HIV Clinics Lower Financial Risk and Improve Revenue
HIV Clinics Lower Financial Risk and Improve Revenue
The intervention was conducted at 6 HIV clinics located in Boston, MA, Brooklyn, NY, Baltimore, MD, Miami, FL, Birmingham, AL, and Houston, TX. All clinic staff were trained to provide print and verbal motivational messages to patients about the importance of staying in care. Details of the intervention (called "Stay Connected") have been previously published; a description of the intervention process and training activities, as well as downloadable copies of the brochures, posters, and messages can be found at the link in reference 7. The preintervention year ran from May 1, 2008, to April 30, 2009; the intervention year ran from May 1, 2009, to April 30, 2010. The content of the posters, brochures, and messages was approved by Institutional Review Boards at each site.
During the intervention year, we conducted 3 quarterly waves of provider surveys that included physicians, nurse practitioners, and physician assistants. The surveys asked, "Compared to before the Stay Connected project started, how much attention is the clinic giving to the importance of patients keeping clinic appointments?" We report the percentages of providers (pooled across waves and provider type) who responded "Somewhat" or "Much more than before" the intervention started.
Primary care visit data from each clinic's attendance database were sent to CDC. Each scheduled visit had 3 possible outcomes: a kept visit, a missed (no-show) visit, and a cancelled visit. Kept and missed visits were counted; cancelled visits were excluded. The outcome variables were the number of kept PC visits in the 2 study years, and the clinic's revenue gained or lost due to the difference in kept PC visits between the 2 years.
Visit claims and capitation payments data were submitted separately to CDC after the end of the intervention year by the academic medical centers with which the clinics were affiliated. These centers supplied HIV primary care visit revenue (professional/technical payments and facility payments) for a 12-month period no more than 12 months after the intervention year. Clinics reported revenue by payer (commercial, Medicare, Medicaid, Ryan-White/self-pay) and by Current Procedural Terminology level. The dollar value of 1 visit was calculated by clinic visit payments received divided by the number of kept visits for that year. Revenue gained or lost in the intervention year was calculated by multiplying the dollar value of 1 visit by the number of additional (or fewer) kept visits in the intervention year. Net revenue was the amount of revenue left after including costs to conduct the intervention.
We report actual paid amounts, rather than billed charges, as the payments received are typically lower than the billed charges. The payments, or revenue, are based on fee-for-service (FFS) visits and capitation contracts with third-party payers for professional services and facility fees. The breakdown between FFS visit payments versus capitated visit payments in US primary care settings was derived from published data from the Centers for Medicare and Medicaid Services for Medicaid and Medicare, and published data using the Medical Expenditure Panel Survey for private insurance paid visits. Site principal investigators supplied information to determine whether the Ryan White CARE Act funds were drawn down using a FFS formula or capitation-type formula. With these payer-specific estimates of capitated versus FFS proportions, we then applied the numbers of kept visits by payer type from our 6 clinics to derive a weighted average of capitated and FFS visit proportions for each site. The weighted average was 65% FFS visits and 35% capitated visits.
Training and materials for the intervention were included as costs in the analysis. We assumed that no-cost training would not be universally available, so training was estimated at approximately $2400 for a 2-hour session per clinic. Materials for the intervention (posters, brochures, and provider pocket guides) are available, and can be printed locally for approximately $250 to $500.
In Table 1, we used a linear regression model to calculate absolute and relative improvement in kept visits between the 2 years. Table 2 extended this model, taking into account the cost of the intervention, and producing revenue change based on change in the number of kept visits. We used regression models to calculate the difference in proportion of kept visits between the 2 years, adjusting for variables that differed between the study years, and Generalized Estimating Equations with an unstructured correlation matrix to adjust for repeated measures per patient. Adjusting for scheduled visits was necessary because the net revenue calculations were based on differences in proportions where year-specific denominators of scheduled visits may differ. Analyses were performed with SAS 9.2 (SAS Institute, Inc., Cary, NC).
Methods
The intervention was conducted at 6 HIV clinics located in Boston, MA, Brooklyn, NY, Baltimore, MD, Miami, FL, Birmingham, AL, and Houston, TX. All clinic staff were trained to provide print and verbal motivational messages to patients about the importance of staying in care. Details of the intervention (called "Stay Connected") have been previously published; a description of the intervention process and training activities, as well as downloadable copies of the brochures, posters, and messages can be found at the link in reference 7. The preintervention year ran from May 1, 2008, to April 30, 2009; the intervention year ran from May 1, 2009, to April 30, 2010. The content of the posters, brochures, and messages was approved by Institutional Review Boards at each site.
Provider Surveys
During the intervention year, we conducted 3 quarterly waves of provider surveys that included physicians, nurse practitioners, and physician assistants. The surveys asked, "Compared to before the Stay Connected project started, how much attention is the clinic giving to the importance of patients keeping clinic appointments?" We report the percentages of providers (pooled across waves and provider type) who responded "Somewhat" or "Much more than before" the intervention started.
Visit and Financial Data
Primary care visit data from each clinic's attendance database were sent to CDC. Each scheduled visit had 3 possible outcomes: a kept visit, a missed (no-show) visit, and a cancelled visit. Kept and missed visits were counted; cancelled visits were excluded. The outcome variables were the number of kept PC visits in the 2 study years, and the clinic's revenue gained or lost due to the difference in kept PC visits between the 2 years.
Visit claims and capitation payments data were submitted separately to CDC after the end of the intervention year by the academic medical centers with which the clinics were affiliated. These centers supplied HIV primary care visit revenue (professional/technical payments and facility payments) for a 12-month period no more than 12 months after the intervention year. Clinics reported revenue by payer (commercial, Medicare, Medicaid, Ryan-White/self-pay) and by Current Procedural Terminology level. The dollar value of 1 visit was calculated by clinic visit payments received divided by the number of kept visits for that year. Revenue gained or lost in the intervention year was calculated by multiplying the dollar value of 1 visit by the number of additional (or fewer) kept visits in the intervention year. Net revenue was the amount of revenue left after including costs to conduct the intervention.
We report actual paid amounts, rather than billed charges, as the payments received are typically lower than the billed charges. The payments, or revenue, are based on fee-for-service (FFS) visits and capitation contracts with third-party payers for professional services and facility fees. The breakdown between FFS visit payments versus capitated visit payments in US primary care settings was derived from published data from the Centers for Medicare and Medicaid Services for Medicaid and Medicare, and published data using the Medical Expenditure Panel Survey for private insurance paid visits. Site principal investigators supplied information to determine whether the Ryan White CARE Act funds were drawn down using a FFS formula or capitation-type formula. With these payer-specific estimates of capitated versus FFS proportions, we then applied the numbers of kept visits by payer type from our 6 clinics to derive a weighted average of capitated and FFS visit proportions for each site. The weighted average was 65% FFS visits and 35% capitated visits.
Training and materials for the intervention were included as costs in the analysis. We assumed that no-cost training would not be universally available, so training was estimated at approximately $2400 for a 2-hour session per clinic. Materials for the intervention (posters, brochures, and provider pocket guides) are available, and can be printed locally for approximately $250 to $500.
Statistical Analysis
In Table 1, we used a linear regression model to calculate absolute and relative improvement in kept visits between the 2 years. Table 2 extended this model, taking into account the cost of the intervention, and producing revenue change based on change in the number of kept visits. We used regression models to calculate the difference in proportion of kept visits between the 2 years, adjusting for variables that differed between the study years, and Generalized Estimating Equations with an unstructured correlation matrix to adjust for repeated measures per patient. Adjusting for scheduled visits was necessary because the net revenue calculations were based on differences in proportions where year-specific denominators of scheduled visits may differ. Analyses were performed with SAS 9.2 (SAS Institute, Inc., Cary, NC).
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