings Program (MSSP)

MSSP designed to improve beneficiary outcomes and increase value of care by promoting: Accountability for patient population; Coordination of care for services; Investment in infrastructure; and Redesign of care processes.

ACOs are the vehicles through which providers/suppliers participate in the MSSP. A legal entity designed to manage and coordinate care

for Medicare fee-for-service beneficiaries under the MSSP.

What Are ACOs?

Fundamental Principles of ACOs

Improve Care for Beneficia

ries

Enhance Health in its Population

Reduce Growth of Beneficia

ry Expendit

ures

What Are ACOs?

Types of ACOs

Integrated Delivery System Model ACO

CMS

Health System ACO

Hospital Physicians

Skilled Nursing Facility

Etc.

PHO Model ACO

PHO ACOHospital

Independent

Practice Assn.

CMS

Types of ACOs

Independent Practice Association Model ACO

IPA ACO

CMS

Physician

Physician

Physician

Physician

Types of ACOs

Group Practice Model ACO

Group Practi

ce ACO

CMS

Specialists

Hospital

Types of ACOs

5% of Members = 45% of costs15% of Members = 35% of costs

80% of Members = 20% of costs

ACO Membership

Predictive Modeling for Last 2 Years of Life: Medical homes Home Calls Care Plans Navigators ER / Hospital Hospice

Multiple Chronic Diseases: Medical Home Care Plans Team Care Navigator ER / Hospital

Utilization Management

Chronic Disease: Medical Home Care Plans Team Care ER / Hospital

All Others: Medical Contact & Education Care Plans ER / Hospital

Utilization Management

Insurance License. Claims Processing. Alignment of Fee Structures. Incentive to Move from Volume to Value. Quality Monitoring Systems.

Payment Evolution

Culture of Restructuring

More Patients in

System

Reduce

Capacity of

System

Risk Sharing

Fraser Trebilcock Davis & Dunlap, P.C.124 W. Allegan Street, Suite 1000Lansing, Michigan 48933www.fraserlawfirm.comPhone: (517) 482-5800Fax: (517) 482-0887

Fraser Trebilcock Davis & Dunlap, P.C.One Woodward Avenue, Suite 1550Detroit, Michigan 48226www.fraserlawfirm.comPhone: (313) 237-7300Fax: (313) 961-1651

Michael P. James, JD, MBA, CSSGB

Phone: (517) 377-0823 (313) 237-7300

Email: mjames@fraserlawfirm.com

www.linkedin.com/in/MichaelJamesLaw

© 2013 Fraser Trebilcock Davis & Dunlap, P.C.

Fraser Trebilcock Health Care Reform

www.mihealthcarelaws.com