GBA 113/114 Flashcards
Independent delivery network
Physician practices and a hospital system
What are the GSK customer Segments
Independent health care provider practice-privately owned businesses/retain autonomy
Institutional Segment
Public health segment
Emerging customers-retail Rx, occupational health facilities concierge practices
What do reimbursements influence
Clinical, economic and operational decisions made within health care provider practices and hospitals
What happens as a result of falling reimbursements
Many health care providers need to increase the volume of patients they see, the hcp has less time available to see reps office staff views reps as an obstacle to the office s efficiency
Forms of Independent health Care Practices
Solo practices
Group practices
Multi specialty practices
What are the fundamental economics of the independent healthcare provider
HCPs provide services to patients and are compensated based on a patients health benefit.the majority of patients have coverage under a commercial health plan or a public plan ie Medicare or medical although a small number pay cash.
Patients pay a copayment.remainder of the fees of the dr are reimbursed by the commercial or public plan.
What are the two largest streams of revenue in a hcp’s office.
Co-pays
Payer reimbursements
What are the ways hcp’s are reimbursed
Fee for service
Capitation
What is Fee for Seevice
Physician is paid for each service he or she provides. Provider sends a claim with their charge and is reimbursed physicians have an incentive to increase the number of services they provide on each visit, as well as the number of visits
What is capitation?
A fixed payment per month or PMPM. In contrast to fee for service payments per member per month is not based on the actual services. Compensation does not rise with utilization. Under a captivated regimen it is financially advantageous to carefully manage service utilization and control costs in order to maximize profits. Capitation transfers a degree of financial risk and reward to physicians.
Discuss the financial challenges of capitation
Capitation transfers a degree of financial risk and reward to physicians. The financial incentives encourage physicians to be more active participants in controlling utilization. From a health plan perspective, captivated arrangements are most effective when the lions share of enrollees utilize capitated groups for care. Health plans establish a relatively closed provider network in order to drive utilization toward capitated physician group. From a physician perspective a capitated system therefore locks in a membership base a revenue source.
What is P4P
Can be built In to fee for service or capitation. These mechanisms include some manner in which the Health Care provider can lose compensation or earn extra compensation
What are the most common mechanisms employed to increase or decrease physician compensation?
Withholds, fee adjustments and bonuses
What are Withholds?
For withhold, a health plan sets up a risk pool that holds a specified percentage of negotiated fees perhaps 20% for a given practice. If the practice charges for the year are less than an agreed upon amount, the plan dispurses the money in a withhold pool to the practice. If costs are higher the health plan retains the money .
Fee adjustments
Fee adjustments are employed as an alternative to or supplement for a withhold-under fee adjustment provisions, the health plan can unilaterally reduce fees in the event of cost overruns. Fee adjustments are most often used in HMOs or strongly managed PPO’s where risk is shared among a particating physicians.
Explain Bonuses
Bonuses are used most frequently with providers who play a gate keeper role, such as primary care physicians. Extra payments can be earned by keeping health an costs such as fees to specialists and hospitals below a budget or utilization target. Bonuses may also be based on patient satisfaction, access or outcomes.
Effects of P4P on physician compensation
Can increase or decrease physician compensation by more than 25% of charges
What are other revenue streams
Botox and concierge practices.
Who are the employees in a HCP’S office that have the most hands on involvement in the practice
Back office-most are related to billing.
Front end process
Middle process-
Back end/billing and collections
What are roles in the back office?
Practice Manager
admin Staff
Billing and reimbursement managers
Claims building and coding specialists
What do admin staff do?
Manage patient flow
Billing and reimbursement managers
Ensure that the practice is being reimbursed properly for the care provided by billing payers and patients.
What do claims. Billing and coding specialists Di
Submit claims for payment to payers and health plans
Billing patients
Dealing with insurance carriers and specialty pharmacy
Handling pre certifications
Handling reimbursement appeals
Managing collections, accounts receivable and aging receivables
New roles- patient advocacy, patient satisfaction and clinical education.
Key responsibility of back office staff
Seeking prior authorization for Rx product that health care provider would like to prescribe but that are restricted on the patients pharmacy benefit. Manage inventory and reimbursement.
GSK formulary disclaimer
Consumers may be responsible for varying out of pocket expenses depending on an individuals plan and formulary coverage does Mott imply efficacy and safety.
Receptionist
The field rep must convince the receptionist of the value they provide the receptionist a gate keeper and could be a barrier to seeing the prescriber.
Who is the most critical member of the back office staff.
Practice Manager
What happens if a claim is denied?
It could potentially mean more of of pocket cost for them. It could lead to frustration by the patient trying to identify why they got a bill for a medical procedure they thought was covered
How are practices being proactive
Understanding each patients financial condition before they come in for treatment.
Capturing more revenue whenever possible at pint of service
Offering charitable care discounts at the point of sale to appropriate patients
Helping patients understand how they pay their bills
Financially clearing patients at the point of sake based on their ability to pay to avoid collection efforts that will be unsuccessful
Health care reimbursements have declined how has this affected physicians
Tied to categories of drugs
Decline in reimbursement ie decrease in practice revenue change in practice policies
Public payers like Medicare underpay by 15%
PPACA now called affordable care act
Failed to address pending cuts in Medicare reimbursements rates for physicians
Doc Fix was kept out of the legislation since it would have negatively affected the cost analysis of the legislation
Temporary fix
No long term solution has been developed
Reduced rate of reimbursements of Medicare and medicaid
What can Drs do when it comes to declining reimbursement
Change the payer mix
Practice may reduce
What is the impact of Health Information Technology and e prescribing
E presribing reduces errors automate the process of checking for drug interactions and allergies
Lower healthcare provider and pharmacy cost
Fewer errors
EMR
Easy access to medical records
Reduction in errors and increase ability to perform clinical reviews
Reminders to schedulers to contact patients for follow up visits
Framework for nurses to perform patient histories
Better adherence and compliance
Significant cost savings
2008 survey health information management system society
1/3 respondents have capability for EMR Initial costs are high Significant barriers to adoption Staff must be trained new software Workflows procedures Significant time loss
Data captured within EMR will be used for what 3 areas of improvement.
Treatment
Quality of services
Outcomes
Benefits to patients of EMR
Better continuity of care
more efficiency of diagnosis
Treatment selection follow up
Improved outcomes
What are the 3 key challenges facing health care providers
Claims denial
Lack of or incomplete patient payment
Declining reimbursement
What is technology being used for?
Increase practice efficiency Reduce errors Enhance communications, demonstrate outcomes Track demographic trends Change practice economics
What are common types of economics
E-prescribing
EMR
e Claims submission
What are the two main models for drugs dispensed in office
Buy and Bill
Specialty pharmacy
What is the profit margin in hospitals?
3-4%
What are the cost saving measures hospitals employ
Treatment guidelines
Formularies for pharma, medical devices and disposable medical products
Restrictions on accessing particular high cost products
Contracting to lower acquisition costs of products used in inpatient
Technology is increase to facilitate cost containment.
What is CPOE
Computerized physician order entry, interfaces with EMR to trigger decision support cues for health care providers including allergy alerts, drug drug interaction and the availability of lab test results
CPOE
Field professionals must ensure that their products and their products utilization is in line with and not running counter to CPOE systems and hospital protocols. Make sure you understand protocols in the hospitals.
GPO
Helps hospitals aggregate their purchasing power to obtain discounts with manufacturers distributors and other vendors. A GPO does not purchase products but it does establish favorable terms for purchasing.
What 2 advantages do GPO”s provide to hospitals
They save money ie 15%
Remove much of contracting burden- they don’t have to negotiate with multiple vendors.
Describe the structure of the hospital
The hospital departments which are staffed by employees such as nurses and administrators
And the medical staff many of who are not hospital employees
Describe the hospitals organizational structure
Inpatient Care-nursing for hospital stay
Ambulatory Care ER, hospital affiliated clinics
Hospital ambulatory surgery centers or infusion suites
Critical Support pharmacy, labs radiology, RT and PT
What are the benefits of capitation?
For Health plan-closed provider network, capita red physician group
For physician locks in a membership base and revenue source and positive cash flow.
Disclaimer
In no way should we engage in conversations or activities that involve helping a practice make money
Who is the most critical member of the back office staff is
Practice manager-this is the person responsible for all aspects of a practice ie day to day operations including scheduling appt. verifying insurance, maintaining patient medical records, answering pharmacy questions, submitting claims to health plans , billing patients and ensuring the business practice is running g smoothly.
What factors do practice managers need to understand
Costs the practice Incurs and the payments revenue the practice earns. They must understand how changes to pricing, reimbursement mechanisms, and contracts that will affect bottom line.
Practice Manager and contracting
Contracting is a critical aspect if the practice Managers role. Practice managers negotiate and maintain contracts between the health care provider practice and multiple health plans . The must understand the terms of each contract, including the maximum allowable charges for various services and for Health care provider administered products.
Biggest challenge for practice managers
Keeping track of changes.
What happens in 2015
For the affordable care act patients who have a diagnosis of COPD and are rehospitalized within 30 days the hospital will not be reimbursed.
Patients returning 30 days after discharge.
What is the main difference between in patient and out patient
The duration of the patients interaction With the hospital during an episode of care.
What was the average length of a hospital stay in 2009
4.6 days
What are the most influential trends impacting independent care provider practices
Practice consolidation
Payer mipay for performance initiatives
Vertical integration.
Practice consolidation
In 1997 40% of HCP”s were in solo practices by 2008 the figure had dropped to 30%
Key trends driving consolidation
Increased costs driving healthcare, decreased reimbursement levels and or the anticipation of lower reimbursements levels in the future and increase competition from traditional or non traditional healthcare entities.
What benefits do mergers offer
Secure or advance a practice position in the market
Positively impact practice revenue and health care provider income and offer greater leverage for negotiating with hospitals and payers.
What is the most significant benefit of practice consolidation?
Economies of Scale which is defined as reductions in operating cost as a percentage of profit. The new revenue is the sum of both mergered companies but there is a reduction in cost eliminating duplicate positions.
What percentage of ER visits end up being Hospitalized
13%
What percent of hospial admissions come through the ER
50% up fro 36% in 1996
What % of ER patients get a prescription
76.6
What drugs prescribed most frequently
Analgesics
Anti microbial
Antiemetic
What is a clinic
A clinic is an outpatient facility that focuses on a single patient group.
What is an ASC
Ambulatory Surgical Center-hospital affiliated,, others are free standing ambulatory surgery centers.
What will the market breakdown be at the end of the decade?
58% in employer sponsored
16% on Medicaid or the children’s health program
9% individual market outside exchanges
9% on exchanges
8% left uninsured
The uninsured will no longer be the second largest segment as it is today.
What will happen as payr clout grows?
Manufactures will see increased pressure on price and there will be increasing importance on the value proposition of products and aggressive use of drug utilization management.
Discuss the importance of Payer mix
Outside of payer mix at the provider level no factor determines reimbursement more than payer mix. Because different payers reimburse at diff rates
What percentage of physicians see Medicaid patients
70%
Each prescription dollar generated by Medicaid is heavily discounted. Do you know what the minimum discount is?
23.1,this means that a Medicaid prescription generates 76.9 cents on the dollar
What is vertical integration
2 basic structures that link a hospital to other Health care facilities
A health system-horizontal integration of multiple facilities of the same level of healthcare services…ie multi hospital systems
IDN or IHN-group of entities
many hospitals
primary care and specialty care clinics
Network of HCP
An IDN is based on a single geographic market.
What are the two main reimbursement methods for hospitals
Per firm-hospital is paid a fixed amount per day of a patients stay
DRG’s-hospital is paid a fixed amount for the entire treatment of a patient based on the condition the patient is treated for.
Why are discharge protocols important?
Hospitals are increasingly accountable for the patients clinical status after discharge.
