ASSUMPTIONS
| # of covered lives per provider | 1000 |
|---|---|
| # of providers per practice | 4 |
| E&M Billing PMPM($) | 16.50 |
| Multiple of procedure billing to E&M billing | 1 |
| Care Management Fee – Track 1($) | 15 |
| Care Management Fee – Track 2: PMPM($) | 28 |
PER PROVIDER PER YEAR
| E&M Billing | E&M Up-Front | E&M Up-Front | Procedure Billing | MACRA 5% | Care Management Fee | Cost/Quality Incentive | Total | |
|---|---|---|---|---|---|---|---|---|
| FFS | $ 198,000 | $ 0 | $ 198,000 | $ 198,000 | $ 0 | $ 50,000 | $ 0 | $ 446,000 |
| CPC+ Track 1 | $ 198,000 | $ 0 | $ 198,000 | $ 198,000 | $ 19,800 | $ 180,000 | $ 30,000 | $ 625,800 |
| CPC+ Track 2-65% | $ 51,975 | $ 141,570 | $ 193,545 | $ 198,000 | $ 19,577.25 | $ 336,000 | $ 48,000 | $ 795,122.25 |
PER PRACTICE PER YEAR
| E&M Billing PMPM | Procedure Billing | MACRA 5% | Care Management Fee | Cost/Quality Incentive | Total | |
|---|---|---|---|---|---|---|
| FFS | $ 792,000 | $ 792,000 | $ 0 | $ 200,000 | $ 0 | $ 1,784,000 |
| CPC+ Track 1 | $ 792,000 | $ 792,000 | $ 79,200 | $ 720,000 | $ 120,000 | $ 2,503,200 |
| CPC+ Track 2-65% | $ 566,280 | $ 792,000 | $ 78,309 | $ 1,344,000 | $ 192,000 | $ 3,180,489 |
Sample Pro Forma Per Provider Per Year
| Per Beneficiary Per Month | Estimated Cost/Year On Your Own | Estimated Cost/Year PHA | |
|---|---|---|---|
| Internal Staff | |||
| Care Coordinator (Full-time RN) | $ 5.96 | $ 71,500 | $ 71,500 |
| Internal Project Manager (Practice Manager level, full time to manage program from scratch, 25% | $ 1.49 | $ 17,875 | $ 4,468.75 |
| Required IT | |||
| Certified Electronic Health Record (annual fee) | $ 0.67 | $ 8000 | $ 8,000 |
| Certified Care Management Software | $ 1.50 | $ 18,000 | Included |
| Claims Data and Practice Level Analytics | $ 1.50 | $ 18,000 | Included |
| Analytics Support and Guidance | $ 0.42 | $ 5000 | Included |
| Additional HIT For Track 2 (TBD-Patient Reported Outcomes and as directed by CMS) | $ 0.08 | $1000 | Included |
| Interface Fees (over 5 years) | $ 0.25a | $ 3000 | Included |
| Quality Reporting Module or QCDR (annual fee) | $ 0.08 | $ 1000 | Included |
| Evidence-Based Care Plans | $ 0.01 | $ 63 | Included |
| Services | |||
| Quality Improvement Training ( to get incentive) | $ 0.21 | $ 2500 | Included |
| Care Coordinator Training and Support | $ 0.33 | $ 4000 | Included |
| 24/7 Nurse Advice Line with access to PCP | $ 0.50 | $ 6,000 | Included |
| Program Participation Consulting Services to ensure compliance, prepare budgets, help guide PFAC, etc. | $ 0.42 | $ 5000 | Included |
| CareVitality CPC+ Program | 5.00 | 60000.00 | |
| Total Recommended Services | $ 160,938 | $ 143,968.75 | |
| Additional CPC+ Payments (Net of FFS) | |||
| Total Additional Income Track 1 | $ 14.98 | $ 179,800 | $ 179,800 |
| Total Additional Income Track 2 | $ 29.09 | $ 349,122.25 | $ 349,122.25 |
| Total Additional AWV/ACP Practice Income | $ 14,625 | $ 73,125 | |
| Net Physician Compensation (Track 1) Per Year | $ 33,487 | $ 108,956.25 | |
| Net Physician Compensation (Track 2) Per Year | $ 202,809.25 | $ 278,278.50 | |
