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Affordable Care Act (ACA)
An Initial Overview Focus on IHS Perspectives
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Agenda ACA and Blackjack Desired End Points Key Ingredients for Success Exploring a Business Plan
Recent Media Perspectives
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ACA and Blackjack Similarities
Recent instruction from renowned CA Blackjack expert
Current perception Basic rules without a strategy Basic rules with a strategy
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Blackjack Basic Rules Without Strategy Pr
obab
le o
utco
me
$ 0 $
Hit and Stand is my sole fund of knowledge
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Blackjack Basic Rules With Strategy
Prob
able
out
com
e
$ 0 $
Hit and Stand plus Double Down, Split, Surrender, Insurance Example – Make insurance bet when hole card has a one in three chance of being a ten
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ACA and Blackjack Similarities
Reasonable conclusion – Chances of success are greater when fund of knowledge is enhanced and you develop strategies that improve the odds in your favor. A logical progression – these same principles could be applied to implementation of the ACA.
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Next Question
How do we develop a strategy for improving our odds of successful ACA implementation?
Step 1 – Determine where we want to go – desired end points.
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Desired End Points Perspective One - Broad Overview
Increased access Expanded health insurance options Clinic open more often (IPC) Increased availability of same day appointments (IPC) Providers accessible more often during day and after
hours (IPC)
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Desired End Points Perspective One - Broad Overview Increased access Improved outcomes
Comprehensive assessments (screening) More effective data management Utilize evidence-based treatment models Monitor patient outcomes Prompt revision of treatment plans as needed
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Desired End Points Perspective One - Broad Overview Increased access Improved outcomes Decreased costs
Improved outcomes Emphasis on primary prevention Greater competition
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Next Question
How do we develop a strategy for improving our odds of successful ACA implementation?
Step 1 – Determine where we want to go – desired end points.
Step 2 – Develop a business plan to define how we will reach the endpoints
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Business Plan Perspective Two – IHS Specific
Three additional targets 1. Number of patients receiving services remains stable or
increases each year 2. Third party collections remain stable or increase each
year 3. Customer service, quality of care, efficiency and
effectiveness improve over time
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Business Plan Basic Components
Seven key areas to address
Assess data reporting requirements*
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Assess Data Reporting Requirements
Awareness of all data reporting requirements Ensure all sources are identified and addressed
Federal (HHS entities, VA) State County Contractual requirements
Support needed upgrades to IT systems
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Business Plan Basic Components
Seven key areas to address
Assess data reporting requirements Assess patient flow*
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Assess Patient Flow
Two key items Implement best practices for improving efficiencies
Capturing data Address patient needs (comfort, waiting times) Thorough and speedy assessment Data assessment that facilitates HCP tx plan development Use of staff in cost-effective ways Electronic versus manual processes
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Assess Patient Flow Two key items
Implement best practices for improving efficiencies
Consider possible staffing additions/changes Patient benefit coordinator (Insurance) Billers Voucher examiners (possible increase in claim denials) Patient registration (do not want patients waiting) Finance support Cost-effective clinician support
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Business Plan Basic Components
Seven key areas to address
Assess data reporting requirements Assess patient flow Referrals and prior authorizations*
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Referrals and Authorizations
Will likely see modifications – Ex. CHS items may now be covered under new insurance programs
Key – revise procedures as needed to ensure agency is
payor of last resort
Other important point: If coverage works elsewhere, CHS budgets and priorities may be revised. One option mentioned – clinical preventive services
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Business Plan Basic Components
Seven key areas to address
Assess data reporting requirements Assess patient flow Referrals and prior authorizations
Patient workload and revenue impact*
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Patient Workload and Revenue Establish baselines for active patient population
3rd party coverage (Medicaid, Medicare, private ins. etc.) Number of 3rd party claims Current monthly collections
Project revenue growth potential for each category
Use this data to help in other clinic decisions
Personnel requirements Supply management
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Business Plan Basic Components
Seven key areas to address
Assess data reporting requirements Assess patient flow Referrals and prior authorizations Patient workload and revenue impact
Assess local health insurance marketplace*
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Assess Local Insurance Marketplace
Consider establishing a local SME to assess local, state and national factors that will impact ACA implementation
Key variables - examples State-based exchanges Medicaid expansion Competition Referral process analysis Patient input and feedback
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Business Plan Basic Components
Seven key areas to address
Assess data reporting requirements Assess patient flow Referrals and prior authorizations Patient workload and revenue impact Assess local health insurance marketplace
Eligibility process*
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Eligibility Process
Need a strategy to ensure maximum enrollment in alternate resources. Example – Continuous monitoring of future patient appointments
Electronic application processes will likely be essential.
May need to establish multiple systems as process will differ by organization
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Business Plan Basic Components
Seven key areas to address
Assess data reporting requirements Assess patient flow Referrals and prior authorizations Patient workload and revenue impact Assess local health insurance marketplace Eligibility process
Marketing*
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Marketing Deemed an essential tool to maintain and increase patient
user populations
Should use approved ACA community education and outreach materials
Will likely emphasize why the Indian Health Care system is the best possible medical home Quality of care Customer service Consider the importance of cultural perspective
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How to Begin Leadership determines desire to prepare for ACA and
develop a new business plan
Assuming the desire, a good place to begin: Clear understanding of data requirements Mechanism to assess and revise clinic flow
Capture data efficiently and effectively Process is easy and comfortable for the patient Update IT infrastructure as needed
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Possible Processes Complete task independently
Use existing staff expertise Establish contractual arrangement with experts
CRIHB Private sector
Work in partnership with IHS
IPC is still available Work collaboratively with specific expertise
Data requirements Clinic flow IT needs
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Other Opportunities Best Practices Meeting
May 20 to 23 Sacramento, CA Will have staff and other experts to explore these areas in
more detail
CMO discussion with Program/Clinical Directors Recent experience at Kima:w Conversations with some clinical directors Will work hard to increase visits Can also schedule some calls
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Recent News USA Today – 03/08/13
Prognosis: Profit Growth in Medicaid New law means providers expect wave of enrollees
Business perspective “This is several hundreds of billions of dollars of new market opportunity.” Jason Garda of Leerink Swan investment bank
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Recent News USA Today – 03/08/13
Government perspective - CBO 8 million new enrollees nationwide in 2014 12 million total new enrollees by 2020
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Recent News USA Today – 03/08/13
California perspective Molina healthcare “We know demand for care is only going to increase, and we are trying to build capacity to get ahead of the curve.” J. Mario Molina, CEO Note – In 1980 J. Molina’s Father started the company in Long Beach, CA. They now have 2 million members in their plan.
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Recent News USA Today – 03/08/13
New ideas - reduce costs Centene – 2.5 million members, 18 states Pay enrollees who get preventive services Money goes into account enrollees can use for basic services – utilities, transportation, etc. 400,000 members joined 7.8 million dollars in basic services provided
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Recent News USA Today – 03/08/13
Some concerns
Lack of healthcare providers Payment rates may not cover costs Connecticut, Kentucky, Nevada, Ohio
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Recent News USA Today – 03/08/13
Some key points Many complex variables need to be considered in a business plan Issues/obstacles may vary throughout CA - Extent of competition - Potential new enrollees
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A Final Thought
“When the world seems to big, it is often best to just start walking.”