Download Resource - TARGET Center

Retaining and Gaining Insured HIV+
Patients in Your Medical Practice:
Surviving the Opportunities and
Challenges Presented by the ACA
Julia Hidalgo, ScD, MSW, MPH
About the AETCs
The AIDS Education and Training Centers (AETCs), a national network of
leading HIV experts, provide locally based, tailored education and technical
assistance to healthcare teams and systems to integrate comprehensive
care for those living with or affected by HIV. The AETCs transform HIV care
by building the capacity to provide accessible, high-quality treatment and
services throughout the United States.
The AIDS Education and Training Centers are funded by the Health Resources and Services Administration, HIV/AIDS Bureau
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Include state and your organization
Date Area
Retaining and
Gaining Insured HIV+
Patients in Your
Medical Practice:
Surviving the Opportunities and
Challenges Presented by the ACA
September 23, 2013
Julia Hidalgo, ScD, MSW, MPH
Positive Outcomes, Inc. &
George Washington University
[email protected]
Disclaimer
 The information provided in this webinar does not necessarily
represent the views of agencies funding George Washington University
or Positive Outcomes, Inc.
 Strategies provided in this webinar may vary by state
 It is important to maintain current knowledge about health care
reform in your state to ensure timely and well informed actions
 For Ryan White HIV/AIDS Program grantees, it is important that you
seek guidance from your project officer or grantee to ensure your
programs’ strategies are consistent with HIV/AIDS Bureau (HAB) policies
and grant requirements
 Thanks to the American Academy of HIV Medicine, HIV Medicine
Association, and HealthHIV for supporting the work reflected in this
webinar
Presentation Focus
 Today’s webinar focuses on helping HIV clinicians to retain and gain
insured HIV+ patients in your practices by
 Participating in commercial and public health insurance provider networks
 While the ACA is our most immediate focus for provider participation, there
are other opportunities for contracting with employer-based health plans,
Medicare and Medicare+ Choice health plans, and other insurers
 Effective contracting strategies
 Gaining access to newly insured patients
 Expanding capacity to serve additional HIV+ patients
 Ensuring that your practice receives sufficient third party reimbursement to
cover your costs
 Educating your patients about the insurers in which you participate
 Screening your patients for current or potential insurance enrollment
“I hope this will be very practical information from the beginning, and less about history of the
reform. I need very practical information! “
Are you ready
to participate
in Marketplace
Qualified
Health Plans
and Medicaid
expansion?
Rationale for Readiness for the ACA: A Review
 Continue to serve your current HIV+ insured
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patients and expand services to additional
HIV+ insured patients
Diversify income sources to reduce
dependency on grant funds
Fiscal solvency
Generate discretionary income for capital
investment, administrative expenses, and
services not supported by grant funders
Adhere to HAB policies
Rationale for Readiness of HIV Clinics in States That Have Chosen
Not to Expand Medicaid Coverage
 Health insurance coverage available to
patients with pre-existing health
conditions who were denied benefits or
enrolled in Pre-Existing Condition
Programs
 Readiness for Medicaid participation,
particularly managed care systems, can
be a slow process
 You can gain important experience by
participating in commercial health
insurance provider networks
 Many HIV+ individuals may benefit from
enrollment through Marketplaces
Key Domains of Readiness for Health Reform: A Review
 Aligning with your organization’s vision
 Building infrastructure
 Defining your products and target
populations
 Computing the cost of your products
 Re-engineering your practice management
 Assessing the health insurance market
 Contracting with health insurers
 Educating HIV+ patients about navigating
health insurance systems
Practice Management Readiness Activities
 Expanding workforce capacity to deliver covered services to enrolled HIV+
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beneficiaries
Designing telephone systems that promote patient communication rather than
create barriers to access
Scheduling systems to optimize clinician productivity, reduce broken
appointment rates, and promote retention in care
 Open access or same day appointment scheduling
Assessing and improving wait times for new and established patients
Streamlining registration and intake process
Assessing and improving patient flow to optimize efficiency and maximize
resources
Enhancing eligibility determination, e-verification, and enrollment assistance
systems
Addressing factors resulting in HIV+ patient lost to care
 Do you know your lost to care rate? Have you designed and implemented a
strategy for improving retention in care?
Practice Management: A Review
 Adopt practice and panel management systems
 Adopt patient empanelment processes (i.e., assigning each provider a set
number of patients) to improve clinical processes and outcomes
 Assess and address patient flow, opportunities for task shifting (ideally to billable
personnel), continuity of care, time consuming activities (e.g., medication refills),
impact of part-time clinical staff on productivity and quality
 Automate patient process and outcome data, quality management
systems, and capacity to improve clinic and provider performance
 Team with CBOs and other community partners to undertake
community-based linkage to care and retention activities
 Become educated about the concepts and adopt tools to create
accredited patient-centered medical homes
 Update practice policies and procedures and mobilize your staff
Eight Steps
for
Contracting
With
Insurance
Plans and
MCOs
Eight Key Steps for Contracting
 Check with your organization about
their health plan contracting process
 Identify opportunities in the health
insurance markets
 Gather information about insurers
 Assess insurers’ track records
 Understand how insurers will pay for
your services
 Evaluate the adequacy of payment
based on your actual costs
 Contract with insurers
 Assess payoffs and pitfalls
Resource: HIVMA, Strategies for
HIV Medical Providers
Contracting With Health Insurers
 Check With Your Organization About Their Plan
 Before moving forward with health reform readiness activities, it is
critical to
Ensure your HIV practice’s efforts are aligned with your organization’s
overarching readiness efforts
 An important step for HIV practices in large integrated health
systems, hospital-based or university-affiliated health systems, city
or county health departments, large FQHCs
 Contracts may have been negotiated or are being negotiated now
for 2014
 Medicaid managed care contracts have probably been finalized for
the current year
Engage organizational leadership, including corporate board support
Identify organizational resources that can be applied to your
readiness activities
 Identify Insurance Contracting Opportunities
 The American Academy of HIV Medicine
and Positive Outcomes, Inc. teamed to
gather State-specific information about
provider enrollment in Marketplace
Qualified Health Plans and Medicaid
(including fee for service and managed
care): http://www.aahivm.org
 Your State’s Health Insurance
Commissioner has information about other
licensed health insurance plans in your
state: http://www.naic.org/state_web_map.htm
 Gather Basic Information About Insurers’ Networks
 Research health insurers and managed care plans in your service area to
assess network participation by
 Specialty care providers
 Do the providers serve your patients?
 Are there gaps in specialties and subspecialties needed by your patients?
 Are the providers conveniently located?
 Pharmacies
 Are you familiar with the pharmacies?
 Are they conveniently located?
 Do they routinely stock HIV medications?
 Is mail order delivery available?
 Inpatient hospitals
 Are you familiar with these hospitals?
 Do you have admitting privileges with these hospitals?
 What is the hospital’s track record about notifying you about your patients’
admissions?
 What is their track record for coordinating inpatient discharges?
 Gather Basic Information About Insurers’ Policies and Procedures
 Payment Rates
 Can you negotiate with the plan?
 What are the payment mechanisms and rates?
 Are enhanced payments available for care coordination?
 What is the plan’s policy for timely payment?
 What is the plan’s rate of denied claims for primary care and ID visits?
 Access to HIV Providers and Specialty Care
 Are referrals required for HIV+ patient to receive your services?
 Can HIV specialists serve as primary care providers?
 Is HIV recognized by the insurer as a specialty?
 What is the plan’s credentialing requirements?
 What are the plan’s access standards?
 For Marketplace Qualified Health Plans, what is the process for
contracting as an Essential Community Provider?
 Gather Basic Information About Insurers’ Policies and Procedures
 Coverage and Benefits
 Who determines medical necessity?
 What is the plan’s policy for coverage of HIV tests, antiretrovirals, CD4 tests, viral
load tests, and genotype and phenotype resistance test?
 Is prior authorization required?
 Are disease managers or case managers routinely assigned to HIV+ patients?
 What is their role in care coordination? What are their training requirements
and expertise?
 What are their utilization management and review procedures?
 Quality and Reporting
 Does the plan have HIV-related quality measures?
 What are the provider reporting requirements?
 What is the plan’s quality track record?
 Resource: The Harvard Law School Center for Health Law and Policy Innovation has
developed a resource for assessing other aspect of health plans:
http://www.hivhealthreform.org/assessment/
 Assessing the Insurer’s Track Record
 Many health insurers operate in multiple states
 Reach out to your colleagues in other HIV clinics and ID practices to learn of
their perceptions of the insurer:
 The insurer’s willingness to negotiate contracts, including enhanced HIV
payment arrangements
 Adequacy and timeliness of payments
 Financial stability
 Propensity to deny claims due to “lack of evidence of medical necessity”
 Willing to allow standing referrals
 Coverage of HIV testing, ARVs and other HIV medications, and HIV-related
lab tests
 Use of disease managers to “manage” HIV, mental health, substance
abuse treatment utilization
 Understand How Insurers Will Pay for Your Services
 Fee-for-service (FFS) continues
to be commonly used by
commercial and public health
insurers
 Capitation payment models
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Primary care coordination payments
Condition-specific capitation
Shared savings
Global payments
Pay for performance
Budget-based payment systems
Accountable care organizations
Carve outs and carve ins
Ways to Limit Risk in Managed Care Contracting
 Payments models vary in the extent to which the provider assumes
financial risk
 Accept capitation only for services your practice directly provides or controls
 Carve out high-cost, low-frequency services more appropriately reimbursed
on a FFS basis
 Strive to retain FFS payment until a statistically valid enrollment level has
been achieved by health plan
 Purchase stop-loss insurance coverage
 Seek risk adjustment in the payment system
 Define precise boundaries between your practices’ services and other
providers’ care to avoid “dumping”
 Gain experience with small-scale contracts
 Ensure that adequate termination options exist
 Evaluating the Adequacy of Payment Systems Based on Your Costs
 The AMA has developed tools to help medical practices calculate their
costs: http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/claimsrevenue-cycle/managed-care-contracting/evaluating-payment-options/establishing-baseline.page
 HAB offers resources to calculate unit costs
 http://hab.hrsa.gov/deliverhivaidscare/tactoverview.html
 It is important to include the actual components of cost for the contract
period, including salary adjustments
 The amount of grant funds awarded to your program by HAB or other
funders is not your cost
 Conduct break-even analysis comparing costs to likely third party
insurance revenue
 Consider opportunity costs, such as the likely reduction in revenue from HAB
grants resulting from the payer of last resort policy and federal funding reductions
 Credentialing and Contracting With Commercial and Public Insurers
 Credentialing
 Many health insurers use the
Universal Provider Data Source
maintained by the Council for
Affordable Quality Healthcare for
their credentialing process:
http://www.caqh.org/overview.php
 Contracting
 Seek legal advice
 Prepare to negotiate
 Carefully evaluate the contract
 Contract terms
 Coverage and benefits
 Payment and claims
 Assessing the Payoffs and Pitfalls of Contracting
 In the first year of contracting with insurers, you may want to weigh the
financial benefits of your contracts versus issues that arose with the
insurer and their enrolled patients
 Small number of enrolled patients, resulting in administrative costs and
hassle but small revenue yield
 Insufficient revenue to cover administrative costs
 Staff time to research and resubmit rejected claims
 Untimely payment
 Payment that does not cover labor and overhead
 Rejection of claims due to lack of medical necessity
 Limits on the number of visits covered, burdensome cost controls, or
other utilization management policies
 Prior authorization or other requirements for specialty referrals
Marketing
to Health
Insurers
Considerations in Marketing to Health Insurers
 What are the products you are offering?
 How many plan members could benefit from your products?
 Will your products attract new members to the plan?
 How much does your product cost?
 Will the plan have to pay for your products (e.g., grant-funded service)?
 What distinguishes your products from that of another provider?
 How will your products enhance the plan’s network?
 How will your products help meet health plans’ benefits, network,
access, or quality assurance standards?
Defining Your Products and Target Populations
 Assess your current payer mix
 Identify services commonly covered by public and commercial insurers
 Parse non-billable services that may legitimately continue to be paid
by the Ryan White Program
 Identify services that may be covered by some insurers to help them to
manage service utilization, prevent morbidity or mortality, promote
positive health outcomes, and reduce unnecessary costs
 Prevention services, disease management, care coordination, linkage
and retention services
 HIV+ patients only, patients with communicable diseases (e.g., Hep C),
other patients
 HIV+ patients and provision of reimbursable HIV screening to insured
populations
Key Marketing Messages for HIV Providers
We are experienced in
 Delivering clinical services that reflect state-of-the art HIV care
 Delivering clinical and psychosocial services to hard-to-reach
populations
 Managing behavior to achieve positive clinical and behavioral outcomes
 Avoiding or reducing psychosocial crises that impact adherence to
clinical regimens
 Delivering culturally sensitive and appropriate services
 Working in an integrated network of clinical and support services
 Providing prevention services to reduce HIV infection among
beneficiaries, their sexual partners, and newborns
 Assisting newly identified HIV+ to link to care, be retained in care, and
be located if lost to care
 Delivering cost-effective services through low overhead
Educating
Patients About
Your
Participation in
Health
Insurance
Networks
Gaining and Retaining HIV+ Patients
 Develop and implement a patient marketing strategy
 If your website is part of the strategy, consider how it can be used strategically
 Ask your community advisory board and peer workers for strategies for gaining and
retaining HIV+ patients
 Educate HIV+ individuals about selecting an insurance plan in which you participate
and select an affiliated primary care provider
 Educate current patients about pathways to insurance enrollment through
Marketplaces, premium subsidies, ADAP assistance, current and expanded Medicaid
programs, importance of selecting a Medicaid managed care plan to avoid autoassignment
 Educate insured HIV+ individuals that are unlikely to need to enroll through the
Marketplace
 Reasons some insured patient should enroll in the Marketplace include that their
current plan does not meet ACA Essential Benefits requirements, lower cost
premiums, provide better benefits for their family, or to join a plan in which you
participate
Gaining and Retaining HIV+ Patients
 Actively facilitate the work of CMS and State-funded facilitators and
navigators, in-person assisters, and certified application counselors
 Arrange for on-site activities at your HIV clinic or practice
 Sponsor patient education sessions
 Inform current and new patients about your policies if eligible individuals do
not enroll in Marketplace or Medicaid health plans
 For new and ongoing patients, provide linguistically and culturally appropriate
patient education to empower patients to navigate your HIV clinic, the
broader health care system, and the health insurance system
 Adopt web-based patient tools to help them schedule appointments, request
medication refills, and get information about their health, HIV care, and
medications
 Help patients to understand “health insurance basics” through group and
individual training, including their roles and responsibilities
2014
Oct Nov Dec Jan
2014
2014
2013
2013
2013
While it is important to educate your HIV+ patients about
enrolling in the Marketplace during the Ryan White
Program eligibility determination and recertification
cycle, some patients may enroll before their next
determination appointment
Feb Mar
Common Errors Found in Intake and Assessment
 Household Size: assumption that the patient is a single adult, individuals
meeting EMA/TGA household definition are not identified during
assessment (particularly spouses and dependent children)
 Household Income: patients’ income poorly documented, family
members’ income not assessed, patients claiming $0 income not probed
for how they manage with no income, undercounting income from selfemployment, and missed income from sources other than wages
 Insurance Enrollment: inability to understand health insurance
deductions documented on paystubs, not researching if an employer
offers insurance benefits to full or part-time employees, not assessing
enrollment of spouses in plans that could cover the HIV+ spouse, failing to
query college students about enrollment through their college
 General Errors: not updating key information when things change
Tips for Assessing Health Insurance Enrollment
 Check paystubs carefully
 Ask the patient directly if he/she or his/her spouse is insured
 Ask the patient if he/she can enroll in insurance through his/her employer
 If the patient reports that he/she declined available health insurance, find out why, and help to
address concerns (e.g., cost or disclosure)
 If the patient reports his/her employer does not offer insurance, check the
employer’s human resources website and/or ask for an employer letter
 If the patient is less than 26 years of age, ask if his/her parents are insured and
inquire if he/she can enroll in parents’ insurance
 If the patient is a university or college student, verify available insurance, and
counsel the patient to enroll in available insurance
 Query the Medicaid electronic verification system and use commercial web-based
query systems to identify current Medicare and commercial insurance enrollment
 Avality, Capario, Medifax POS, Passport Health Communications, WebMD Envoy
Ready,
Set,
Go
Develop a Readiness Plan
 Remain calm
 Identify key members of your readiness team based on the
domains identified today
 Team members might include policy, practice management, finance, clinical,
information technology, human resources, and other staff
 If feasible, designate an in-house expert on health reform
 Honestly assess your readiness using the domains discussed
today, identify barriers, and develop realistic strategies for
overcoming them
 Readiness planning and implementation are likely to be
evolutionary, long-term, and improve with experience
 Even highly experienced HIV clinics report new challenges
Develop a Readiness Plan
 The readiness team should set priorities, create a schedule,
assign tasks, and meet routinely
 Anticipate that some tasks are likely to be slow
 Set short-term achievable goals- start slow and then grow
 Identify interorganizational and outside resources and seek help
 Routinely update the HIV clinic staff to solicit their suggestions and buy-in
 Aim for durable sustainability regardless of staff turnover
 Evaluate infrastructure and other costs and compute the likely
return on investment
 Identify and seek funds to cover costs
 Identify strategies to collaborate with other HIV clinics to form
formal or informal networks
Key
Resources
Key Resources
 American Academy of HIV Medicine
 http://www.aahivm.org/
 American Medical Association Practice Management Center
 http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center.page?
 Families USA Health Reform Central
 http://www.familiesusa.org/health-reform-central/
 Harvard Law School Center for Health Law and Policy Innovation
 http://www.hivhealthreform.org/assessment/
 CMS Medicaid Provider Payment Provisions Under the ACA
 http://www.medicaid.gov/AffordableCareAct/Provisions/Provider-Payments.html
 CMS Documentation Guidelines for Evaluation and Management (E/M) Services
 http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html
 Falcone AJ. Negotiating Contracts with Managed Care Organizations. A presentation at the HAB All
Grantees Meeting. November 2012.
 https://careacttarget.org/library/negotiating-contracts-managed-care-organizations
 HIV Medicine Association
 http://www.hivma.org/Home.aspx
 HRSA Bureau of Primary Health Care
 http://bphc.hrsa.gov/technicalassistance/index.html
 HRSA HIV/AIDS Bureau TARGET Center
 https://careacttarget.org/library/affordable-care-act-ryan-white-hivaids-program
Key Resources
 National Association of Community Health Centers
 http://www.nachc.com/complete-list-of-trainings.cfm
 National Academy for State Health Policy. Engaging Safety-net Providers in Expanded Coverage: Tips on
Enhancing Billing Capacity. http://www.nashp.org/sites/default/files/SNP.tips.billing.capacities.pdf
 National Association of State and Territorial AIDS Directors
 http://www.nastad.org/care_and_treatment/resources.aspx?category=health%20reform
 National Conference of State Legislatures, Medical Homes and State Implementation of the ACA and
Medicaid Expansion
 http://www.ncsl.org/issues-research/health/the-medical-home-model-of-care.aspx
 http://www.ncsl.org/issues-research/health/affordable-care-act-state-action-newsletter.aspx
 National Committee for Quality Assurance Patient-Centered Medical Homes
 http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx
 HIV Medical Homes Resource Center
 http://fxbcenter.org/mhrc.html
 Substance Abuse and Mental Health Services Administration
 http://www.samhsa.gov/healthreform/
 US Department of Health and Human Services ACA Resources
 http://www.healthcare.gov/
Questions
and
Discussion
Download the slides: www.HIVHealthReform.org
Maximizing HIV Care Reimbursement in 2014
http://www.aidsetc.org/aidsetc?page=etres-display&resource=etres-703&
EVALUATION
Please complete a brief evaluation survey that
will be emailed to each participant following
this presentation. All responses are
appreciated.
9/23/13
Thank You!!