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CY15 Medicare Physician Fee Schedule Proposed Rule Fact Sheet
This document summarizes the revised policies pertaining to payment policies under the Medicare physician fee schedule for calendar year 2015 (CY15).
HFMA comments to CMS on the 2015 Medicare OPPS Proposed Rule
HFMA comments the 2015 Medicare and Medicaid Programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; Physician-Owned Hospitals: Data Sources for Expansion Exception; Physician Certification of Inpatient Hospital Services; Medicare Advantage Organizations and Part D Sponsors: Appeals Process for Overpayments Associated With Submitted Data; Proposed Rule (hereafter referred to as the 2015 OPPS Proposed Rule) published in the July 14, 2014, Federal Register.
CY15 OPPS Proposed Rule Fact Sheet
This document provides an overview of the CY15 proposed changes to payment rates under the outpatient prospective payment system (OPPS).
Moving Forward
Moving Forward The steps toward finalizing an acquisition or affiliation will differ depending on the degree of integration involved. A basic road map for moving forward is provided below. Initial Actions Engage legal counsel. Regardless of the degree of integration you seek, all acquisition and affiliation approaches can raise legal issues involving antitrust, fraud and abuse, and other state and federal laws and regulations. Approach/engage your potential partners. If your organization seeks to be acquired by another organization in a competitive process, it may engage an advisory firm that will seek detailed proposals from potential acquiring organizations. Less fully integrated affiliation models may be initiated through conversations between leaders of the potential partner organizations, often with the assistance of an advisory firm. Consider the need for a confidentiality agreement in early discussions with potential partners. Commit to going forward. If a merger is involved, the parties will likely sign a letter of intent or memorandum of understanding on the proposed merger. Depending on the size and market impacts of the acquisition or affiliation, a Hart-Scott-Rodino premerger notification filing with the Federal Trade Commission and Department of Justice may be required. The deal will not be able to close until the federally prescribed waiting period has expired or the government grants early termination of the waiting period. State/local laws and regulations may also apply. Due Diligence The degree of due diligence required will vary by approach. A merger will require the greatest extent of access to books and records to confirm the financial viability/desirability of the acquisition. “Cultural” due diligence is also important. If there are significant potential cultural incompatibilities between organizations, their chances of working effectively together, whether as a merged entity or as collaborative partners, can be significantly diminished. Internal Communications Rumors and gossip that can spread among staff in any acquisition or affiliation strategy can easily delay progress or derail the activity altogether. Once your organization has committed to moving forward, it is critical to inform staff on possible impacts of the acquisition or affiliation activity. The two PowerPoint templates below outline key discussion points in fully integrated and less than fully integrated acquisition and affiliation models. Tool: Communicating with Staff: Full Integration Tool: Communicating with Staff: Less than Full Integration Business Planning While due diligence proceeds, the management teams of the partner organizations should develop: Vision statement Organizational structure Capitalization plan Governance model (powers, roles and responsibilities, reserved powers, voting rights, etc.) Management structure (including, in the case of a merger, the transition team) Early initiatives and priorities Financial projections (including scenarios related to the rate of movement towards value-based payments) Final Agreement The partners should now be ready to negotiate their final acquisition or affiliation agreement. Use the following scenarios to see how different organizations might work through the steps toward an acquisition or affiliation. A stand-alone hospital determines its acquisition and affiliation approach An academic medical center aims for long-term sustainability A multi-hospital pursues a regional strategy and system-wide economies of scale
Determining Your Options: Identifying Potential Partners
Determining Your Options: Identifying Potential Partners With a sense of how your organization’s goals and approaches align, assess which organizations are the best candidates for potential acquisition or affiliation partners. Identifying partnership needs and options What organizations might be potentially interested in partnering? Does your organization require more than one kind of partner? Why? Weighing the options With respect to each potential partner, consider: How would a partnership with this organization change your organization’s current situation? Which needs would they meet? Which needs of the potential partner organization would your organization meet for them? What is the comfort level between your organization’s leadership team and the leadership team of the potential partner organization? Do you see any challenges or disadvantages in partnering with this organization? Is it possible to develop high-level financial projections of the impact of this partnership? Would a partnership with this organization have an impact (positive or negative) on your organization’s: Image or brand? Efforts at physician integration? Culture? Relations with patients, employers, governmental entities, or other community interests? After evaluating each potential partner organization, consider: How do the potential options differ from each other? What does examination of the detailed elements of each option reveal in terms of comparative pros and cons? Of all of the characteristics of the available options, which are the most important to your organization (e.g., governance, capital needs, impact on financial performances, ease of change, physician structures, etc.) ? Why? Based on this comparison, what appear to be viable options? Which is the best option, and which is the next best (i.e., best alternative to a negotiated agreement)?
Determining Your Options: Common Acquisition and Affiliation Approaches
Determining Your Options: Common Acquisition and Affiliation Approaches Now that you understand your organization’s goals and needs, consider whether some form of acquisition or affiliation activity can help your organization reach its goals. Common acquisition and affiliation approaches are defined below. This is just a representative listing; new approaches to acquisition and affiliation continue to emerge. As you review these approaches, consider the following questions: Does vertical or horizontal expansion, or both, best align with your organization’s strategic priorities? How would these be prioritized? Why? How important is diversification as a strategy vis-à-vis traditional market expansion? Are there certain approaches that seem like a better fit for your organization? Why? Would any of these options allow your organization to stop owning certain resources, and instead obtain them through partnership or outsourcing? Does partnership with a health plan offer your organization something strategically important and distinct from other forms of affiliation? In what ways? Tool: Matching Goals with Options Common Approaches Merger of a not-for-profit (NFP) hospital into a NFP system. Usually the merger parent board assumes all assets and liabilities of the newly merged organization. In some cases, the local board continues to exist and may have selected responsibilities such as quality, credentialing, or community need. Merger of an NFP hospital into a for-profit (FP) system. This is typically an acquisition. The acquired NFP is valued, and the value (net of liabilities) often becomes a community foundation. Merger of a NFP hospital into a FP/NFP joint venture. Some transactions involve less than a 100 percent purchase, with the local entity continuing as a joint venture partner. Merger of a NFP into a FP system plus a “quality partner.” FP systems sometimes link with an academic medical center or other organization known for its quality. The “quality partner” may be a joint venture owner of the acquired hospital. Contractual system. Not all consolidated systems are merged entities. For example, local boards within the system might retain all fiduciary powers. The top leaders of the local hospital or system are employed by the larger system in order to coordinate strategies; however, the overall arrangement may be a renewable contractual relationship. Collaborative partnerships. Health systems are increasingly joining, often through contractual joint ventures, to address selected issues together – such as revenue cycle, supply chain, or regional network formation. Examples include the BJC Collaborative, AllSpire Health Partners, and the Integrated Health Network of Wisconsin. “Super” accountable care organization/clinically integrated network (ACO/CIN). Increasingly, clinically integrated networks recognize the opportunity to achieve economies (e.g., sharing population health infrastructure and expertise) by combining with each other. Health plan/provider partnership. These “vertical consolidations” take many forms. In some cases, a health plan, physician group(s), and hospital systems enter a joint venture relationship to serve a large employer. In some cases, health plans have acquired physician groups. Employer/provider partnership. These contractual relationships, usually involving very large employers or a group of large employers, relate directly with provider networks.
Assessing Your Situation – Common Acquisition and Affiliation Goals
Assessing Your Situation: Common Acquisition and Affiliation Goals The answers to questions about your organization and its market in should help define the goals of an acquisition or affiliation strategy. Note that your organization may have multiple goals, which may suggest multiple approaches to acquisition or affiliation. Common goals include: Favorable access to capital. If the investments your organization needs to make to reach its goals exceed its financial resources, a full merger (e.g., one that consolidates balance sheets and fiduciary responsibilities between the merging organizations) may offer access to superior borrowing terms and rates. System-wide economies. If your organization is struggling to find further opportunities for cost reductions, it might benefit from system-wide economies that can come from increased size and scale. Some of these (e.g., supply chain, revenue cycle, specialized expertise) are not dependent on physical proximity of the affiliating organizations, while others (e.g., service line or asset rationalization) do require closer physical proximity. Primary care aggregation. If your organization needs to support specialty and acute-care services, it is important to connect/integrate more primary care physicians with the system. A strong patient referral network is even more critical since inpatient and even outpatient facility utilization per patient will likely decrease. Population health expertise. Your organization may want to affiliate with another organization that is farther along the path to population health. Note that an organization with multiple needs (e.g., improved capital access and population health expertise) may choose different partners and different methods of affiliation to meet these needs. Population health infrastructure. The costs of developing an infrastructure to manage population health can be significant. Collaborative development of this infrastructure with other partners (including interoperable EHRs, other IT and business intelligence tools, clinical benchmarks and care pathways) may make more sense than going it alone. ACO/CIN formation. Organizations need not merge in order to amass the large populations that are desirable to manage care efficiently. Time will tell whether merged or affiliated CINs perform most effectively. Other regional economies. Many health systems are working now to aggregate an efficient, cross-continuum regional delivery system: from primary care, to specialist and acute services, to pre- and post-acute care options, and beyond. Other payment initiatives. Vertical integration between providers and insurers, employers, and other payers can leapfrog capabilities for the aggressive health system that wants to participate in managing the premium dollar. These benefits may or may not require other forms of consolidation (such as mergers).
Assessing Your Situation – Market Assessment
Assessing Your Situation: Market Assessment The next step is to take a close look at the market or markets your organization operates in. What communities and populations does it serve? How much competition is there among provider organizations? Who are the major payers in your market? Market Area What is the demographic makeup of your patient population? How is this likely to change in the future, and what are the implications for your organization? How well does your organization understand community needs at a sub-population level? What are the sub-populations, and what challenges and opportunities do they present for your organizations? How do you predict that the needs of the populations you serve will change in the future? How well do you think your organization can adapt to meet these needs? Provider Market What is the competitive landscape in your market area? How is it changing, and what are the drivers of these changes? What are the potential implications of changes among/by competitors for your organization? Which organizations among your competitors are real threats? Why? Which organizations among your competitors represent potential partners? Why? Payer and Purchaser Market Does a single payer dominate your market or is there competition among payers? How aggressively are payers moving toward value-based reimbursement? How are payers determining with which providers to partner on new payment methods, population health infrastructure, limited networks, etc.? Is your organization a potential partner, or is it excluded from these discussions? What would make it a more attractive partner? How prevalent are provider-owned plans in your market? What is the potential for new provider-owned plans to develop? How influential is the employer purchasing community in your market? What demands and expectations do they have of providers, and how are these changing? What impact, if any, have insurance exchanges and limited network plans had? What is the potential, and what are the possible implications for your organization? Reflecting on your answers After reviewing the answers to your organizational and market assessment, how you would answer the following questions: How will your organization fare in an environment of both fee-for-service and value-based payment in its current state? Would it fare better if it pursued some form of acquisition or affiliation? How much effort and investment lies ahead to prepare for population health management, which is required under most value-based payment mechanisms? Is your organization equipped to dedicate the needed effort and capital, or will it need additional resources? Is your organization’s strongest position for negotiating participation in an acquisition or affiliation model now or later?
Assessing Your Situation – Organizational Assessment
Assessing Your Situation: Organizational Assessment The first step in developing an acquisition and affiliation strategy is to assess the strategic vision and goals of your organization, its financial and market position, and current readiness to meet its goals. Answers to the questions below will help identify the strengths and weaknesses of your current situation and begin to define your organization’s needs to meet its goals. Strategic Vision and Goals What has your organization articulated as its strategic priorities? What business or businesses is your organization? How have answers to these questions changed, or how do you predict they might change, in light of emerging market pressures? What are your organization’s long-term goals in terms of care delivery, operational performance, community service, brand reputation, other? How willing, and capable, is your organization to take risks to accomplish this emerging vision? Is your organization willing to change its tax status, or affiliate with organizations of a different tax status, to accomplish these goals? Can your organization accomplish its strategic priorities on its own, or is there a need to be part of a larger organization in order to be successful? Financial Position How solid is your organization’s financial position in terms of its ability to meet its capital requirements in the future? Why? Has financial performance been improving, steady, or deteriorating? Why? How does your organization anticipate that market trends will affect utilization and future financial performance? Can your operating margin and balance sheet weather these projected changes? What is the growth trajectory for your business, and what are your investment needs to support this growth? What are your organization’s key strategies to improve financial performance? How important is it to your organization to diversify sources of revenue? Why? Is your organization financially positioned to consider acquisition of another organization? Will it need to consider being acquired to meet its financial needs Market Position What is your organization’s estimated market share? Is it improving, flat or decreasing? What are the underlying reasons? What estimated market share do you think you need to be successful in the future? How well does your organization meet your community’s needs for hospital services? How do you know? Where is your organization ranked in your marketplace on the basis of: Service Clinical Quality Cost to Care Purchasers Physician network How strong is your existing physician network? Do you have an adequate base of primary care providers to meet current and projected future needs? Do you have the right mix and number of specialists to meet current and projected future needs? Are there opportunities in your market(s) to align with additional primary care or specialist practices to meet your current and projected needs? Current readiness What are your organization’s internal strengths and weaknesses? Do you have the right executive team and board members in place to position for the future? If not, what types of people do you need? How well does your organization understand the health needs of your patient population? What investments will you need to make to manage these needs? What capabilities does your organization have to improve care delivery processes and outcomes? What track record does your organization have? Has your organization been able to make significant cost reductions in any of its service lines or clinical processes? If not, what are the barriers to achieving cost reductions? How capable is your organization of change? How do you know? How has leadership enabled flexibility, or made it more difficult to achieve? How prepared is your organization to accept contracts involving value-based reimbursement?
Acquisition and Affiliation Toolkit – Home
Introduction This toolkit is a companion to HFMA’s Value Project report on Acquisition and Affiliation Strategies. Consolidation is a rapidly evolving strategic focus for health care organizations. As the report suggests, new forms are continually appearing. This toolkit offers tools for assessing your organization’s situation, determining acquisition and affiliation options, and moving toward finalizing an agreement with an acquisition or affiliation partner. It also provides three examples scenarios to illustrate how these tools might be put to use in setting a course for your organization. Toolkit Directory We encourage first-time users of this toolkit to review the sections in the order listed below. You can then use this directory to navigate to particular sections of interest. Assessing Your Situation Organizational assessment Market assessment Common acquisition and affiliation goals Determining Your Options Common acquisition and affiliation approaches Identifying potential partners Educating your board Moving Forward Communicating your strategy internally Key steps in finalizing an agreement Example Scenarios A stand-alone hospital determines its consolidation approach An academic medical center aims for long-term sustainability A multihospital pursues a regional strategy and system-wide economies of scale