Managed Care Contracts and Health System Operational Alignment

CASE EXAMPLE of how we breakdown contracts and tie the terms to operational alignment

Because the business of healthcare is to deliver the highest quality care to patients, improving clinical performance is the driving focus. However, understanding and responding to financial pressures through increased efficiency and enhanced revenue capture is what makes high-quality clinical delivery possible and sustainable.

Reimbursement StructureActivity triggering a more robust financial return
Reimbursed primarily on a fee-for-service basis, generate more revenue by using your care team as a provider–extender, enabling more patients to see the provider for a billable visit each day
The organization accepts full risk for patient costs, Ensuring patients are taught how best to manage their illness and avoid specialist or emergency room visits. 
Capitated fee for primary care services, experimenting with alternative visit types may maximize your ability to care for more patients
Nonphysician payment for CCMPractices that rely on nonphysician team members to deliver CCM services will probably experience substantial net revenue gains but must enroll a sufficient number of eligible patients to recoup costs.
“If nonphysician staff were to deliver CCM services, net revenue to practices would increase despite opportunity and staffing costs. Practices could expect approximately $332 per enrolled patient per year (95% CI, $234 to $429) if CCM services were delivered by registered nurses (RNs), approximately $372 (CI, $276 to $468) if services were delivered by licensed practical nurses, and approximately $385 (CI, $286 to $485) if services were delivered by medical assistants. For a typical practice, this equates to more than $75 ,00 of net annual revenue per FTE physician and 12 hours of nursing service time per week if 50% of eligible patients enroll. At a minimum, 131 Medicare patients (CI, 115 to 140 patients) must enroll for practices to recoup the salary and overhead costs of hiring a full-time RN to provide CCM services.”
Non-visit-based payment for chronic care management (CCM)Measuring Net revenue per full-time equivalent (FTE) physician; time spent delivering CCM services.
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