Retaining and Gaining Insured HIV+ Patients in Your Medical Practice: Surviving the Opportunities and Challenges Pre

1. Retaining and Gaining Insured HIV+ Patients in Your Medical Practice:Surviving the Opportunities and Challenges Presented by the ACA Julia Hidalgo, ScD, MSW, MPH

2. About the AETCs • The AIDS Education and Training Centers (AETCs), a national network of leading HIV experts, provide locally based, tailored education and technical assistance to healthcare teams and systems to integrate comprehensive care for those living with or affected by HIV. The AETCs transform HIV care by building the capacity to provide accessible, high-quality treatment and services throughout the United States. The AIDS Education and Training Centers are funded by the Health Resources and Services Administration, HIV/AIDS Bureau

3. Housekeeping & Announcements • Audio is via the telephone • Session is being recorded • Please type questions for the presenter into the chat room • Include state and your organization

4. Retaining and Gaining Insured HIV+ Patients in Your Medical Practice: Surviving the Opportunities and Challenges Presented by the ACASeptember 23, 2013 Julia Hidalgo, ScD, MSW, MPH Positive Outcomes, Inc. & George Washington University Julia.hidalgo@positiveoutcomes.net

5. Disclaimer • The information provided in this webinar does not necessarily represent the views of agencies funding George Washington University or Positive Outcomes, Inc. • Strategies provided in this webinar may vary by state • It is important to maintain current knowledge about health care reform in your state to ensure timely and well informed actions • For Ryan White HIV/AIDS Program grantees, it is important that you seek guidance from your project officer or grantee to ensure your programs’ strategies are consistent with HIV/AIDS Bureau (HAB) policies and grant requirements • Thanks to the American Academy of HIV Medicine, HIV Medicine Association, and HealthHIV for supporting the work reflected in this webinar

6. Presentation Focus • Today’s webinar focuses on helping HIV clinicians to retain and gain insured HIV+ patients in your practices by • Participating in commercial and public health insurance provider networks • While the ACA is our most immediate focus for provider participation, there are other opportunities for contracting with employer-based health plans, Medicare and Medicare+ Choice health plans, and other insurers • Effective contracting strategies • Gaining access to newly insured patients • Expanding capacity to serve additional HIV+ patients • Ensuring that your practice receives sufficient third party reimbursement to cover your costs • Educating your patients about the insurers in which you participate • Screening your patients for current or potential insurance enrollment “I hope this will be very practical information from the beginning, and less about history of the reform. I need very practical information! “

7. Are you ready to participate in Marketplace Qualified Health Plans and Medicaid expansion?

8. Rationale for Readiness for the ACA: A Review • Continue to serve your current HIV+ insured patients and expand services to additional HIV+ insured patients • Diversify income sources to reduce dependency on grant funds • Fiscal solvency • Generate discretionary income for capital investment, administrative expenses, and services not supported by grant funders • Adhere to HAB policies

9. Rationale for Readiness of HIV Clinics in States That Have Chosen Not to ExpandMedicaid Coverage • Health insurance coverage available to patients with pre-existing health conditions who were denied benefits or enrolled in Pre-Existing Condition Programs • Readiness for Medicaid participation, particularly managed care systems, can be a slow process • You can gain important experience by participating in commercial health insurance provider networks • Many HIV+ individuals may benefit from enrollment through Marketplaces

10. Key Domains of Readiness for Health Reform: A Review • Aligning with your organization’s vision • Building infrastructure • Defining your products and target populations • Computing the cost of your products • Re-engineering your practice management • Assessing the health insurance market • Contracting with health insurers • Educating HIV+ patients about navigating health insurance systems

11. Practice Management Readiness Activities • Expanding workforce capacity to deliver covered services to enrolled HIV+ beneficiaries • Designing telephone systems that promote patient communication rather than create barriers to access • Scheduling systems to optimize clinician productivity, reduce broken appointment rates, and promote retention in care • Open access or same day appointment scheduling • Assessing and improving wait times for new and established patients • Streamlining registration and intake process • Assessing and improving patient flow to optimize efficiency and maximize resources • Enhancing eligibility determination, e-verification, and enrollment assistance systems • Addressing factors resulting in HIV+ patient lost to care • Do you know your lost to care rate? Have you designed and implemented a strategy for improving retention in care?

12. Practice Management: A Review • Adopt practice and panel management systems • Adopt patient empanelment processes (i.e., assigning each provider a set number of patients) to improve clinical processes and outcomes • Assess and address patient flow, opportunities for task shifting (ideally to billable personnel), continuity of care, time consuming activities (e.g., medication refills), impact of part-time clinical staff on productivity and quality • Automate patient process and outcome data, quality management systems, and capacity to improve clinic and provider performance • Team with CBOs and other community partners to undertake community-based linkage to care and retention activities • Become educated about the concepts and adopt tools to create accredited patient-centered medical homes • Update practice policies and procedures and mobilize your staff

13. Eight Steps for Contracting With Insurance Plans and MCOs

14. Eight Key Steps for Contracting • Check with your organization about their health plan contracting process • Identify opportunities in the health insurance markets • Gather information about insurers • Assess insurers’ track records • Understand how insurers will pay for your services • Evaluate the adequacy of payment based on your actual costs • Contract with insurers • Assess payoffs and pitfalls Resource: HIVMA, Strategies for HIV Medical Providers Contracting With Health Insurers

15. Check With Your Organization About Their Plan • Before moving forward with health reform readiness activities, it is critical to • Ensure your HIV practice’s efforts are aligned with your organization’s overarching readiness efforts • An important step for HIV practices in large integrated health systems, hospital-based or university-affiliated health systems, city or county health departments, large FQHCs • Contracts may have been negotiated or are being negotiated now for 2014 • Medicaid managed care contracts have probably been finalized for the current year • Engage organizational leadership, including corporate board support • Identify organizational resources that can be applied to your readiness activities

16.  Identify Insurance Contracting Opportunities • The American Academy of HIV Medicine and Positive Outcomes, Inc. teamed to gather State-specific information about provider enrollment in Marketplace Qualified Health Plans and Medicaid (including fee for service and managed care): http://www.aahivm.org • Your State’s Health Insurance Commissioner has information about other licensed health insurance plans in your state: http://www.naic.org/state_web_map.htm

17.  Gather Basic Information About Insurers’ Networks • Research health insurers and managed care plans in your service area to assess network participation by • Specialty care providers • Do the providers serve your patients? • Are there gaps in specialties and subspecialties needed by your patients? • Are the providers conveniently located? • Pharmacies • Are you familiar with the pharmacies? • Are they conveniently located? • Do they routinely stock HIV medications? • Is mail order delivery available? • Inpatient hospitals • Are you familiar with these hospitals? • Do you have admitting privileges with these hospitals? • What is the hospital’s track record about notifying you about your patients’ admissions? • What is their track record for coordinating inpatient discharges?

18.  Gather Basic Information About Insurers’ Policies and Procedures • Payment Rates • Can you negotiate with the plan? • What are the payment mechanisms and rates? • Are enhanced payments available for care coordination? • What is the plan’s policy for timely payment? • What is the plan’s rate of denied claims for primary care and ID visits? • Access to HIV Providers and Specialty Care • Are referrals required for HIV+ patient to receive your services? • Can HIV specialists serve as primary care providers? • Is HIV recognized by the insurer as a specialty? • What is the plan’s credentialing requirements? • What are the plan’s access standards? • For Marketplace Qualified Health Plans, what is the process for contracting as an Essential Community Provider?

19.  Gather Basic Information About Insurers’ Policies and Procedures • Coverage and Benefits • Who determines medical necessity? • What is the plan’s policy for coverage of HIV tests, antiretrovirals, CD4 tests, viral load tests, and genotype and phenotype resistance test? • Is prior authorization required? • Are disease managers or case managers routinely assigned to HIV+ patients? • What is their role in care coordination? What are their training requirements and expertise? • What are their utilization management and review procedures? • Quality and Reporting • Does the plan have HIV-related quality measures? • What are the provider reporting requirements? • What is the plan’s quality track record? • Resource: The Harvard Law School Center for Health Law and Policy Innovation has developed a resource for assessing other aspect of health plans: http://www.hivhealthreform.org/assessment/

20. Assessing the Insurer’s Track Record • Many health insurers operate in multiple states • Reach out to your colleagues in other HIV clinics and ID practices to learn of their perceptions of the insurer: • The insurer’s willingness to negotiate contracts, including enhanced HIV payment arrangements • Adequacy and timeliness of payments • Financial stability • Propensity to deny claims due to “lack of evidence of medical necessity” • Willing to allow standing referrals • Coverage of HIV testing, ARVs and other HIV medications, and HIV-related lab tests • Use of disease managers to “manage” HIV, mental health, substance abuse treatment utilization

21.  Understand How Insurers Will Pay for Your Services • Fee-for-service (FFS) continues to be commonly used by commercial and public health insurers • Capitation payment models • Primary care coordination payments • Condition-specific capitation • Shared savings • Global payments • Pay for performance • Budget-based payment systems • Accountable care organizations • Carve outs and carve ins

22. Ways to Limit Risk in Managed Care Contracting • Payments models vary in the extent to which the provider assumes financial risk • Accept capitation only for services your practice directly provides or controls • Carve out high-cost, low-frequency services more appropriately reimbursed on a FFS basis • Strive to retain FFS payment until a statistically valid enrollment level has been achieved by health plan • Purchase stop-loss insurance coverage • Seek risk adjustment in the payment system • Define precise boundaries between your practices’ services and other providers’ care to avoid “dumping” • Gain experience with small-scale contracts • Ensure that adequate termination options exist

23. Evaluating the Adequacy of Payment Systems Based on Your Costs • The AMA has developed tools to help medical practices calculate their costs: http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center/claims-revenue-cycle/managed-care-contracting/evaluating-payment-options/establishing-baseline.page • HAB offers resources to calculate unit costs • http://hab.hrsa.gov/deliverhivaidscare/tactoverview.html • It is important to include the actual components of cost for the contract period, including salary adjustments • The amount of grant funds awarded to your program by HAB or other funders is not your cost • Conduct break-even analysis comparing costs to likely third party insurance revenue • Consider opportunity costs, such as the likely reduction in revenue from HAB grants resulting from the payer of last resort policy and federal funding reductions

24.  Credentialing and Contracting With Commercial and Public Insurers • Credentialing • Many health insurers use the Universal Provider Data Source maintained by the Council for Affordable Quality Healthcare for their credentialing process: http://www.caqh.org/overview.php • Contracting • Seek legal advice • Prepare to negotiate • Carefully evaluate the contract • Contract terms • Coverage and benefits • Payment and claims

25. Assessing the Payoffs and Pitfalls of Contracting • In the first year of contracting with insurers, you may want to weigh the financial benefits of your contracts versus issues that arose with the insurer and their enrolled patients • Small number of enrolled patients, resulting in administrative costs and hassle but small revenue yield • Insufficient revenue to cover administrative costs • Staff time to research and resubmit rejected claims • Untimely payment • Payment that does not cover labor and overhead • Rejection of claims due to lack of medical necessity • Limits on the number of visits covered, burdensome cost controls, or other utilization management policies • Prior authorization or other requirements for specialty referrals

26. Marketing to Health Insurers

27. Considerations in Marketing to Health Insurers • What are the products you are offering? • How many plan members could benefit from your products? • Will your products attract new members to the plan? • How much does your product cost? • Will the plan have to pay for your products (e.g., grant-funded service)? • What distinguishes your products from that of another provider? • How will your products enhance the plan’s network? • How will your products help meet health plans’ benefits, network, access, or quality assurance standards?

28. Defining Your Products and Target Populations • Assess your current payer mix • Identify services commonly covered by public and commercial insurers • Parse non-billable services that may legitimately continue to be paid by the Ryan White Program • Identify services that may be covered by some insurers to help them to manage service utilization, prevent morbidity or mortality, promote positive health outcomes, and reduce unnecessary costs • Prevention services, disease management, care coordination, linkage and retention services • HIV+ patients only, patients with communicable diseases (e.g., Hep C), other patients • HIV+ patients and provision of reimbursable HIV screening to insured populations

29. Key Marketing Messages for HIV Providers We are experienced in • Delivering clinical services that reflect state-of-the art HIV care • Delivering clinical and psychosocial services to hard-to-reach populations • Managing behavior to achieve positive clinical and behavioral outcomes • Avoiding or reducing psychosocial crises that impact adherence to clinical regimens • Delivering culturally sensitive and appropriate services • Working in an integrated network of clinical and support services • Providing prevention services to reduce HIV infection among beneficiaries, their sexual partners, and newborns • Assisting newly identified HIV+ to link to care, be retained in care, and be located if lost to care • Delivering cost-effective services through low overhead

30. Educating Patients About Your Participation in Health Insurance Networks

31. Gaining and Retaining HIV+ Patients • Develop and implement a patient marketing strategy • If your website is part of the strategy, consider how it can be used strategically • Ask your community advisory board and peer workers for strategies for gaining and retaining HIV+ patients • Educate HIV+ individuals about selecting an insurance plan in which you participate and select an affiliated primary care provider • Educate current patients about pathways to insurance enrollment through Marketplaces, premium subsidies, ADAP assistance, current and expanded Medicaid programs, importance of selecting a Medicaid managed care plan to avoid auto-assignment • Educate insured HIV+ individuals that are unlikely to need to enroll through the Marketplace • Reasons some insured patient should enroll in the Marketplace include that their current plan does not meet ACA Essential Benefits requirements, lower cost premiums, provide better benefits for their family, or to join a plan in which you participate

32. Gaining and Retaining HIV+ Patients • Actively facilitate the work of CMS and State-funded facilitators and navigators, in-person assisters, and certified application counselors • Arrange for on-site activities at your HIV clinic or practice • Sponsor patient education sessions • Inform current and new patients about your policies if eligible individuals do not enroll in Marketplace or Medicaid health plans • For new and ongoing patients, provide linguistically and culturally appropriate patient education to empower patients to navigate your HIV clinic, the broader health care system, and the health insurance system • Adopt web-based patient tools to help them schedule appointments, request medication refills, and get information about their health, HIV care, and medications • Help patients to understand “health insurance basics” through group and individual training, including their roles and responsibilities

33. While it is important to educate your HIV+ patients about enrolling in the Marketplace during the Ryan White Program eligibility determination and recertification cycle, some patients may enroll before their next determination appointment

34. Common Errors Found in Intake and Assessment Household Size: assumption that the patient is a single adult, individuals meeting EMA/TGA household definition are not identified during assessment (particularly spouses and dependent children) Household Income: patients’ income poorly documented, family members’ income not assessed, patients claiming $0 income not probed for how they manage with no income, undercounting income from self-employment, and missed income from sources other than wages Insurance Enrollment: inability to understand health insurance deductions documented on paystubs, not researching if an employer offers insurance benefits to full or part-time employees, not assessing enrollment of spouses in plans that could cover the HIV+ spouse, failing to query college students about enrollment through their college General Errors: not updating key information when things change

35. Tips for Assessing Health Insurance Enrollment • Check paystubs carefully • Ask the patient directly if he/she or his/her spouse is insured • Ask the patient if he/she can enroll in insurance through his/her employer • If the patient reports that he/she declined available health insurance, find out why, and help to address concerns (e.g., cost or disclosure) • If the patient reports his/her employer does not offer insurance, check the employer’s human resources website and/or ask for an employer letter • If the patient is less than 26 years of age, ask if his/her parents are insured and inquire if he/she can enroll in parents’ insurance • If the patient is a university or college student, verify available insurance, and counsel the patient to enroll in available insurance • Query the Medicaid electronic verification system and use commercial web-based query systems to identify current Medicare and commercial insurance enrollment • Avality, Capario, Medifax POS, Passport Health Communications, WebMD Envoy

36. Ready, Set, Go

37. Develop a Readiness Plan • Remain calm • Identify key members of your readiness team based on the domains identified today • Team members might include policy, practice management, finance, clinical, information technology, human resources, and other staff • If feasible, designate an in-house expert on health reform • Honestly assess your readiness using the domains discussed today, identify barriers, and develop realistic strategies for overcoming them • Readiness planning and implementation are likely to be evolutionary, long-term, and improve with experience • Even highly experienced HIV clinics report new challenges

38. Develop a Readiness Plan • The readiness team should set priorities, create a schedule, assign tasks, and meet routinely • Anticipate that some tasks are likely to be slow • Set short-term achievable goals- start slow and then grow • Identify interorganizational and outside resources and seek help • Routinely update the HIV clinic staff to solicit their suggestions and buy-in • Aim for durable sustainability regardless of staff turnover • Evaluate infrastructure and other costs and compute the likely return on investment • Identify and seek funds to cover costs • Identify strategies to collaborate with other HIV clinics to form formal or informal networks

39. Key Resources

40. Key Resources • American Academy of HIV Medicine • http://www.aahivm.org/ • American Medical Association Practice Management Center • http://www.ama-assn.org/ama/pub/physician-resources/practice-management-center.page? • Families USA Health Reform Central • http://www.familiesusa.org/health-reform-central/ • Harvard Law School Center for Health Law and Policy Innovation • http://www.hivhealthreform.org/assessment/ • CMS Medicaid Provider Payment Provisions Under the ACA • http://www.medicaid.gov/AffordableCareAct/Provisions/Provider-Payments.html • CMS Documentation Guidelines for Evaluation and Management (E/M) Services • http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html • Falcone AJ.Negotiating Contracts with Managed Care Organizations. A presentation at the HAB All Grantees Meeting. November 2012. • https://careacttarget.org/library/negotiating-contracts-managed-care-organizations • HIV Medicine Association • http://www.hivma.org/Home.aspx • HRSA Bureau of Primary Health Care • http://bphc.hrsa.gov/technicalassistance/index.html • HRSA HIV/AIDS Bureau TARGET Center • https://careacttarget.org/library/affordable-care-act-ryan-white-hivaids-program

41. Key Resources • National Association of Community Health Centers • http://www.nachc.com/complete-list-of-trainings.cfm • National Academy for State Health Policy. Engaging Safety-net Providers in Expanded Coverage: Tips on Enhancing Billing Capacity. http://www.nashp.org/sites/default/files/SNP.tips.billing.capacities.pdf • National Association of State and Territorial AIDS Directors • http://www.nastad.org/care_and_treatment/resources.aspx?category=health%20reform • National Conference of State Legislatures, Medical Homes and State Implementation of the ACA and Medicaid Expansion • http://www.ncsl.org/issues-research/health/the-medical-home-model-of-care.aspx • http://www.ncsl.org/issues-research/health/affordable-care-act-state-action-newsletter.aspx • National Committee for Quality Assurance Patient-Centered Medical Homes • http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx • HIV Medical Homes Resource Center • http://fxbcenter.org/mhrc.html • Substance Abuse and Mental Health Services Administration • http://www.samhsa.gov/healthreform/ • US Department of Health and Human Services ACA Resources • http://www.healthcare.gov/

42. Questions and Discussion Download the slides: www.HIVHealthReform.org

43. Maximizing HIV Care Reimbursement in 2014 • http://www.aidsetc.org/aidsetc?page=etres-display&resource=etres-703&

44. EVALUATION • Please complete a brief evaluation survey that will be emailed to each participant following this presentation. All responses are appreciated.

45. Thank You!!