What happens to your modeling if those are wrong?

ve discussed the St. Show more Case #2 Taking Total Cost of Care Risk as an ACO PLEASE ANSWER PART B As weve discussed the St. Sebastian system is considering becoming certified as an Accountable Care Organization (ACO). A national payor with a Medicare Advantage (MA) plan in your market has recently approached your system with a proposal for a new contract that gives your organization significant financial risk. They have operated an MA product in your market for several years but recently the financial performance has worsened. Their projected performance for the current year is shown below. Revenue PMPM CMS REVENUE Member premium Revenue to be allocated Claims Inpatient claims Outpatient claims Physician claims Ancillary claims Part D (retail RX) Total Medical Costs Actual MER $680 $- $680 $240 $125 $140 $15 $105 $625 91.91% The plan believes that to be successful long term they must achieve a Medical Expense Ratio (MER) of at least 85% (in other words only 85% of the premium revenue would be spent on medical claims). If they cant fix this they will most likely leave the market. They believe that their best chance to correct the MER is to engage you the local IDS in a true risk contract in which theyll share both surpluses and deficits. As you consider whether to accept the deal assume the following: 1. Assume not all of the hospital spending happens within your hospital. 2. Each year you can expect a 1% increase in premium revenue from CMS. Likewise you can expect a 1% rise in Medicare payment rates to hospitals. 3. Your hospitals operating costs are rising at 3% per year (both fixed and variable) 4. The 2016 Membership in this product is 10000 members. The plan is projecting growth of 2000 members per year for the next 5 years 5. If you dont sign the deal the 10000 members will still use your hospital but they will revert to Traditional Medicare patients. 6. The revenues coming from CMS are risk-adjusted with a base premium payment of $850 at a Medicare Risk Adjustment (MRA) score of 1.0. Currently the average MRA score for this population is 0.80. 7. The risk contract will set a Medical Services budget at 85% of the Premium from CMS. If the MER is below 85% that will be a surplus to be shared between the plan and IDS. If the MER exceeds 85% that will be a deficit to be shared. The schedule of risk sharing is as follows: Year 1 25% IDS; 75% Payer Year 2 50% IDS; 50% Payer Year 3 75% IDS; 25% Payer Year 4 100% IDS; 0% Payer Year 5 100% IDS; 0% Payer 8. The IDS can invest in people and IT resources to improve the MRA score for the population being managed. You estimate that for every $500000 spent per year you can raise the average MRA score by 500 basis points (5 percentage points). Assume that once you commit to spending this money its in your budget every year. 9. Although the IDS can raise the average MRA score there is a one year lag between the score being raised and the revenue raising. (hint this is important since you are bringing in new members each year) 10. The IDS can invest in people and IT systems to reduce costs by reducing utilization of services. For every $500000 invested per year we can reduce the utilization of services by 5% vs. the previous year. (Assume the $500k and 5% figures are maximums per year i.e. you cant spend $1 million to get 10% in one year) Assume that once you commit to spending this money its in your budget every year. All inpatient and outpatient services will be reduced by 5% but NOT physician or drug utilization. 11. Although the plan considers hospital spending a cost your hospitals considers it revenue. A breakdown of the projected actual utilization of services from current year is below. Unless you act to change it you can expect that the utilization per/1000 will remain same. SVC Line Cases Days Charges Payments Variable Costs Fixed Costs IP Total 1585 7376 $50400000 $14400000 $8594479 $9772546 OP Total 30800 $26250000 $7500000 $4085687 $6484893 Total MA $76650000 $21900000 $12680166 $16257438 The president of your PHO is enthusiastic about the project since she believes this will be an opportunity for the PHO to shine. The system COO is a long-time hospital administrator and is urging you to reject the deal since it will reduce hospital admissions at a time when Medicare revenue is already insufficient to meet costs. As CEO you have to make some decisions. Should you take this deal? If you do should you invest in people and resources to improve performance? Are you too young to take an early retirement? In order to answer these questions you should do the following: Part B 3. Prepare different scenarios that assume that you invest in measures to improve revenues and reduce utilization (prepare one that shows you reducing utilization one that shows you improving revenue and a third that shows improvement in both 4. Prepare a five year projection of your Hospital internal Revenues and Expenses (again taking into account inflation and membership growth) that assumes you do take the deal and make improvements. As you model ways to improve Plan performance by reducing utilization be sure that your hospital revenue/expense model reflects the reduced utilization. Assuming that the right answer is the one that maximizes net revenue to the IDS what should you do? Explain why that is your recommendation. Are there any of the assumptions that were made along the way that youd find fault with? What happens to your modeling if those are wrong? Show less

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