Certified Healthcare Financial Professional

1. Certified HealthcareFinancial Professional Module I The Business of Health Care Course 6: Looking to the Future Jeff Helton, PhD, CMA, CFE, FHFMA Assistant Professor – Health Care Management Metropolitan State University of Denver, Denver, Colorado

2. Learning Objectives YOU will be able to • Describe some of the new healthcare reimbursement models; • Define the use of business intelligence in the context of health care; • Describe how finance professionals, physicians and payers will need to work together;

3. Learning Objectives YOU will be able to • Define the trend of population health in future healthcare delivery models; and • Apply the lessons learned in this course to your future work in the healthcare industry.

4. Purpose of this Chapter Learning Program • Highlight key knowledge for strong job performance • Provide an overview of important concepts. The in-depth presentation is in the online course.

5. Evolving Models of Reimbursement • Our current model is very inefficient • Fee-For-Service reimbursement = Incentive to providers to provide more services • Other models – • DRG or per case rates • Per diem rates • Capitation was used as a step toward efficiency – but imperfect too

6. Evolving Models of Reimbursement • Capitation has limitations • Linking reimbursement to quality outcomes • With the Affordable Care Act, there is more incentive for providers to coordinate care – and provide only the care that is needed • A move from “volume” to “value”

7. Evolving Models

8. Evolving Models – The ACO • Network of providers • Share financial and clinical responsibilities • Serve a defined group of patients • Key feature: Primary Care physicians in a lead role • May include PCMH

9. ACO Challenges • Knowing who you are responsible for – “attribution” • Patient Loyalty • Managing costs and quality of care of non-ACO providers • Bundled payments

10. Bundled Payment • Essentially, “Fee-for-Service” payment – for a specific service • Collaborative care delivery meets funding autonomy • Collaborate on rewards … and risks • Introduces a need to really consider who to partner with

11. The Point of Medical Homes, ACOs and Bundled Payments • Providers working together to generate positive patient outcomes • Align incentives • Decrease incentive for providers to strive to provide an increasing volume of services • Increase incentive to focus on quality of outcomes and value for the prices paid • A challenge – what to do to maintain revenues?

12. BA and BI in Health Care

13. Business Intelligence Implementation Key Factors: • Data Strategy • Determine metrics to monitor: Business and strategic plans • Access (and timeliness) to data for decision makers • Maintaining data integrity • Collaborative relationships to validate metrics and interpret results

14. Aligning to Drive Value value : “quality in relation to the total payment for care”

15. Financial and Clinical Alignment

16. Population Health Management

17. Population Health Management • Determining patient care needs • “Make vs. buy” decisions • Measuring performance • Determining incentives for participants • Managing what you measure and measure what you manage

18. Implications • Rapid change in business model: From volume to value • New skill sets required: • Collaborative team skills • Multidisciplinary approaches • “Optimizing costs” • See the big picture: less about numbers alone and more about viewing the context of the numbers and what is needed to meet the patient’s needs

19. Implications • New Skills (cont) • Insight into clinical sciences i.e. professional practice models • Clinical professional must help inform business decisions • Focus: benefit the business and the patient