How To Run A Health Care Home

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Shaping Healthy Communities

Shaping Healthy Communities.

Lone Star Circle of Care

A Patient-Centered Health Home

Denise Esper, Chief Operating Officer, Chief Revenue Officer Amy Peacock, Senior Billing Manager

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Session Summary

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Highlight the success and work of LSCC as a PCMH

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Discuss FQHC revenue streams in a PCMH

•

Contract renegotiations w/PCMH Status

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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

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Our Philosophy

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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

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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

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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

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Increasing Access

0 50,000 100,000 150,000 200,000 250,000 300,000 350,000 400,000 2005 2006 2007 2008 2009 2010 2011 Conservative Projection FY2012 24,895 35,348 74,224 96,131 127,121 202,568 298,269 360,832

Lone Star Circle of Care Visits FY2005 - FY2012 (Projected)

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Uninsured Patients

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Uncompensated Care

2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000 14,000,000 2005 2006 2007 2008 2009 2010 Projected 2011 Budget 2012 $1,180,000 $1,802,417 $2,759,441 $4,691,808 $10,591,671 $12,236,462 $13,332,346 $13,501,175

Uncompensated Care

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Payments for Services

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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

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Those who do not qualify for a program pay for services on a sliding

fee scale based on the Federal Poverty Level (FPL) guidelines

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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

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CHASSIS Software and

Medicaider™

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CHASSIS Software is a suite of software tools designed by

Network Sciences

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Used for eligibility case management and program

management

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Medicaider™ is a CHASSIS tool that provides a fast and

accurate way to screen for a large set of programs

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Both are web-based tools used by both providers

and payers to efficiently and successfully connect the

uninsured to benefit programs

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CHASSIS Software and

Medicaider™

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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

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Agencies can use Medicaider™ to electronically receive

applications, determine eligibility consistently and accurately,

and manage their program

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Medicaider™ is a paperless solution that can be used

independently or to connect organizations online and includes

reporting capabilities

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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

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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

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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

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Program Application (Interview) and Assistance

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Electronic Application Submission

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Program Certification/Enrollment

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New Program Enrollment (TMHP)

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History of applications/screenings within ICC*

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Repository for Screening Documents within ICC*

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Shared Documents within ICC*

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Measure? Manage? Improve?

Uninsured

Inpatient Outpatient EMR Clinics

Patient not interviewed

Patient interviewed

Screening was Accurate

Each Program has different criteria Eligibility is complicated Eligibility is inter-related

Interview considered all programs

Assignment/Strategic Follow-up No Follow-up

File Application and Documents Mail/Fax

Eligibility Determination,

Certification, Verification Training

Inaccurate Screening

?

Limited Programs

Wrong Docs Lost Docs

Notify CIHCP of Service Missed 72 hr window

?

Errors

Excel

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Financial Gain of Uninsured Converted to Payer

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Spreadsheet represents 780 patients in Q4 2010

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Equates to 3,120 in one full year

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Calculated at 3.8 visits/year per patient…11,856 encounters

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Benefits Go Far Beyond Financial

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Preventive Care

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Quicker response when acute issues arise

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Fewer ER visits

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Controlled Chronic Disease, Increased Compliance

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Healthier patient

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Healthier community

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Health Care Home (Value Add of PCMH)

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Value of Services

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Access to affordable care regardless of payor helps curb

unnecessary ER visits and reduces avoidable hospital admissions



Evening and weekend hours, after hours coverage

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Access to free or low cost medications promotes health

maintenance, working to lower downstream costs of

non-compliance

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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

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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

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Behavioral Health Visits

2005 2006 2007 2008 2009 2010 2011 Projected FY2012 519 1,119 3,937 5,023 10,000 23,737 37,219 51,417

Lone Star Circle of Care BH Visits FY2005 - FY2012 (Projected)

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Revenue Codes for BH Services

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The Medicare manual states 90801 and 90862 are diagnostic codes

and could be billed as Revenue Codes 0521, 0524 and 0525

therefore not being subject to the psychiatric reduction.

 90801 billed to Medicare as 0900 revenue code would be reimbursed around $12-$30 because it is subject to the psychiatric reduction

 The same 90801 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 290-319?

 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

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Medicare Psychiatric Reduction Phase Out

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January 1, 2010 : The limitation percentage is 68.75 percent

(Medicare pays 55 percent and the patient pays 45 percent)

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January 1, 2012: The limitation percentage is 75 percent

(Medicare pays 60 percent and the patient pays 40 percent)

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January 1, 2013: The limitation percentage is 81.25 percent

(Medicare pays 65 percent and the patient pays 35 percent)

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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)

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Pediatrics

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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

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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

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LSCC also has a distinct Adolescent Clinic located at the

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Childhood Immunization Status

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: http://www.ncqa.org

74.1% 80.6% _79.3% 0.0% 25.0% 50.0% 75.0% 100.0%

Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov

Lone Star Circle of Care Childhood Immunization Status December 2010 - November 2011

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Obstetrics and Gynecology

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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

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OB/GYN Outcomes

Lone Star Circle of Care (LSCC), Texas, and United States Live Births by Birth Outcome

Outcome LSCC1 _Texas2 _{United States}3

Preterm births4

(<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, 2009 - 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 2008. National Center for Health Statistics, Vol. 59, No.1, December 2010.

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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

Financial Class

LBW Percent

Savings Achieved by LSCC

Savings Achieved if Texas Rates Equaled LSCC

LSCC1 _Texas _Total _{Per Baby} _Total _{Per Baby} Medicaid/CHIP 3.3% 8.9% $1,009,884 $11,178 $118M $11,178

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Coordination of Services within the PCMH

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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

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Patient Navigation Center Staff

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PNC is staffed with Patient Service Representatives, Clinical

Interventionist RNs, LVNs, Medical Assistants, Behavioral Health

Service Representatives, and Specialty Referral Representatives

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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

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Clinical Interventionist

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LSCC Clinical Interventionists are experienced Registered Nurses

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Identifies risks and proactively manages patient

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Increases compliance

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Fills in the space between episodic visits with preventive contacts

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Work in tandem with LSCC clinicians

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Clinical Interventionist

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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

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Chronic Disease Management

 Asthma  Diabetes

 Hypertension  Obesity

 Others as needed or targeted depending on provider request, seasonality, and trends

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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 30th 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

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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

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Pediatric Outcomes

60.0% 65.0% 70.0% 75.0% 80.0% 85.0% A ug S ep _Oct No v De c J an F eb Ma r A pr Ma y J un Jul A ug S ep _Oct No v De c J an F eb Ma r A pr Ma y J un Jul A ug S ep _Oct No v De c J an F eb Ma r A pr Ma y J un Jul A ug S ep

Well Child Check Kept Rate (Aug 2008 to Sept 2011)

Scheduler Continuity Tracking Start Training Start Paneling Start Confirmation Calls Start (Call Center)

Email Notifications

Start

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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

Did Child Receive at Least One WCC Visit?

Total, Age 1-5 Age Group 1-2 Age Group 3-5

LSCC Texas LSCC Texas LSCC Texas

Yes Number 2,357 683,602 1,074 356,176 1,283 327,426 Percent 90.4 69.8 92.8 71.2 88.5 68.3 No Number 250 296,159 83 144,223 167 151,936 Percent 9.6 30.2 7.2 28.8 11.5 31.7 Total 2,607 979,761 1,157 500,399 1,450 479,362

1. Source: Lone Star Circle of Care encounters occurring in FY2010 (December 1, 2009 - November 30, 2010).

2. Source: Texas Form CMS-416: Annual EPSDT Participation Report for encounters occurring in FY2009 data (October 1, 2008 - September 30, 2009).

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Hemoglobin A1c Testing

National Quality Forum Measure 0059: Hemoglobin A1c Management.

Percentage of adult patients with diabetes aged 18-75 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.) 44.0% 24.5% 25.7% 0.0% 25.0% 50.0% 75.0% 100.0%

Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov

Lone Star Circle of Care Hemoglobin A1C Management December 2010 - November 2011

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Summary

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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

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Payment Reform

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PCMH Value Add

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Improves health outcomes

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Prevents emergency visits

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Reduces hospitalizations (number and length of stay)

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Reduces cost in an ACO by substituting provider-patient face

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Contract Negotiations with PCMH Designation

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Raised, gold seal next to listing in provider directory

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Higher reimbursement for certification

 Based on higher Medicare Region  Higher % of standard (1-5%)

 Higher % of Medicare (114%)

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Patient Navigation and ACO Forecast

Short Term ↓ Office Visits ↑ Phone, Telemedicine, and Email Visits ↓ Cost labs, diagnostic tests, referrals, medications

Care team works at highest level of licensure Long Term ↓ Emergency Department Visits ↓ Hospitalizations ↓ Readmissions ↓ Length of Stay

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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 Regardless of Patient

Outcome

Depends on Patient Outcomes

Patient Experience Does not affect Reimbursement

Impacts Reimbursement

Data Only Share Good

Outcomes

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Options

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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

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MCO Site Visit (2 Day Audit)

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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.”

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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.

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PQI Program

Program Objectives

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Improve targeted clinical quality results

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Promote quality, safe and effective patient care across the health

care delivery system

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Improve provider operational efficiency

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Improve medical cost management by providing incentives for

improving quality care and tools for providers to reduce medically

unnecessary utilization and costs

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Options

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“Member” Concept in an Accountable Care Organization

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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

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