Louisiana Office of Primary Care and Rural Health

1. 1 Options for Supporting Primary Care Louisiana Office of Primary Care and Rural Health

2. 2 Who We AreBDMP/Westport Berry , Dunn, McNeil & Parker is the largest CPA firm in the New England Region Westport Group merged with BDMP in 2000 and became BDMP/Westport National practice specializing in programs that focus on the underserved Rural Health Clinics Community Health Centers Federally Qualified Health Centers Critical Access Hospitals Other Hospitals Network Development

3. 3 What We DoBDMP/Westport Focus on programs that enhance reimbursement Assist providers in the determination of which programs best meet local needs Assist communities in the development of strategies to maximize resources for the community

4. 4 Options for Supporting Primary Care Why is This Topic Important? The number of options has increased (>ten) There is no one �right� option for a state or a community or an institution��It Depends�.� Requirements and benefits of each option are becoming more complex Options are being pursued by multiple provider types Resources are more limited�hard to support Opportunities may be time limited Number of un and under insured are increasing

5. 5 Options for Supporting Primary Care Why is This important in Louisiana? LHA recommends the development of a �decentralized, community-based approach to care for the indigent and uninsured� 43% of physicians enrolled in Medicaid do not submit claims LHA recommends �an aggressive and state supported effort to develop CHCs/FQHCs as a complement to LSU clinics wherever possible� Act 162 directs the �reorganization of the delivery of medical care so that rural hospitals become centers of primary and preventive health delivery and medical services�

6. 6 Options for Supporting Primary Care Why is This important in Louisiana? 16 hospitals are eligible for CAH status 11 have converted 10 are actively considering conversion 27 current Federally Qualified Health Centers 17 core sites 10 satellite clinics 31 new FQHCs planned 19 new starts 12 expansions 6 Public Health Unit conversions (included in new starts and expansions) 49 Rural Health Clinics Are any of these in MUPs? Some HPSAs were last updated in 1988 Facility HPSA designation is new�requires fee discounts

7. 7

8. 8 What This Workshop Will Do Provide an overview of several options Describe what benefits are available Describe what you have to do to access benefits Describe why some options might not work for you May confuse you!! May result in information overload�.

9. 9 What This Workshop Will NOT Do Provide you with a specific answer for your organization or your community

10. 10 Options for Supporting Primary Care Overview-Types of Models Hospital Based Outpatient department of a hospital <100 beds Outpatient department of a hospital >100 beds CAH outpatient department electing all inclusive payments CAH outpatient department not electing all inclusive payments Rural Health Clinics Freestanding Provider based in hospitals with >50 beds Provider based in hospitals with <50 beds Community Health Centers Public Entity FQHC/CHC Federally Qualified Health Centers FQHC Grantees FQHC Look Alikes

11. 11 Options for Supporting Primary Care Overview-Specifics of Each Model Medicare reimbursement Medicaid reimbursement Eligibility criteria Basic requirements for participation Other benefits (grants, drug pricing, malpractice coverage)

12. 12 Summary of Model Types

13. 13 Background for Model Types History of program development Types of shortage area designations Description of provider based requirements

14. 14 HistoryPrograms That Support Primary Care 1960s�CHC (Community Health Centers) Grant funding (PHS Act Section 330) to support rural and urban access. This provider type must be a nonprofit corporation or public entity. 1970s�RHC (Rural Health Clinics) Cost-based Medicare/Medicaid reimbursement to support midlevel providers and access. This provider type may be provider-based, freestanding or sole proprietor. 1980s�FQHC (Federally Qualified Health Centers) Cost-based Medicare/Medicaid reimbursement for CHCs. This provider type must be a nonprofit corporation.

15. 15 HistoryHospitals and Primary Care 1980s-1990s Hospitals acquire primary care practices Hospital practices seek RHC designation to enhance reimbursement and financial viability 1990s 80% of hospital-owned practices lose money BBA 1997 establishes CAH (Critical Access Hospital) CAHs own provider-based RHCs Present Hospitals divest practices and form CHCs/FQHCs CHC program doubles in number of sites

16. 16 Shortage Area Requirements

17. 17 A provider-based entity is a provider of health care services, or an RHC as defined in Sec. 405.2401(b) of this chapter, that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the name, ownership, and administration and financial control of the main provider, in accordance with the provisions of this section. A provider-based entity comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. A provider-based entity may, by itself, be qualified to participate in Medicare as a provider under Sec. 489.2 of this chapter, and Medicare conditions of participation do apply to a provider-based entity as an independent entity. Provider-Based Status Definition

18. 18 Provider-Based Entities May Include: Department of the provider A remote location of the provider Satellite of the provider Must Conform to the Following: Licensure Clinical services Financial integration Public awareness Obligations of hospital-based entities Operation under ownership and control of the main provider Administration and supervision Location Provider-Based Status Requirements

19. 19 Operates under the same licensure Except where a state requires a separate license, or State law does not permit licensure of the provider and the entity under a single license Licensure

20. 20 Clinical Services Professional staff have clinical privileges at the main provider Same monitoring and oversight Same reporting relationship � frequency, intensity, accountability Same supervision and accountability Medical staff committees are responsible for the entity QA, utilization review, coordination and service integration Medical records are integrated Unified retrieval system, or cross referenced Services are integrated to assure continuity of care

21. 21 Financial Integration Shared income and expenses Cost reported in a cost center of the provider Financial data integrated into the provider�s trial balance

22. 22 Public Awareness The provider-based entity is held out to the public as part of the main provider Patients know they will be billed as part of the main provider

23. 23 Obligations of Hospital-Based Entities Operation under ownership and control 100% owned by the provider Have the same governing body Operated under same organizational documents � bylaws Main provider has final approval of contracts, personnel actions, personnel policies, medical staff appointments

24. 24 Obligations of Hospital-Based Entities (cont�d) Administration and supervision The entity is under the direct supervision of the main provider Same monitoring and oversight Billing Records Human resources Payroll Benefits Salary structure Purchasing services

25. 25 Obligations of Hospital-Based Entities (cont�d) Location 35 mile rule Exceptions for DSH (11.75%), State or local government facilities Or facilities contracted by State or local government Unless At least 75% of entity patients reside in the same zip code areas as at least 75% of the main provider�s patients, or At least 75% of the entity�s patients who require care as of the type provided by the main provider receive care from the main provider RHCs are not subject to the 75-75 rule

26. 26 Hospital Based Model Department of Hospital >100 Beds Medicare reimbursement Outpatient Prospective Payment based on APCs (For most services. There are still some fee schedule services)

27. 27 Hospital Based Model Department of Hospital >100 Beds Medicaid reimbursement Prospective Payment Mechanism (?)

28. 28 Reimbursement Calculations

29. 29 Hospital Based Model Department of Hospital >100 Beds

30. 30 Hospital Based Model Department of Hospital <100 Beds

31. 31 Hospital Based Model Department of Hospital <100 Beds Medicaid reimbursement Prospective Payment Mechanism Small rurals - 83% of cost plus DSH

32. 32 Hospital Based Model Department of Hospital <100 Beds

33. 33 Hospital Based ModelDepartment of CAH Electing All Inclusive Payment Medicare reimbursement All-inclusive billing consisting of: Technical component reimbursed at cost, plus Professional component reimbursed at 115% of the Medicare fee schedule Does not apply to departments with a unique provider numbers (e.g.RHC, HHA)

34. 34 Hospital Based ModelDepartment of CAH Electing All Inclusive Payment Medicaid reimbursement Presently 83% of cost with DSH reimbursement closing the gap between prospective payment and cost May be moving to cost based reimbursement

35. 35 Hospital Based ModelDepartment of CAH Electing All Inclusive Payment

36. 36 Hospital Based Model�Department of CAH NOT Electing All Inclusive Payment Medicare reimbursement Split billing consisting of: Technical component reimbursed at cost, billed to Fiscal Intermediary Professional component reimbursed at the Medicare fee schedule, billed to the Part B Carrier Does not apply to departments with a unique provider number (e.g. RHC, HHA)

37. 37 Hospital Based Model�Department of CAH NOT Electing All Inclusive Payment Medicaid reimbursement Presently 83% of cost with DSH reimbursement closing the gap between prospective payment and cost May be moving to cost based reimbursement

38. 38 Reimbursement Calculations

39. 39 Hospital Based Model�Department of CAH NOT Electing All Inclusive Payment

40. 40 Rural Health ClinicFreestanding Medicare reimbursement All-inclusive reimbursement rate, capped at $66.72 in CY 2003 Payments = 80% rate + 20% RHC�s charges Payments are made only for face-to-face encounters with physicians, midlevel practitioners, licensed clinical social workers and clinical psychologists Fee schedule payments for lab, x-ray, hospital, skilled nursing facility services

41. 41 Rural Health ClinicFreestanding Medicaid reimbursement Prospectively determined all-inclusive reimbursement rate Based on historic Medicaid costs for 1999 and 2000, increased by the Medicare Economic Index (2.2% to 3.0% annually), or Based on other clinics� rates in the area Payments are made for face-to-face encounters with covered Medicaid providers included in the State Plan

42. 42 Reimbursement Calculations

43. 43 Rural Health ClinicFreestanding

44. 44 Eligibility criteria Employment of MLPs Midlevel practitioners: Physician Assistant Nurse Practitioner Certified Nurse Midwife Must be available to see patients at least 50% of the time the practice is open to see patients RHCs located on islands are exempt from employing MLPs RHCs that lose MLP staff can obtain a waiver for one year Rural Health ClinicFreestanding

45. 45 Corporate Status Eligibility criteria Corporate status Nonprofit For-profit Sole proprietor or partnership Owned by another organization

46. 46 Rural Health ClinicFreestanding Eligibility criteria Other issues Four walls test (RHC must be contained within four walls) Extensive policy manual Clinical protocols Primarily in the business of primary care Provide six basic lab tests Quality Improvement Program Annual program evaluation

47. 47 Shortage Area Requirements Must be LOCATED IN a Qualifying Shortage Area MUA HPSA (primary care only) HPSP MUP � No longer qualifies for RHC status Governor designation (specific to RHC program) New RHCs must be located in an area with a current (<3 years old) shortage area designation Current RHCs granted facility HPSA status (12/02 - Health Care Safety Net Amendments)�RHC status protected if HPSA is lost Rural Health ClinicFreestanding

48. 48 Rural Health ClinicFreestanding Other Benefits 12/02 - Health Care Safety Net Amendments authorized grants (about $50,000) for training and technology in underserved areas No appropriation yet�maybe next year

49. 49 Rural Health Clinic Provider Based in Hospitals >50 Beds Medicare reimbursement All-inclusive reimbursement rate, capped ($66.72 for 2003) Payments = 80% rate + 20% RHC�s charges Payments are made only for face-to-face encounters with physicians, midlevel practitioners, licensed clinical social workers and clinical psychologists Fee schedule payments for lab, x-ray, hospital, skilled nursing facility services

50. 50 Rural Health Clinic Provider Based in Hospitals >50 Beds Medicaid reimbursement Prospectively determined all-inclusive reimbursement rate Based on historic Medicaid costs for 1999 and 2000, increased by the Medicare Economic Index (2.2% to 3.0% annually), or Based on other clinics� rates in the area Payments are made for face-to-face encounters with covered Medicaid providers included in the State Plan

51. 51 Reimbursement Calculations

52. 52

53. 53 Rural Health Clinic Provider Based in Hospitals <50 Beds Medicare reimbursement All-inclusive reimbursement rate, uncapped Payments = 80% rate + 20% RHC�s charges Payments are made only for face-to-face encounters with physicians, midlevel practitioners, licensed clinical social workers and clinical psychologists Fee schedule payments for lab, x-ray, hospital, skilled nursing facility services

54. 54 Rural Health Clinic Provider Based in Hospitals <50 Beds Medicaid reimbursement Prospectively determined all-inclusive reimbursement rate Based on historic Medicaid costs for 1999 and 2000, increased by the Medicare Economic Index (2.2% to 3.0% annually), or Based on other clinics� rates in the area Payments are made for face-to-face encounters with covered Medicaid providers included in the State Plan

55. 55 Reimbursement Calculations

56. 56 Rural Health ClinicProvider Based in Hospitals <50 Beds Eligibility criteria Same as provider based >50 Beds Shortage area requirements Same as provider based >50 Beds Other benefits Same as provider based >50 Beds

57. 57 Community Health Center (FQHC Grant Funded) Medicare reimbursement All-inclusive reimbursement rate, capped (Rural - $89.06, Urban - $103.58 for 2003) Payments = 80% rate + 20% CHC�s charges Payments are made only for face-to-face encounters with physicians, midlevel practitioners, licensed clinical social workers and clinical psychologists Fee schedule payments for lab, x-ray, hospital, skilled nursing facility services

58. 58 Community Health Center Medicaid reimbursement Prospectively determined all-inclusive reimbursement rate Based on historic Medicaid costs for 1999 and 2000, increased by the Medicare Economic Index (2.2% to 3.0% annually), or Based on other CHCs� rates in the area Payments are made for face-to-face encounters with covered Medicaid providers included in the State Plan

59. 59 Reimbursement Calculations

60. 60 Community Health Centers Receive grant funding under Section 330 of the Public Health Service Act Goal of the CHC program To maintain, expand and improve the availability and accessibility of essential primary and preventive health care services and related �enabling� services provided to low-income, medically underserved and vulnerable populations that traditionally have limited access to affordable services and face the greatest barriers to care

61. 61 Community Health Centers As fundamental components of the health care �safety net,� CHCs provide a comprehensive system of care reflective of the community�s needs and available to all persons residing in their service area(s), regardless of the person�s or family�s ability to pay for such services.

62. 62 Community Health Centers CHCs further ensure access to care by establishing a schedule of discounts for persons unable to pay a full fee, including nominal or no fees for services provided to the poorest of the populations served, persons whose incomes are below 100% of the Federal poverty guidelines.

63. 63 Community Health Centers One of the cornerstones of the CHC program is community involvement in both the management and governance of the health center. The CHC must be governed by a community-based Board of Directors, a majority of whom are users of the health center�s services and who represent the health center�s service area in terms of demographic factors such as race, ethnicity and gender.

64. 64 Community Health Centers The Board must autonomously exercise key decision-making regarding operating and service policies, approval of the budget and grant application, strategic and operational planning and the hiring of the executive director or chief executive officer. In addition, the involvement of third parties in health center governance is specifically limited by Federal policy.

65. 65 CHC Qualifying Shortage Designations Must serve an MUA/MUP designated population (differs from RHC which must be located in) HPSA/HPSP does not qualify Governor designation (Exceptional MUP) No time limit on shortage area designation

66. 66 CHC Basic Eligibility Criteria Rural or urban Must provide a sliding fee discount plan Must prove need for the FQHC in the area Other CHC requirements (program expectations) Not required to employ an MLP

67. 67 CHC Corporate Eligibility Criteria Must be 501(c)(3) nonprofit (hospital divest practice) May not be owned/operated by another entity Must have a consumer controlled board Between nine to 25 members Users = 50% Self perpetuating < 50% of non-users may derive >10% income from health care Must represent the population served May not include employees or relatives of employees Tribal programs are exempted from governance requirements Can set aside a limited number of seats to be filled by another organization (hospital)

68. 68 CHC Board Responsibilities Define/preserve the mission of the organization Make policy Safeguard the assets of the center Select, evaluate and support the CEO Monitor/evaluate center and board performance Plan for the long-range future of the center

69. 69 CHC Sliding Fee Scale Sliding fee program Required for users = 200% FPL Apply to all required services Medicare annual deductible Waived Medicare co-insurance 20% of charge

70. 70 CHC Staffing CEO must be employed by the CHC Other key management personnel preferred to be employed, but can be contracted: CFO Medical Director Chief Information Officer Clinical staffing as appropriate for service delivery Must employ �core staff� of providers Other clinical staff may be contracted Administrative/support staff may be contracted

71. 71 CHC Required Services Provide directly, through contract, or through documented arrangements�regardless of ability to pay Primary care by physicians and/or MLPs Family medicine Internal medicine Pediatrics Obstetrics/gynecology Diagnostic laboratory and radiology services

72. 72 CHC Required Services (Cont�d) Preventive health services Prenatal and perinatal services Screening for breast and cervical cancer Well-child services Immunizations against vaccine-preventable diseases Screenings for elevated blood lead levels, communicable diseases and cholesterol Pediatric eye, ear and dental screenings Voluntary family planning services Preventive dental services Mental health/substance abuse

73. 73 CHC Required Services (Cont�d) Emergency medical services Pharmaceutical services as may be appropriate for the health center Referrals to providers of medical services and other health related services Patient case management including a system for tracking and follow-up

74. 74 CHC Required Services (Cont�d) Enabling services Outreach Transportation Language interpretation if a substantial number of patients are of limited English proficiency Education regarding the availability and proper use of health services

75. 75 CHC Benefits Access to CHC grants Access to 340B Low Cost Drug Program FTCA malpractice coverage for grantees (not for FQHC Look-Alikes) Support for outpatient programs at risk Support for other services (i.e., mental health, dental, specialty services) Tool for network development

76. 76 Access to CHC Grants National goal of creating 1,200 new or expanded CHCs New Access Point grants are capped at $650,000 Expansions of current grantees eligible for additional funding Grants renewed annually Statewide strategic plan for CHC growth

77. 77 Types of CHC Grants Community Health Centers Migrant Health Centers Homeless Health Centers Public Housing Health Centers School-Based Health Centers

78. 78 340B Low Cost Drug Program Section 602 of the Veterans Health Care Act of 1992 enacted section 340B Allows eligible providers to: Purchase prescription and non-prescription medications at or below Medicaid costs Add a dispensing fee Pass savings on to users of the CHC

79. 79 340B Program (Cont�d) Eligible providers (partial list): Community Health Centers Migrant Health Centers Homeless Health Centers Public Housing Health Centers School-Based Health Centers HIV/AIDS projects Tribal Health Centers Urban Indian Health Centers Sexually Transmitted Disease Clinics Tuberculosis Clinics Title X Family Planning Clinics Federally Qualified Health Center Look-Alikes Disproportionate Share Hospitals that exceed 11.75%

80. 80 340B Implementation Access to discounted pharmaceuticals may be provided through: In-house pharmacy Contracts with local pharmacy Arrangements with remote centralized pharmacy Other innovation arrangements

81. 81 FTCA Coverage for CHCs Federal Tort Claims Act covers Federal employees Malpractice coverage for: Employees Clinical staff Some contractors Board members

82. 82 Support for Outpatient Programs at Risk CHC model encourages integration of other health services into the CHC Family planning agencies Maternal and child health programs Public health Ancillary services, such as podiatry Others May be some confusion about specialty providers in CHCs

83. 83 Support for Other Services Any service that is a covered service in the state Medicaid plan must be reimbursed on the basis of cost in the CHC/FQHC

84. 84 CHC Ownership of Other Entities CHC may own and operate other businesses: Home health Durable medical equipment Meals on Wheels Daycare Critical Access Hospitals Other�.

85. 85 CHC Networks Preference is for multiple site networks Can add new sites to networks Preference is to �expand� existing grantees

86. 86 Negotiating With Other Providers Identify area providers that might be included in a CHC Meet with them and explain the CHC program Offer to include them in a CHC �preliminary analysis� Shows financial impact Shows what has to change to access new dollars Proprietary information can usually be kept confidential Will recommend which study participants are good CHC member candidates Share preliminary report with participants Decide who is in and who is out Toughest issue: Formerly private providers becoming employees

87. 87 CHC Application Process See PIN 2003-01 Complete Need for Assistance Scoring Identify organizations to be included Assure compliance with requirements Must be operational within 90 days of grant award Prepare grant (comprehensive and complex) Grant application deadlines (to be announced) November February April Awards usually 90 days after application date Must submit annual grant application

88. 88 Hospital Support of CHC/FQHCs Hospitals may continue to provide financial support OIG guidelines for terms of support Be careful about anti-kickback regulations

89. 89 Trends in CHC/FQHC Development Hospitals are anxious to move practices off their balance sheets RHCs converting to FQHCs Existing FQHC adding new sites Hospitals developing FQHC networks Small hospitals becoming FQHCs that own hospitals Vertically integrated FQHC networks

90. 90 Hospitals and CHC/FQHCs Due to historical tension between CHCs and hospitals, many hospitals are not familiar with either the FQHC or CHC options for supporting primary care Hospitals that were familiar with the FQHC program were not necessarily interested due to strict governance requirements for an independent corporation

91. 91 Public Entity CHCs A CHC must be a 501(c)(3) or a public entity Public entity must meet all Section 330 requirements, or Public entity must have a co-applicant board that meets the Section 330 requirements Public entity in a co-applicant arrangement may Retain general policy setting functions and authorities Establish personnel policies Develop management and control systems Approval of CHC budget Others Public entity can �share� authorities with board Approval of budget Approval of CEO Others

92. 92 Public Entity CHC/FQHCs A �public entity� may become a CHC/FQHC if: A. The public entity meets all Section 330 requirements (including governance) OR B. The public entity partners with a �co-applicant� entity and together these two entities meet Section 330 requirements Under Option B, the public entity must have a co-applicant board that meets Section 330 requirement, but the public entity may: Participate in joint decision making that precedes board approval (ie, also approves the budget)

93. 93 Public Entity Authorities The Public Entity may retain authority for the following personnel issues: Personnel policies and procedures Staff selection and dismissal procedures Salary and benefit scales Employee grievance procedures Equal employment opportunity practices

94. 94 Public Entity Authorities The Public Entity may retain authority for the following fiscal issues: Develop management and control systems Provision of the annual audit Approval of the CHC/FQHC budget Development of systems for fee discount eligibility determination Bill and collection policies (including partial payment) Long range financial planning The Public Entity may retain other decision making authorities as justified in the application and approved by the BPHC

95. 95 Federally Qualified Health Center FQHC Look Alikes Medicare reimbursement All-inclusive reimbursement rate, capped (Rural - $89.06, Urban - $103.58 for 2003) Payments = 80% rate + 20% CHC�s charges Payments are made only for face-to-face encounters with physicians, midlevel practitioners, licensed clinical social workers and clinical psychologists Fee schedule payments for lab, x-ray, hospital, skilled nursing facility services

96. 96 Federally Qualified Health Center FQHC Look Alikes Medicaid reimbursement Prospectively determined all-inclusive reimbursement rate Based on historic Medicaid costs for 1999 and 2000, increased by the Medicare Economic Index (2.2% to 3.0% annually), or Based on other CHCs� rates in the area Payments are made for face-to-face encounters with covered Medicaid providers included in the State Plan

97. 97 Federally Qualified Health Centers Community Health Centers (�grantees�) have automatic FQHC status Receive grant funds and cost reimbursement FQHC �Look-Alike� Meet all the requirements of CHC Do not receive grant funds, but may be given preference for funding Eligible for cost reimbursement Eligible for 340B Tribal Outpatient Programs are eligible to receive FQHC cost reimbursement

98. 98 When Look Alikes Don�t Community Health Centers (�grantees�) have 90 days from grant award to become �fully operational� Example: The transfer of hospital-owned practices will occur upon approval FQHC Look-Alikes must be fully operational at the time of application Example: The transfer of hospital-owned practices must be a done deal at the time of application No more �wanna be� Look Alikes do not qualify for FTCA coverage ??Other areas----maybe

99. 99 FQHC Look Alike Process Complete a Look-Alike application New DRAFT application is being used Not a competitive process Not �if�, but �when� Plan on 12 months for approval!!!! The less you look like the expected model, the longer approval will take Must recertify annually Sometimes it makes sense to �dual track� a look alike and grant application

100. 100 Why Not CHC/FQHC? Control What price control? It is a complex process Get some help CAH grants State resources State primary care association

101. 101 Summary Comparison

102. 102 Comparison of Benefits

103. 103 Summary of Model Types

104. 104 Reimbursement Methodologies

105. 105 National Political Environment Very strong support for CHCs Two national studies to investigate hospital/CHC opportunities CHCs are very leery of hospitals Significant changes at HRSA (increased tensions) Difficult to have successful CHC grant without PCA/PCO support Never propose a new CHC/FQHC in competition with an existing CHC/FQHC

106. 106 Potential Threats to Hospitals CAHs and small hospitals are concerned about CHCs moving into their communities and �competing� CHCs can provide ancillary diagnostic testing CHCs can own CAHs (and other businesses)

107. 107 How to Negotiate Meet and talk Recognize that each organization is a local �safety net� provider CHCs have grant funding to support services to uninsured, which relieves strain on hospital ER Hospitals provide emergency services that would be difficult for CHCs to provide Develop a community-wide strategy for the care and nurturing of all safety net providers Meeting of board members will likely be more effective than meetings of just organizational leaders

108. 108 A New Philosophy If we are to maximize the resources and services available to the people we are committed to serving, then we have to start thinking at the community level�not the organizational level. We challenge you to be willing to go out of business if that is the best strategy for your community.

109. 109 Case Study � HAN FQHC Community Network The players include: A freestanding RHC A provider based RHC A private podiatry practice A fee-for-service OB/GYN practice

110. 110 Case Study � HAN (Cont�d) Conversion to FQHC network Combined four practices had an annual budget of $2,252,000 A Medicare/Medicaid mix of 47% Financial impact of FQHC reimbursement $318,000 from Medicare and Medicaid Hospital is a CAH � Impact $22,000 They have a pending 330 CHC grant $650,000 per year Another expansion grant is likely in two or three years Expanded Mental and Dental Health grant is likely Total annual grant funds totaling $2 Million in five years

111. 111 Case Study � RHC, Inc. FQHC Community Network The players include: A freestanding RHC Four hospital sponsored primary care practices Combined deficit for the five practices � ($580,000) Conversion to FQHC network Financial Impact of FQHC reimbursement $149,000 for four hospital sponsored practices $ 87,000 for RHC Total of $236,000, leaving a deficit of ($344,000)

112. 112 Case Study � RHC, Inc. (Cont�d) Received a 330 New Start annual grant of $650,000 Expanded services Increased users

113. 113 Case Study � DEHC Convert six freestanding primary care practices to CAH provider based The players include: A pediatrics practice Three internal medicine practices An OB/GYN practice A general surgery practice Impact greatest for the pediatrics practice � $107,000 Average impact for internists � $25,000 Surgery practice impact � $37,000 OB/GYN impact, decrease � ($11,000)

114. 114 Case Study � DEHC (Cont�d) Convert a freestanding RHC to CAH provider based Single physician and MLP Impact is $17,000 Studies consider impact on existing CAH reimbursement

115. 115 Case Study � CHWCGT Proposed conversion of small fee-for-service practice to FQHC Small hospital sponsored (barely) practice 395 visits in five months � 948 annualized FQHC reimbursement impact � $9,100 five months, $21,820 annualized Practice needs to grow Will submit a 330 New Start grant in April�..stay tuned

116. 116 Case Study � OGH Conversion of four provider-based primary care practices to FQHC status The players include: Four primary care practices in a University Primary Care network 33,370 annual visits Financial impact of FQHC At current levels � ($9,900) decrease With increase in Medicaid managed care @ 50% � $104,000 (Includes wrap-around payments)

117. 117 Case Study � AMG of MCH Comparison of freestanding RHC, provider based RHC and provider based department reimbursement The existing practice was a freestanding fee-for-service family practice The financial impact by status compared with FFS Freestanding RHC � $4,900 Provider based RHC � $52,100 Provider based department of hospital � $42,000

118. 118 Evaluation Form

119. 119