Ocracoke Health Center, Inc



MVMC, Inc.

MVMC

PRACTICE REVIEW

On Site – February 12 & 13, 20XX

Presented to Board – March 12, 20XX

Prepared by: Tammy Norville

Office of Rural Health

NC Department of Health and Human Services

311 Ashe Avenue

2009 Mail Service Center

Raleigh, NC 27699-2009

Direct Office Phone Number (919) 527-6476

I. BACKGROUND

The Office of Rural Health (ORH) was asked by the MVMC, Inc. Board Chairman to provide a practice review to ascertain any inefficiencies and/or areas needing improvement.

Tammy Norville was assigned to the review spending time on site observing practice operations and interviewing staff about specific operating procedures and review of financial documentation.

This summary presents the results of the practice review. It is divided into sections: general administrative operations, physical plant, clinical operations, board of directors, and other observations. Each section outlines strategies and recommendations for improvement.

We would like to thank the staff at the MVMC for their cooperation and assistance during the practice review. Each staff member should be commended for his or her dedication and commitment to the Hays community.

The ORH review team found sound business practices and good financial and operating systems at MVMC. The following are recommendations and strategies that may improve organizational structure and operational systems in the practice, and do not represent substantive changes to current operations.

II. REVIEW

A. ORGANIZATION OVERVIEW – provided by

MVMC

MVMC is a community owned non-profit 501 (c) (3) tax exempted rural health clinic located in Town, North Carolina, which is in the central part of Wilkes County. Our center was founded in 1977 through door to door donations of money, which in turn was matched by money given from the Office of Rural Health. The mission of MVMC is to provide quality health care at the most affordable price and to provide these services to those who may be best served in a community setting, regardless of their ability to pay. The center has a group of 8 board members that oversee operations. The group of members is very diverse, ranging from farmer, author, business leader, teachers, construction contractor, retired factory worker, and Baptist minister. We feel the diversity of this group helps to respond to all health care needs of the community with quality and respect that each individual deserves. At present MVMC employs 1 physician, 1 physician’s assistant, 1 family nurse practitioner, 1 registered nurse, 4 certified medical assistants, and an Executive Director that is shared with WWMC and BMC.

MVMC administers the Medical Access Plan in cooperation and funding from the Office of Rural Health. This plan allows patients without other resources (and meeting economic indicators) to have a primary medical care home, strengthening the access to care safety net in the Wilkes County area. The medical center provides curative, preventive, and diagnostic medical service in addition to chronic disease management. MVMC currently has 6 exam rooms, a trauma / procedure room, and an in-house CLIA waved laboratory.

MVMC is a CMS-RHC for Medicare and Medicaid Services. Patient services are provided from 8:00 AM until 5:00 PM Monday, Wednesday, Thursday and Friday and from 8:30 AM until 7:30 PM on Tuesday.

B. GENERAL ADMINISTRATIVE OPERATIONS

The ORH review team reviewed the center’s financials, billings and collections and policies. Extensive interviews revealed consistency with staff members and duties. Important to note is the level of cross-training discussed during interviews. There is a high level of loyalty and dedication to the organization and the community. Policies are reviewed annually and approved by the board of directors. In addition, all other Rural Health Clinic requirements are consistently met or exceeded. MicroMD electronic health record (both practice management and medical record) is in place. The PM side seems to work fairly well. The EMR side is a bit more burdensome. It appears there are connectivity and speed issues on a fairly regular basis. There are also hardware issues.

Another challenge with MicroMD is outside laboratory results. The results are not easily attainable and historical records are not in the EMR. The provider must use the electronic version of current lab results and the paper medical record for historical reference. This process is both burdensome and time consuming.

Currently, staff may have to “hunt” for paper medical records. Until all patients are “in” and the providers have a comfort level in the information in the EMR, there will be continued reliance on the paper medical record. It was stated that all providers should give up the paper medical record and rely solely on the EMR.

Since MVMC shares their Executive Director (Sandra Cleary) with both BMC and WWMC, a few other staff share their expertise as well. One staff provides billing services to all three clinics and another serves as the “Super User” for MicroMD (the electronic health record). These collaborative efforts have assisted in moving the three practices forward.

Financial Observations:

The following tables and charts demonstrate the current financial state of the organization. All of the information presented here was taken directly from the MicroMD practice management system and the financial reports supplied by MVMC.

|Accounts Receivable | | |

|as of 2/20/XX | | |

| | | | | |

| | |$ 11,187.88 |7.04% | |

| |31-60 | | | |

| | |$ 12,306.79 |7.74% | |

| |61-90 | | | |

| | |$ 90,941.95 |57.20% | |

| |Over 90 | | | |

| | |$158,984.60 |100.00% | |

| | |2.18 | |

| |Months in A/R | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|Top 5 A/R by Payer | | | | | | |

| |

| | | | | | | |

| |Total Patient count |839 |

| | |1523 |

| |Outstanding Claims | |

| | |$143,228.05 |

| |Total Claims Due | |

| | | | | | | |

| |

| |

| |

|Number of Claims Due by Payer - Top 4 |

| | | |Amount of |% of Total |

| | | | |Claims |

| | |Number of | | |

| | |Claims |Claims | |

| | |435 |$41,097.64 |28.69% |

| |Medicare | | | |

| | |593 |$51,826.69 |36.18% |

| |Medicaid | | | |

| | |229 |$24,112.35 |15.04% |

| |BC/BS | | | |

| | |91 |$10,217.00 |5.98% |

| |MedCost | | | |

| | |1348 |$127,253.68 |85.90% |

| |Total | | | |

|Visit History |

|between 7/1/XX and 12/31/XX (6 months) |

| | | | | | | |

| |Distinct Patients |1589 |

| | |3897 |

| |Total Visits | |

| | |2.45 |

| |Ave Visits per Patient per Month | |

| | |265 |

| |Ave Patient per Month | |

| | |650 |

| |Ave Visits per Month | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|Top 5 by Payer | | |

| | | |

| | |Patients |Visits |Visit/Pat | | |

| | |365 |887 |2.43 | | |

| |Medicare | | | | | |

| | |310 |624 |2.01 | | |

| |Medicaid | | | | | |

| | |321 |632 |1.97 | | |

| |BCBS | | | | | |

| | |29 |71 |2.45 | | |

| |MedCost | | | | | |

| | |293 |654 |2.23 | | |

| |MAP | | | | | |

| | |1318 |2868 |2.18 | | |

| |Total | | | | | |

| | |82.95% |73.60% | | | |

| |% Total | | | | | |

|Visits and Charges by Provider |

| | |Visits |Charges |Charge/Visit |

| |Hubbard |1177 |$139,214.50 |$118.28 |

| | |1057 |$110,527.00 |$104.57 |

| |Shumate | | | |

| | |1663 |$188,479.00 |$113.34 |

| |Stone | | | |

| | |3897 |$438,220.50 |$112.45 |

| |Total | | | |

| | |650 |$73,036.75 |$112.45 |

| |Average | | | |

| | | | | | |

| |

| |

| |

|New Patients |

| | | | | | |

| |Provider #1 |Provider #2 |Provider #3 |Total |

| |11 |82 |20 |113 |

| | | | | |

|Top 10 Diagnosis Codes |

| |

| |

| |

| |

| |

| |

| |

| |

| |

|Diagnosis Code |

|Description |

|Quantity |

| |

| |

|401.1 |

|Hypertension |

|1351 |

| |

| |

|250.00 |

|Diabetes w/o complications |

|723 |

| |

| |

|272.0 |

|High Cholesterol |

|465 |

| |

| |

|530.10 |

|ReFlux Esophagitis |

|448 |

| |

| |

|466.0 |

|Acute Bronchitis |

|330 |

| |

| |

|244.9 |

|Unspecified Hypothyrodism |

|218 |

| |

| |

|311 |

|Depressive Disorder |

|203 |

| |

| |

|414.00 |

|Coronary Atherosclerosis |

|197 |

| |

| |

|496 |

|COPD |

|174 |

| |

| |

|724.2 |

|Lumbago |

|160 |

| |

| | | | | | |

| | | | |

| | | | |

| | | | |

| | |4269 |

| | | |

| |Top 10 total | |

| |Total Diagnosis Count |9538 |

| | |45% |

| |Top 10 Percent | |

| | |540 |

| |Total Distinct Diagnosis | |

| | |2% |

| |Top 10 Percent | |

| |REVENUE |

| |

| |

|$30,000 or less. | | | | |

| 86% of all A/R is in 5 payer classes. This is where limited collection resources should focus. |

|Total cash value of the existing A/R is approximately $70,000, at best. | | | | | | |

| | | | | | | |

| | | | | | | |

|Claims Processing | | | | | | |

|Reduction in number of open claims will diminish by concentrating efforts on Medicare, Medicaid and BCBS. | | | | | | |

| | | | | | | |

| | | | | | | |

|There is a direct correlation between open claims and accounts receivable. | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

|Visit History | | | | | | |

|BCBS is well below the average number of visits per patient. Are these patients less chronic? | | | | | | |

| | | | | | | |

|2% of the diagnosis codes account for 45% of the utilization. | | | | | | |

|The relatively low number of new patient visits may be a “red flag” for potentially diminishing the organization’s long term | | | | | | |

|viability. | | | | | | |

| | | | | | | |

| | | | | | | |

| | | | | | | |

| |

Expenses

o Provider compensation is the largest portion of expenses. The organization cannot afford to continue to pay base salary alone. Some production and other quality indicators must be factored in to provider compensation for long term success of the organization. One example of this type of compensation package may include base salary (lower than current ‘base’ salaries), plus Relative Value Unit (production based factor), plus citizenship (how well do you work with others? Are you willing to be part of the team?), plus quality, which would require that the providers use the EMR exclusively in order to track the data. The lack of sound data limits MVMC’s ability to participate in current incentive opportunities.

o Currently, MVMC is not getting available incentive dollars for implementation of EHR. As it currently stands, MVMC cannot move toward meeting Meaningful Use or Patient Centered Medical Home status. Eventually (within the next few years), if MVMC cannot meet these standards, there will be monetary penalties for both Medicare and Medicaid.

o In the first six months of this fiscal year, $5,800 was spent on Dues & Subscriptions. This seems high for this category.

o The insurance line is another large expenditure. In the first six months of the fiscal year, $59,906.40 was assigned to this category. Again, the organization cannot afford to continue with this expense rate. It may be time for the staff to pay part of their premiums or for the organization to raise the deductible. Another option may be to work with Boomer and West Wilkes to attempt the Physician Care Direct () - or some other ‘concierge’ type - plan. This recommendation is a bit complex, so we will not go into more detail here, however, let your assigned field staff know if you are interested in having the conversation.

o Finally, medical supplies may be streamlined a bit based on number of visits. Unfortunately, this is rather subjective without an in-depth coding and chart review to determine the level of chronic patient needs.

Billing/Coding/Reimbursement of Services Observations:

Based on staff interviews, there are challenges with Medicaid Secondary payments. This has been an ongoing concern for some time. It appears the MicroMD support folks do not have the knowledge to assist with the corrections. There was also discussion regarding “Home Health” services.

Other claims information is included in the Financial Section of this report.

Billing/Coding/Reimbursement of Services Recommendations:

o Work with ORH assigned Field Staff representative on Home Health services assuring correct CPT code use.

o Work with ORH assigned Field Staff representative to facilitate resolution of needed assistance from MicroMD support.

o Additional claims recommendations may be found in the Financial Section of this report.

General and Regulatory Administrative Observations:

As a certified Rural Health Clinic, there are requirements mandating fire drills, annual clinical, personnel and financial policy reviews, as well as a few clinical requirements. MVMC policy manuals are up-to-date.

It appears there is no long-term strategic plan for the organization. The ORH review team suggests a business plan/strategic plan be developed for continued use. This type of plan may serve as a road map for the organization.

General and Regulatory Administrative Recommendations:

o Develop and implement a plan to renegotiate insurance payer fee schedules for potential increased reimbursement.

o Develop and implement a long-term strategic/business planning process to provide an organizational road map.

C. PHYSICAL PLANT

Physical Plant Observations:

The physical plant appears to be structurally sound and has been renovated in last few years.

Physical Plant Recommendations:

There are no recommendations for this section.

D. CLINICAL OPERATIONS

Clinical Operations Observations:

The practice conducts regular (annual) chart audits, which is required as a certified Rural Health Clinic.

Clinical Operations Recommendations:

There are no recommendations for this section.

E. BOARD OF DIRECTORS

Board of Directors Observations:

The Board of Directors appears to work well together and meets regularly.

Board of Directors Recommendations:

o Continue with current dedication level and support of MVMC administrator, providers and support staff members.

o Meet with ORH field staff representatives to discuss budget and subsidy concerns prior to submitting next fiscal year’s (FY 2013/2014) budget.

F. OTHER CONSIDERATIONS

Other Considerations Observations:

In looking to future efforts in Hays, Wilkes County and the western region as a whole, as well as with current trends in health care it is imperative that organizations actively seek out collaborative opportunities that will not only benefit the individual organization, but the entire region. BMC and WWMC are within “easy collaborative reach” of MVMC. Like MVMC, these primary care medical centers are safety net providers with a mission of service to their respective communities. In addition, with the rising costs of providing services and diminishing financial resources (governmental subsidy and other grant opportunities) it seems some type of collaborative effort may increase efficiencies and ease some expense issues.

Over the last three years, MVMC has worked tirelessly in collaboration with BMC and WWMC to obtain Federally Qualified Health Center New Access Point (FQHC-NAP) status and Federally Qualified Health Center Look-Alike (FQHC-LA) status. These three sites have spent almost $30,000 (comprised of subsidy from both ORH and the Kate B. Reynolds Charitable Trust with the balance divided among the three sites) in these pursuits to no avail. It appears, based on conversation with a new grant writer, the way to become more certain of gaining Look-Alike status is to consolidate the three organizations into one organization.

The “Super Board” would use the BMC, Inc 501(C )(3) status. Since all of the organizations own property, the current organizations (including the boards) would remain intact. As the FQHC-NAP or FQHC-LA, all staff, including providers, would become Boomer Medical Center employees. The “Super Board” would become the true governing body of the organization with the boards of each organization operating as landlord and/or advisory only. The “Super Board” is comprised of current board members from each organization. A minimum of six months “Super Board” meeting minutes are required before resubmission (per grant writer) for FQHC-LA status consideration.

With facilitation of your assigned Field Staff Representative, we recommend this discussion begin with conversation within each board. These conversations should be followed by meeting(s) with the three Board Chairs.

III. CONCLUSION

We hope this document will be a useful tool as the organization moves forward in these uncertain times. Please review this document in its entirety. Once reviewed, make note in the minutes of the next regular Board meeting stating that all board members have received a copy of this report, have read it and have had the opportunity to ask questions.

Also, we request the Board Chair or the Board Secretary provide to the assigned ORH Field Staff in writing via email the report has been received, reviewed and any discussed potential action based on the recommendations or that the recommendations are under the board’s consideration. The ORHCC field staff assigned to MVMC is Tammy Norville (tammy.norville1@dhhs.).

The preceding observations and recommendations were based on interviews, document/record review and site visit. We believe implementing these recommendations will have a positive effect on organizational efficiency and service provision.

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