Key Messages: December 2017 + January 2018 Clinical Chairs Committee Meetings

December 2017

UPG CFO Susan Rumsey presented information to promote understanding of the current method of Indigent Care Allocation and alternate methodologies. While payments are made based on cost, the VA Administrative Code and Virginia State Plan are silent on the distribution of funds. In FY06, a task force of Clinical Chairs recommended an allocation methodology based on patient care volumes without a cost component, which was accepted by the Clinical Chairs. When UPG Clinical Operations were included in the cost reporting, total funding increased but internal allocation wasn’t modified. As a result, funding to the 21 SOM Clinical Departments increased disproportionately.

According to the current method of Indigent Care Allocation, funds are allocated to each unit proportionate to indigent care RVUs. This assumes cost per RVU is constant across all units. Alternate methodology would have funds allocated to units based on their individual ratio of cost to charges applied to indigent volumes. Medicaid funds are currently allocated to each unit proportionate to Medicaid claims payments (as a proxy for Medicaid volumes) – which assumes that costs are constant across units. Alternate methodology would have funds allocated to each unit based on individual cost to charge ratios applied to Medicaid charges.

After discussion and questions, the chairs proposed delaying the decision until there is greater clarity about the group practice model is developed. The motion was made and seconded, and passed unanimously.

The remainder of the meeting was spent in Closed Executive Session focused on discussing UPG services, fees and costs.

January 2018

UPG Director of Finance Beth Allen presented information regarding Calculation of Facility Fee Payment, including history of the Provider Based Clinic MOU, the need for the change in calculation, the existing method of calculation and proposed method and implementation options. Ms. Allen said that she intended to ask Department Chairs to make two (2) decisions: 1. Implementation for FY18, and 2. Calculation method for FY19 and beyond. After discussion and questions, Department Chairs decided to vote by email after reviewing cash numbers through November 2017.

UPG COO Corey Feist provided an update on Anthem negotiations. The current contract with Anthem doesn’t expire until December 2019, but negotiations began in spring 2017. Input is being obtained from the Contracting & Performance Based Payment Committee. Throughout the negotiating process the UPG negotiating team (Corey Feist, Melanie Lewis and Dr. Alan Matsumoto) have attempted to balance a number of factors including: 1. The complex care provided by UPG physicians; particularly those recognized in the super specialty codes; 2. How reimbursement from Anthem compares to peer physician groups; 3. Efforts to continually provide Anthem the best rates and 4. Maintaining fee for service reimbursement for the long term. UPG is currently waiting for Anthem to reply to the recent UPG counter offer. Once the reply is received, it will be analyzed and a recommendation will be made to Clinical Chairs.

Key Messages: November 2017 Clinical Chairs Committee Meeting

Piedmont Liability Trust Annual Report

Piedmont Liability Trust (PLT) CEO Rebecca West, General Counsel Bill Archambault and COO Bruce Gehle shared the PLT Annual Report which included an Executive Overview, Claims Report, Risk Management, Education and Legal Services Report, and Financial Report. There were more changes in governance this year than in the past few years. PLT representatives asked Department Chairs for help in getting new clinicians to attend orientation sessions for educational credit. Department Chairs were apprised of key long term and short term issues.

 

CMS Quality Payment Program/MACRA

UPG Chief of Audit & Billing Quality Melanie Lewis provided an update on the CMS Quality Payment Program. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) streamlined three (3) legacy programs with the Quality Payment Program: Medicare Electronic Health Record (EHR) Incentive Program for Eligible Professionals; Physician Quality Reporting System (PQRS) and Value-Based Payment Modifier (VM). There are two ways to take part in the Quality Payment Program: Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (AAPM). UPG will participate in MIPS as a group. Ms. Lewis outlined MIPS participants and exemptions, as well as scoring for quality, scoring for improvement activities and scoring for costs. In 2018, several changes will take place including: Cost Performance category is increased to 10% of the total MIPS final score, Quality Performance category is reduced to 50%, MIPS performance threshold increased from 3 to 15 points, a bonus for using only 2015 Certified Electronic Health Record Technology, 5 bonus points on the MIPS final score for treatment of complex patients and the number of dually eligible patients treated, and the Patient Centered Medical Home Activity requirement is revised to include at least 50% of the practice sites within the Taxpayer Identification Number.

 

Epic Phase 2 Implementation Status Update

UPG Chief Financial Officer Susan Rumsey provided an Epic Phase 2 Implementation Status update. Issues have been identified around referrals and reporting; resolution efforts are underway. Of the 510,000 referral contacts made between July and October, 350,000 are linked to a scheduled appointment. Of the remaining 160,000 referrals, 100,000 don’t need an appointment and the remaining 60,000 referrals are being worked. Focused sessions with Department Administrators and the Epic Reporting Team are taking place to identify areas of need including locating existing reports, modifying existing reports and developing additional reports in Epic or Webi. Current metrics demonstrate strong performance overall, with several areas measuring above average and four in the top quartile across organizations at the same week of implementation. According to average performance projections, we are positioned to come out of the current trough in both AR Days and Cash later in FY18.

 

The remainder of the meeting was spent in Closed Executive Session focused on discussing top faculty priorities.

 

 

Key Messages: October 2017 Clinical Chairs Committee Meeting

Opening Remarks

Dr. Bobby Chhabra made opening remarks in his first meeting as President of UPG, having been elected on September 12, 2017. Dr. Chhabra stated that he was honored to have been elected and that he looked forward to using this time of transition as an opportunity to evaluate UPG’s role in UVA Health System and determine how its evolution should take shape in order to best fulfill its mission. Dr. Chhabra expressed interest in using his leadership role to help improve UPG dialogue with stakeholders, encourage transparency and a review of UPG cost structure, and ensure that UPG is the best possible advocate for clinicians. Dr. Chhabra had already met with several Health System leaders to discuss alignment in purpose and vision. Three aspects in which Dr. Chhabra would like to see UPG play a significant role as a supporting ally of the Health System are: outreach practices, improvement of ambulatory operations and developing a group practice model.

As part of his mission to improve dialogue across the Health System and seek opportunities to strengthen UPG’s position as an advocate for physicians while staying committed to its core mission, Dr. Chhabra asked Department Chairs to reach out to faculty in order to identify top issues, and bring these to the next Clinical Chairs Committee Meeting.

Dr. Chris Ghaemmaghami, Chief Medical Officer and Senior Associate Dean for Clinical Affairs, said that he and Dr. Chhabra had discussed the transition and that he was fully committed to working collaboratively with UPG in his role as liaison for clinical activities among the UVA School of Medicine, UVA School of Nursing and UPG.

Indigent Care and Medicaid Supplemental Funding 

Brad Haws presented an update on Allocation of Indigent Care and Medicaid Supplemental Funding. The two programs, Indigent Care and Medicaid Supplemental, are intended to cover 95% of costs of providing clinical care and are based on those costs. Regulations are silent on how funds are allocated internally, and internal allocation has no impact on total funding. The existing internal allocation method is based on Indigent/Medicaid patient volumes with no cost component. This method was proposed by a sub-committee of the Clinical Chairs and adopted by the Clinical Chairs in FY06.  Historically, the program covered costs for only the 21 SOM Clinical Departments but effective FY13 UPG Clinical Operations was added. The addition of these practices increased the total amount of funding; the Clinical Departments benefitted from the increase in total funding due to the internal allocation method. The question has since been raised as to whether the internal allocation should mirror the way funding is received. Such a change would align the funding with the costs, and shift funding toward UPG Clinical Operations from the 21 SOM Clinical Departments. Mr. Haws said that it was not his intention to come to a resolution during this meeting, but to begin the discussion regarding potential models: either keeping the current volume-based model, or changing to a cost-based model. Discussion on the topic included the nature of RVU valuation for different specialties as well as the suggestion of a blended formula rather than a binary decision.

Aetna Medicare UVA Health System Prime Plan 

UVA Medical Center Contract Management Administrator Milton Dunlap introduced the Aetna Medicare UVA Health System Prime Plan. UVA and Aetna have jointly established a co-branded Medicare Advantage Plan which is being offered in the market effective January 1, 2018. Open enrollment runs from October 15 through December 7. This is a UVA-only plan with a closed network of UVA providers and UVA facilities including UVA HealthSouth, the UVA Imaging Center and Culpeper Medical Center. For the first year, the plan is being offered to patients in the City of Charlottesville as well as the counties of Albemarle, Fluvanna, Greene, Louisa, Madison and Nelson. Approximately 1200 individuals are expected to enroll in the first year. Potential plan benefits for UVAHS include: Capturing new patients who aren’t currently in UVAHS and retaining them for all services, an opportunity to learn how to better manage patient populations, the possibility of influencing payment rules and gaining access to patient data we would not otherwise have had, and the potential for future gain sharing. Providers were asked to direct patients with questions to call Aetna at the phone number provided.  A handout with plan comparison data was distributed.

Ufirst/UPG HR Future State

Mr. Haws provided an update on UPG’s involvement in the Ufirst initiative. With regard to division of services, specifics were not yet available because data is still being mined and gathered to determine which services will remain at UPG after the transition and which will be shared with UVA HR. It is likely that the more “high touch” services will remain at UPG, and that the split will be roughly 50/50. Mr. Haws thanked the group for their support and data, and said that leadership would follow up with more information when it becomes available.

Epic Phase 2

Mr. Haws presented an update on Epic Phase 2. The system implementation phase of the project is complete; the next phase is to optimize the system within our workflows and business processes. During the system transition, performance is being monitored against other Epic implementations of the Professional Billing (PB) functionality. Comparisons indicate that UVAHS is performing above average in most metrics, and in the top quartile for a few metrics. Based on experience with previous clients, Epic has provided expectations for Days in AR and cash collections. We are just entering the most difficult period, when Days are highest and Collections are lowest. Recovery is expected after the turn of the calendar year.

Key Messages: Clinical Chairs Committee Meeting September 12, 2017

The Committee approved Timothy G. McLaughin as a new public member of the UPG Board of Directors.

Bobby Chhabra, M.D. was elected President of University of Virginia Physicians Group. Dr. Chhabra’s three (3) year term became effective September 12, 2017. Dr. Chhabra succeeds Paul Levine, M.D., who served as UPG President since 2012 and whose term concluded on August 31, 2017.

Key Messages from Clinical Chairs Committee Meetings June 13, 2017 and July 11, 2017

Key Messages from Clinical Chairs Committee Meeting June 13, 2017

Robin Parkin, Epic Phase 2 Administrator, provided an Epic update focusing on the Command Center plan for Epic Go-Live, the Super User Support Plan and what to expect at Go-Live.

UPG Interim CFO Beth Allen provided an overview of UPG financial performance and operations. The consolidated balance sheet at the end of April showed a 0.8% decline in net assets over the 10-month period in FY2017, while cash on hand remained strong at $33.5M. The consolidated accrual-based UPG income statement for FY2017 showed an operating deficit of $12.3M through April, reflecting the first year of a new Health System Funds Flow model and transition to mission-based financial reporting for the clinical departments. Total revenue was marginally favorable to budget (1%), and indigent care revenue was over budget with mid-year projections indicating that this revenue would exceed budget for the year by roughly $7.8M. Total pension expense for the fiscal year is expected to be $25.8M; the unbudgeted cost of which is expected to be $15.3M. While this is not a direct cash outlay, it reflects annual expense and therefore can create an operating loss. Workload trends reflect strong productivity in March with lower productivity in April, and higher productivity is expected in May and June based on trend data from FY2015 and FY2016. Clinical departments as a whole are exceeding the 65th percentile in productivity. Investment results for the 9-month period ending March 31, 2017, showed positive returns with strong market conditions. Cash collections from patient care services exceed cumulative year-to-date targets but April results reflect low collections due to a Medicare processing issue. Below are the slides Ms. Allen presented at the meeting.

 

 

 

 

 

 

 

Corey Feist provided a contracting update. UPG and UVAMC have contracts with Anthem expiring December 31, 2019. In May 2017, UPG and UVAMC representatives began negotiations for new contracts to be effective upon expiration. UPG has received commitment from UVAMC Associate VP for Business Development and Finance Larry Fitzgerald that the Medical Center contract will not be signed unless UPG terms are met. Melanie Lewis has been chairing the Performance-Based Contracting Committee and discussing strategy with the group. Feedback and questions can be directed to Ms. Lewis: msl4a@hscmail.mcc.virginia.edu

Brad Haws shared feedback from the June 1 UPG Discussion Session with providers and UPG Board of Directors public members. Roughly 100 clinicians attended the two-hour event, which provided clarity on some issues and brought clinician questions and concerns to light. Further dialogue and forums can be expected in the near future. UPG members are encouraged to submit input of any kind to the new email address designated for feedback: upgfeedback@virginia.edu. Link to video footage of the presentation can be found here as well as a copy of the slide presentation and an executive summary of the event.

 

Key Messages from Clinical Chairs Committee Meeting July 11, 2017

Brad Haws provided an update on UPG’s involvement with the Ufirst initiative and solicited input from the group on their recommendation to obtain faculty input regarding the UPG Board’s decision about whether or not to participate in Ufirst. Mr. Haws explained that there are two parts to the initiative: changes in technology using the Workday IT platform, and changes in management and staffing structure. The UPG Board of Directors wants to ensure the feedback from UPG’s constituents is received to help inform the Board’s decision. Pat Hogan, UVA EVP and COO, plans to bring a presentation to the UPG Board of Directors at the September 2017 meeting and, we believe, ask for UPG’s participation in all of Ufirst. The chairs asked to be educated about the details of Ufirst including a list of pros and cons.

Dr. Levine plans to step down as UPG President in September 2017. An election for his replacement will take place during the September 2017 Clinical Chairs Meeting. Nominations can be sent to Brad Haws. Nominees will be asked to provide biographical information upon acceptance.

There are two public members of the UPG Board of Directors who will be rotating off the Board in December: Mr. James Rutrough and Ms. Ella Strubel. The Nominating Committee of the UPG Board of Directors requests that Public Director nominations be sent to Brad Haws or Corey Feist.

UPG Interim CFO Beth Allen provided a summary of the FY2018 budget. The UPG Consolidated budget reflects a loss of $15.8M before transfers and $10.6M after transfers. The 21 clinical departments represent an $8.2M loss before transfers and $3M after transfers. UPG has worked with actuarial firm AON Hewitt to assist with analysis on the future expenses of the retirement plans. Should rates change, the possible fluctuation of the expense is significant, which UPG is monitoring closely. However, both the CSRP and CRP plans are well funded with the expectation that the CRP plan will be fully funded by FY2021. Overall, the impact of the expense is concerning to the overall performance of the group practice plan; however, the expense is an amortization cost and not a direct cash outlay. Below are the slides Ms. Allen presented at the meeting.

UPG Chief of Audit and Billing Quality Melanie Lewis provided an Epic Go-Live update. Indications from implementation team members are that implementation has gone well with some issues to address. Most Go-Live areas are meeting their Key Performance Indicators. Clinical Pathology issues need attention; Medical Center charges are roughly 66% while UPG is 97%. Feedback from departments was that most were doing well but there was some difficulty with charges being posted and concern about long registration times. There were 1300 tickets outstanding and over 6,000 tickets received to date. There is an increase in manual work-arounds, which should be avoided when possible in favor of reporting issues and submitting tickets to optimize the system during implementation. Brad Haws expressed appreciation to the group for their dedication and hard work throughout the transition.