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MORE Medical Home Reimbursement Models: ROI from Risk Adjustment, Shared Savings and Multi-Payor Partnerships
MORE Medical Home Reimbursement Models: ROI from Risk Adjustment, Shared Savings and Multi-Payor Partnerships
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The Patient Protection and Affordable Care Act is rife with incentives, pilots and demos to improve healthcare delivery and efficiency — many of which are directly tied to team-based, integrated care approaches such as the patient-centered medical home (PCMH).

Strategies for generating revenue from the PCMH are documented in MORE Medical Home Reimbursement Models: ROI from Risk Adjustment, Shared Savings and Multi-Payor Partnerships.

In this 45-page resource, learn how the identification of high-risk patients, meaningful distribution of healthcare data and collaborations with like-minded organizations are increasing medical home profitability for three healthcare organizations — including one that has been touted as "the gold standard for healthcare reform:"

  • Get inside details on Grand Junction, Colorado's shared savings model — an approach that first gained notoriety when The New Yorker contrasted its low-cost, high-quality delivery with one of the most expensive healthcare systems in the country. Grand Junction hospitalist, family physician and healthcare consultant Dr. David West shares the four strategies that have helped to hone the area's cost efficiencies in the face of physician shortages, high numbers of uninsured and many of the same challenges faced by healthcare systems around the country.

  • Dr. Jeff Schiff, medical director of Minnesota healthcare programs for the Minnesota Department of Human Services, describes the state's risk-adjusted reimbursement model for medical homes. Dr. Schiff dissects the risk-adjusted methodology at work in Minnesota, where health plans are required by law to include healthcare or medical homes in their networks. The delivery system has a built-in payment reform that reflects the patient's complexity and the time required by the medical home to care for complex patients. This novel approach to management of chronic disease is showing early returns of improved outcomes and reduced costs.

  • Sharing lessons learned from Colorado's nearly three years of participation in a multi-state multi-payor medical home pilot is Julie Schilz, co-chair of the Center for Multi-Stakeholder Demonstrations and IPIP manager for the Colorado Clinical Guidelines Collaborative. Ms. Schilz describes four key considerations for a multi-payor medical home program — from establishing demonstration guidelines and gaining stakeholders' support to considerations for payment reform and alignment of demonstration goals.

    Drawing upon the benefits of her experience since initially presenting the multi-payor pilot in 2007, Ms. Schilz also addresses the practicalities of practice recruitment and screening, the pilot's three-pronged reimbursement model and the challenges of integrating participating practices into a medical home neighborhood.

In addition to funding fundamentals from these innovative models, this resource describes other program aspects supporting cost-efficient care delivery, including:

  • Colorado's learning collaborative and quality improvement coach;
  • Grand Junction's secrets to reducing readmissions of Medicare patients;
  • How Grand Junction is capitalizing on the competitive nature of physicians and peer review to bring healthcare costs in line;
  • Minnesota's consideration of some non-medical complexity factors that can increase the amount of time required from the care team;
and much more.

Table of Contents

  • Risk Adjustment in Medical Home Reimbursement
    • Attributes of the Medical Home
    • Origin of the Minnesota Medical Home
    • Payment Mechanisms for Care Coordination
    • Considering the Patients Complexity
    • Identifying High-Risk Patients
    • Details of the Risk-Adjusted Model
    • Calculating Physician Time for Complex Patients
    • Refining the Financial Model for the Healthcare Home
    • Non-Medical Complexity Factors
  • Shared Savings in the Medical Home
    • Addressing Physician Shortages
    • Meeting Healthcare Needs of Uninsured
    • How Hospitals Benefit
    • Meaningful Data for Physicians
  • Funding Multi-Payor Medical Home Programs
    • Gaining Stakeholder Commitment
    • Addressing Anti-Trust Considerations
    • Exploring Payment Reform
    • Technical Assistance
    • Creating a Medical Home Neighborhood
    • Pre-Visit Preparation
  • Q&A: Ask the Experts
    • Determining Relative Risk
    • Handling Medical Risk
    • Breaking Down Provider Payments
    • Combining Risk Adjustment Factors into a Reimbursement Strategy
    • Doctors in the Minnesota Model
    • Grand Junctions Reconciliation Process
    • Specialist Incentives in Medical Home Reimbursement Models
    • Sharing the Shared Savings Model Across Markets
    • Identifying Quality Indicators
    • Reducing Readmissions Among the Medicare Population
    • Reacting to Match Day Family Medicine Residency Rates
    • Preparing Medical Students for the Healthcare Business
    • Essential Component of the Medical Home
    • Impact of CMS Demo on the Medical Home
    • Payor Fee Structures
    • Preliminary Multi-Payor Results
    • Evaluating ROI and Patient Satisfaction in Multi-Payor Programs
    • Developing Payor Contracts
    • Practice Recruitment, Selection and Funding
    • Planned Colorado Enhancements
    • Ensuring Quality of Medical Home Services
    • Role of the Quality Improvement Coach
    • Specifics of the Learning Collaborative
  • Glossary
  • For More Information
  • About the Presenters
Publication Date: June 2010
Number of Pages: 45
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