Fitting the Puzzle Pieces Together Contracting with Your Outcome Data

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Fitting the Puzzle Pieces TogetherContracting
with Your Outcome Data
of Charges
Per Diem?
of UCR
Satisfaction
Value
Severity
Duration
Improved
FUNCTION
Trish Hoover, Insurance Relations Coordinator
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• Established December 1, 1977
• Dream to grow profession
• To provide innovative care
• One office in West Knoxville single
• Physical Therapist
• Care to orthopedic population

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Growth of Practice . . .

• Factors
• Passion
• Risk
• Quality care
• Going the extra mile
• Patient satisfaction word of mouth
• Supporting / complimenting services of referral
  sources
• Culturing and commitment of additional staff,
  promoting the benefits of private practice.

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Mission Statement

• Excellence in the compassionate and efficient
  delivery of rehabilitative and preventive health
  care to the people we know, love and serve.

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Celebrating 25 Years of Service

• Seven Facilities in East Tennessee
• 33 Physical Therapists
• 15 of the 65 therapists holding Specialty
  Certification in Tennessee from the ABPTS are TTC
  Staff.
• 3 Occupational Therapists
• 2 Speech Pathologists

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• Programs
• Orthopedic
• Aquatics
• Pain Management
• Orthotics
• Womens Health
• Neuro
• Pediatrics
• Sports
• Lymphedema
• Wellness / HOPE

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Why Outcomes?

• Began participation in F.O.T.O. 1994
• Rationale
• Internal Quality Assurance
• Practice
• Facility
• Individual Clinician

Secondary Benefit Development of CE programs to
enhance skills of staff

• External Marketing
• Proof of Quality to referral
  sources and payors

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• Since 1994, TTC has ranked in the top 10th
  percentile in Functional Outcomes!

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• Quality Care,
• Functional
• Improvement,
• and Patient
• Satisfaction continue to be vital components of
  the growth of the practice.

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Managing Your Practice GrowthMarketing
Contracting with Proof of Quality
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Marketing vs ContractingIs there a difference?

• Key to successful contracting is successful
  marketing.
• Monitoring your mix and targeting new or changing
  population targets from
• Referral Sources
• Employers (Health WC)
• Case Managers
• Payor Sources

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Proving Quality to . . .

• Physicians
• Offer your physicians Outcome Data on the
  patients they refer (Include physician ID number
  to FOTO data we use referral ID field 2)
• Incentive to refer at least 25 patients even
  high risk

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Proving Quality to . . .

• Physicians
• Investigate panel status with employers offer
  outcome data to validate your quality of care
• Investigate high volume DX for
  physician offer outcome data for
  that DX category.

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Proving Quality to . . .

• Physicians
• Potential Result
• Physician recommendation / support of your
  participation on an employers panel and/or your
  PAR status with an insurance carrier.
• Increased referrals due to win/win

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Proving Quality

• To Employers
• Identify increasing populations of patients from
  an employer target.
• Coupled with program information, functional
  outcome data regarding the quality of your care
  can be a powerful tool.
• Note possibilities of identifying problematic WC
  injuries offer outcome data.

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Proving Quality to . . .

• Employers
• Potential Result
• Employer recommendation / support of your
  participation on their panel and/or your PAR
  contract status with their Health and/or WC
  insurance carrier.
• Increased referrals due to win/win

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Proving Quality

• To Case Managers
• Primary goal case closure managing costs.
• Use outcome data to not only validate your
  quality of care but compare the amount of
  functional improvement as it relates to
• Utilization
• Value
• Risk adjustments the benefits
  of early referral

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Proving Quality

• To Case Managers
• Potential Result
• Case Manager recommendation / support of your
  contracted participation with their Case
  Management Firm.
• Ability to negotiate a higher reimbursement level
  based on proven outcomes.
• Increased referrals due to win/win from the case
  management group, physicians associated
  with the case management firm, and
  employers

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Proving Quality

• To Insurance Carriers / Networks
• Identify increasing numbers of patients or failed
  referrals (non-PAR, no out of plan benefit) and
  target for contract status.
• Provide outcome data
• Overall
• Health Insurance only
• WC only

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Proving Quality

• To Insurance Carriers / Networks
• Provide explanation of OI as it relates to
• Utilization
• Duration
• Value
• Risk adjustments the benefits
  of early referral

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Proving Quality

• To Insurance Carriers / Networks
• Potential Result
• Potential to negotiate a higher reimbursement
  level based on proven outcomes.
• Increased referrals due to win/win from
  the physicians, case managers, and employers
  associated with the carrier/network

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Proving Quality

• The bottom line . . .
• Never miss an opportunity to share your outcome
  data
• A successful marketing contact with a physician,
  employer, case manager, or insurance
  representative can affect the entire
  referral/payor chain.
• For example . . .

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Sample of Outcome Data for Physician on Knee
Category
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Showing Overall OI and Highlighting Knee Category
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Knee Category OI Consistency
TTCs outcomes for knee patients consistently
higher than National or Regional FOTO means.
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Scenario Resulting in Network Contract
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Network Contract

• Contact with a regional workmans compensation
  network
• Identified as a target during verification as
  non-PAR.
• This network represented 340 municipal
  governments across the state

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Network Contract

• Initial contract rates offered
• 96.00 per Evaluation
• 80.00 subsequent therapy visits.
• 30 off normal and customary charges for WH/WC
  and FCE services

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Network Contract

• Negotiations for this contract included the
  provision of the following information
• Work Injury Management Program materials
• Outcome data on all patients as well as an
  outline of OI on our WC
  population

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Network Contract
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Network Contract
Interpretation TTCs OI in all impairment
categories above FOTO regional mean.
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Network Contract

• Interpretation
• 59 of TTCs WC patients fell into the Severe
  category compared with only 47 of Regional FOTO
  patients.
• Based on the high of patients in the Severe
  Category, the Net revenue/episode is justified
  and intensifies the OI variance

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Network Contract

• FINAL OUTCOME
• Network agreed to revised contract rates as
  follows
• 135.00 per Evaluation
• (41 increase over original contract rate)
• 100.00 subsequent therapy visits
• (25 increase over original contract rate).
• 25 off normal and customary charges for
  WH/WC and FCE services
• (5 increase)

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Scenario Resulting in Renegotiation of HMO
Contract
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HMO Contract

• 3rd Largest in Region
• Offered 44 per visit, Commercial and Medicare
  Risk, stating standard ancillary contract rate.
• Growing of TTC business (at that time 4 and
  increasing)
• During first negotiating session, sold Quality
  and Value and used FOTO Reports in discussions
• O.I. Change Per Episode
• V.I. Change Per Dollar Spent
• U.I. Change Per Visit

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HMO Contract
Outcomes by HMO Patients All Impairment Categories
FOTO Data Initially collected for South Central
Region To Provide Side/Side Comparison
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HMO Contract
Second Meeting Must see specifics . . .
TTCs cost / visit for this carrier was in line
with South Central and National means. However
TTCs OI, VI, and UI far exceeded means.
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HMO Contract
Final Negotiations
Must see specifics . . . Looking for Proof of
Quality Consistency
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HMO Contract
Also provided with data. . .
By Impairment Category
Cervical
Lumbar
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HMO Contract
Also provided with data. . .
By Highest Risk Adjustment Very Severe
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HMO Contract
TTC Comments

• 85 per Visit is Average HMO price Nationally
  102 Regionally
• Our Avg Charges for your Patients now is 110
  per Visit
• Gatekeepers high percentage of Very Severe
  impairment category . .
• Patients receiving care at TTC more functional
  improvement per episode

By Highest Risk Adjustment Very Severe
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HMO Contract
HMO Comments

• 55 is highest we have given this year
• Your Outcomes are the best
• Our employers need to see that kind of data
• We will promote TTC

• 80 Per Visit, Per Area, Per Therapy

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HMO Contract
Result

• 42 increase in per diem rate from original
  contract offer.
• HMOs percentage of mix for all products (Health,
  Medicare Risk, and TennCare) combined now
  represents 9.2 of TTCs business.
• Ability to retain contract and our financial
  status would have been severely impacted without
  the negotiated increase in this per diem rate
  Outcomes paved the way.

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Scenario of Case Management Opportunity
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Case Management

• Opportunity presented to provide care for Case
  Management Group
• Stumbling Block
• One of the Employers working with CM Group
  stated TTC Overutilized
• Burden of Proof fell to TTC

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Case Management

• CM Group presented with FOTO data on our Visits
  per episode as compared with Regional data.

TTC 65 lt 10 visits 85 lt 15 visits 3 21-25
visits
FOTO 64 lt 10 visits 84 lt 15 visits 4 21-25
visits
OVERUTILIZATION ???
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Case Management

• TTC by payor source.

OVERUTILIZATION ???
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Case Management

• Patient Specific and Concurrent Reports
• Patient Resource Predictor - Motivation
• Patient Outcomes Trend Report - UR
• Patient Discharge Activity Report
• Improved Communication
• Improved Motivation
• Improved Case Management

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Case Management

• Result

OVERUTILIZATION ???
NO! CM Group and Employer relationship now
win/win
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Scenario of Employer Opportunity
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Employer

• During review of mix, noted increased non-work
  related referrals from a regional clothing
  distributor.
• Targeted for marketing for inclusion on panel,
  provision of wellness programs, and possibly job
  site/cumulative trauma education.

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Employer

• Information provided included FOTO Outcome
  statistics.
• While contact was positive, did not result in a
  direct contractual relationship nor the on-site
  care we had hoped to gain.
• Regular contact maintained offered to assist in
  any way that we could
• Noted continued referrals from physicians working
  with the employees of
  this company

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Employer

• Back at the ranch . . . .
• TTC had been making contacts to negotiate a
  contract with one of the major PPO/POS carriers
  in the region.
• Problems encountered in securing a forum to
  discuss contracting possibilities.
• Seemed our efforts were futile

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Employer

• Out of the blue PPO called TTC . .
• Offering TTC PAR contract status . .

Why?
Employer and physicians recommended TTC be
offered contract status due to
the quality of care and services
we offered their employees/patients.
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Employer

• This PPO/POS now represents 3.5 of TTCs
  revenues.
• Business that we would not have received as many
  of this plans products
• Have no out of plan benefit
• Or
• Have a very high patient responsibility for
  services out of net (ie 60/40,
  70/30, etc.)

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In Closing . . .

• Objective Functional Outcome Based Data is the
  way of life
• QA, UR,
• External comparisons saves me every day
• Included in all communications
• Better prepared for any negotiations or
  appeal

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What Do You Need?
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Thank You
Fitting the Puzzle Pieces Together
Trish Hoover Insurance Relations Coordinator 6100
Lonas Road Knoxville, Tennessee 37909 Ph
865.558.6484 Fax [phone] trishhoover_at_thether
apycenter.net