Missouri RHC - Health.mo.gov

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Missouri RHCPerformance Improvement Network PONDBenchmarking System Kickoff WebinarNovember 10, 2020

Missouri Office of Rural HealthThis project is supported by the Health Resources and Services Administration (HRSA) ofthe U.S. Department of Health and Human Services (HHS) as part of a financial assistanceaward totaling 205,000 (25 percent) funded by HRSA/HHS and 615,000 (75 percentage)funded by nongovernment sources through an award with the Missouri Department ofHealth and Senior Services, Office of Rural Health and Primary Care (DHSS, ORHPC). Thecontents are those of the author(s) and do not necessarily represent the official views of,nor an endorsement, by HRSA/HHS, or the U.S. Government.

2019 Missouri RHCsRHC CountsTotal RHCs237 63%Provider-Based347110 29%Independent

2019 Missouri RHCsStatewide Medicare ReimbursementMedicare Reimbursement 117,292,637 94,125,983(Loss) / Gain( 23,166,654)Medicare Costs

PONDPractice Operations National Database

Lilypad partners with the National Organization ofState Offices of Rural Health, individual State Officesof Rural Health and national rural researchers to offerthis unique performance improvement program.6

Our Current NJMDOHILUTCAIAMACT RIVAKYMONCTNAZOKNMSCARMSTXALGALAFLAKHI7

InformationCost Report ScorecardsStateScorecardsClinicScorecardsPOND AnalyticsClinicScorecardInteractiveTools2018 Lilypad Cost Report Scorecard2018 Lilypad Cost Report ScorecardTitusville Area Hosp Physician SvcsState of Oklahoma( CCN: 393438 )State of OklahomaSummary StatisticsCompleted Cost ReportsPBC-RHC/ IncompleteRHCs Not Meeting Min Productivity% RHCs Not Meeting Min ProductivityTotal Visits52 / 6RHC6/0NOSORH Region DTOTALPBC-RHC58 / 6169 / 50RHCTOTAL41 / 9210 / 311)(125,286)Titusville Area Hosp Physician Svcs is a provider-based Rural Health Clinic (RHC) operated as a department ofTitusville Area Hospital with 25 licensed beds. It is not subject to a CMS per visit capped rate of 83.45 for 2018.CCN: 393438Clinic and Provider Metrics2016Practice Operations National Database2018PARegion AUSATotal Visitsxx3,975296,469508,6188,167,553Total Adjusted )(14,094)(34,331)(420,790)Cost per Visitxx 315.47 190.74 207.60 220.10Cost per Visit 188.21 138.67 184.64 201.67 169.70 193.46Cost per Adjusted Visitxx 292.72 182.08 194.48 209.32Cost per Adjusted Visit 173.79 131.07 170.78 192.87 151.69 181.75Variancexx 22.75 8.66 13.12 10.78Variance 14.43 7.60 13.87 8.80 18.02 11.71Visits Subject to RHC Cap of 83.4532,75025,10357,853144,309469,737614,046Total Adjusted Visits350,090Variance(26,834)2017 Summary ReportEastern Clinic2018 PBC Benchmarks2017Cohort: USA Region A Rural Health Clinic (Provider-Based) (15)Staffing MetricsGross Charges per Total StaffNet Revenue per Total Staff 404,117COST 16,903,833 14,485,419COSTREIMBURSEMENTLO S Sfor Medicare Patientsfor Medicare Patientsin Medicare Reimbursements 2,418,414for 2018 Medicare PatientsState of OklahomaVisit and Cost Metrics (Actual)RHCPBC-RHCRHCTOTALPhysician Visits per FTE Physician4,0173,6103,9904,2764,2934,281Physician Cost per Physician Visit 86.97 65.95 85.68 89.98 78.75 86.83APP Visits per FTE APP3,4392,8483,3773,2083,2253,213APP Cost per APP Visit 45.41 38.32 43.86 46.08 41.81 44.85General Metrics (Actual)Medicare Percent of VisitsTotal Overhead per VisitREIMBURSEMENTfor 2018 Medicare Patients25.4%37.9%26.3%23.1%21.9%22.8% 18.59 64.71 21.91 21.34 74.40 34.97 127,46290668.4%50.0%Gross Charges per Clinical Staff 190,769 273,429Gross Charges per Non-Clinical Staff 413,333 321,599in Medicare Reimbursements20162018 PBC BenchmarksClinic Profit Margin20172018PARegion AUSAPhysician Visits per FTE Physicianxx3,4303,3063,5493,960NP Visits per FTE NPxx2,7982,8832,5552,853PA Visits per FTE PAxx–2,5292,5813,080APP Leverage Coefficientxx0.51.31.21.2Physician Cost per Physician Visitxx 153.19– 116.49 47.25 116.61 52.46 100.93Nurse Practitioner Cost per NP VisitxxPhysician Assistant Cost per PA Visitxx– 53.54 53.56 51.75Physician Cost per FTE Physicianxx 525,446 385,161 413,869 399,708 50.80Nurse Practitioner Cost per FTE NPxx– 136,226 134,036 144,954Physician Assistant Cost per FTE PAxx– 135,431 138,239 159,402-6.52%Clinical Profit Margin per Patient VisitClinical Profit Margin per Total FTEExpense per Patient VisitExpense per Total FTE-11.9% -9.60 -14.0 -6,316 -15,300 157 130 103,158 121,979Productivity MetricsWork RVUs per FTE Physician3,571Work RVUs per FTE APC-New Patients per FTE PhysicianNew Patients per FTE APCPanel Size per FTE PhysicianPanel Size per FTE APCProduced exclusively for Gregory Wolf on Saturday, May 25, 2019Copyright 2019 Lilypad, LLC – All rights reserved – info@lilypad207.com 148,982658Clinical Staff RatioLO S SRegion A ClinicsMedian 96,842Performance MetricsNOSORH Region DTOTALPatient Visits per Total Staff 34,318CCN: 393438Provider MetricsPBC-RHC 369,799ClinicValue uced exclusively for Gregory Wolf on Monday, May 27, 2019Copyright 2019 Lilypad, LLC. All rights reserved. info@lilypad207.comPage 1 of 2Copyright 2016 - 2019 Lilypad, LLC. All rights reserved.To gain access to these reports and tools the requireddata must be entered into the POND web application8

POND Tutorialhttps://vimeo.com/466246995/0ebde8b5069

Rural Primary Care PracticeChecklist

10-Point CheckupCost Report ConsolidationPatient Panel DevelopmentProductivity StandardsHCC Education and MonitoringOptimal Hospital LinkageCCM, TCM and BHI Implementation340B OptimizationContracts and ComplianceSpecialty Care IntegrationQuality Measurement/Benchmarks11

Cost Report ConsolidationHospitals have an option to “consolidate” statistics for rural health clinics on their Medicarecost report submissions.Sample ASample BSample C4 clinics, NO consolidation4 clinics, FULL consolidation4 clinics, PARTIAL consolidation4 Schedule M1 Schedule M2 Schedule MNote: Hospitals need to indicate they will consolidate clinics prior to the start of the cost report yearNote: Consolidation of clinics makes financial sense approximately 90% of the timeNote: Hospitals can elect to consolidate all, some or none of their rural health clinics12

Consolidation Case StudyClinic AClinic BCosts 1,440,287 910,724 2,351,011 2,351,011--Visits8,6444,78813,43211,031(2,401) 166.62 190.21 169.14 231.13 43.992,9193493,2683,268-- 486,372 66,383 522,755 696,501 143,746Adjusted Cost/VisitMedicare VisitsReimbursementCombined ConsolidatedVariance13

2019 Missouri RHCsCost Report ConsolidationSitesCost OTAL34723969%

Productivity StandardsCMS defines a minimum expected number of patient visits for physicians and advancedpractice providers (i.e. Nurse Practitioners and Physician Assistants)The goal is always to maximize visit volumes4,200Physicians2,100APPsNote: Only employed providers are subject to the Minimum Productivity standardsNote: Contracted physician volumes are not included in the calculationNote: If clinics do not meet productivity standards, the clinic does not get cost-based reimbursement15

2019 Missouri RHCsMeeting Productivity StandardsTotal RHC Cost Reports169Meeting Standard 101239Cost Reports60%Provider-Based81%7057Cost ReportsMeeting StandardIndependent

Annual Work RVUsPhysicians (n 561)3,276 RVUsAPPs (n 564)2,338 RVUs

Specialty Care IntegrationRural Health Clinics were designed to increase access to primary care in rural communitiesbut RHCs also can offer access to specialty care49%Primary CareAt least 50% of all servicesrendered in the RHC need tobe “primary care services”51%Specialty Candidates General Surgery Orthopedics ENT GI NeurologyNote: RHCs should prioritize specialties that require clinical time to support surgical volumes18

Contracts and ComplianceProvider Compensation is critical but mistakes are commonInconsistencyContracts, valuation opinions, and payroll are not standardized, documented, orexecuted consistently.ReasonablenessDesperation leads to throwing money at recruitment and retention rather thanstepping back and determining what makes sense. Often opportunities for nonmonetary compensation are overlooked.Wrong PeopleOrganizations take a top down approach with compensation and do not involvethe practice administrator or the physicians.BenchmarksHospitals assume MGMA (or POND) median will protect them from acompliance standpoint – it won’t. The OIG has consistently come out sayingsurveys are not the final word on Fair Market Value.MonitoringWhen compensation requires supervision, minimum clinical hours, oradministrative duties, monitoring of scheduling and documentation is critical.19

Annual Compensation (per FTE)Base SalaryPhysiciansAPPs 165,000 (n 285) 85,000 (n 292)Variable 75,000 (n 184) 35,000 (n 143)

Next Steps for Missouri RHCsLet’s Build the Database! Enroll in PONDComplete the Telemedicine surveyEnter data into PONDGenerate reports and benchmarksStay tuned for additional TA and programming

Lilypadand PONDGregory Wolfgwolf@lilypad207.com(207) 232-3733

Note: Hospitals need to indicate they will consolidate clinics prior to the start of the cost report year Note: Consolidation of clinics makes financial sense approximately 90% of the time Note: Hospitals can elect to consolidate all, some or none of their rural health clinics Sample A 4 clinics, NO consolidation 4 Schedule M Sample B

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Page 5 of 8 ICN MLN006398 May 2019 Medicare applies the Part B deductible to RHC services based on total charges. Non-covered . expenses do not count toward the deductible. When the deductible is met, Medicare pays RHCs 80 percent of the AIR for each RHC visit, except preventive se