This business plan proposal is for Patient’s First Medical Clinic, PA (PFMC) to explore the opportunity to add a Population Health department (Pop Health). According to the CDC, “Population health brings significant health concerns into focus and addresses ways that resources can be allocated to overcome the problems that drive poor health conditions in the population.” (U.S. Department of Health & Human Services What is Population Health?) The addition of Pop Health will address the increasing demands that the insurance payors are placing on medical practices to adhere to performance-based metrics for insurance reimbursements. This business proposal reports the findings of an internal audit conducted by PFMC that identified potential lost revenue and the benefits of adding Pop Health to recover it.
Medicare and Medicare Advantage programs allow practices to bill for the completion of Annual Wellness Visits (AWV) and Transitional Care Management Services (TCMS). Additional program opportunities through Medicare and Medicare advantage are the completion of Hierarchical Condition Category (HCC) forms and closing gaps in care based off their quality metrics. These four programs present a vast opportunity to increase practice revenue, improve patient care and reduce provider and staff burnout. Current utilization of these programs within PFMC are minimal. The additional revenue captured by having a dedicated team focused on working these incentive programs far outweigh the additional overhead of the department. Insurance payors are trending toward value-based contracts and meeting quality benchmarks for service payments. The addition of Pop Health would be the first step in creating a value-based care model.