Hello everyone. Thank you for joining us today. Today is a follow-up to Hiding in Plain Sight Part 1. Many of you participated in a couple of weeks. We had our content experts, Nicole and Denise, give a fabulous presentation. Hopefully, Joel and I can meet your standards and do half as well as they did and continue to build on their messaging. I'm wondering if we should just jump right in. Uh-oh, I think I already screwed up and went too far forward. Here we go. Again, typical, same as usual. You'll find the link for the presentation on the left side and send texts and questions to the presenter on the right side. Feel free to, throughout the presentation, ask questions. We look forward, in fact, to all of your questions. So today, the plan is, sorry, I'm just getting myself used to the keyboard here. The key takeaways, again, we're building on a couple of weeks ago. Again, the basic understanding of care management services. Denise and Nicole did an excellent job of presenting that material. Now, we're just going to drill a little deeper in that. We're going to talk about how to build the feasibility analysis in the business case. I like to always say it, nobody else is advocating for you guys. You have to tell your story. Joel and I are going to hopefully give you some tips on how to tell that story. That's the content for today. We're going to start with, again, a quick recap of everything Nicole and Denise had to say. Joel is going to talk to you about how to wrap your arms around those populations, so that basically you can apply financials to that. We're going to look at the resources that you probably are already utilizing, but not billing for, and building the more appropriate sustainable model for the future. With that, let's see. We're going to jump into the quick recap of a couple of weeks ago. I apologize. My mouse is a little quirky today. It's a little faster than I am, not surprisingly. Really quick, those patients. It's kind of a needle in the haystack. You really want to narrow it down. You want to find those patients. I keep saying they're kind of the frequent flyers for you guys, right? The heart failure patients, the AFib patients, the CAD folks that keep coming back. The goal is to identify these patient populations so you can really, again, you're looking to be able to wrap financials around them. It's really hard to do it when you're looking at everybody. If you drill down, it's actually going to be much easier, too, to figure out the resources you're utilizing because you can go to your heart failure team, you can go to your cath lab team, you can go to your EP folks to figure out what's happening, right? So that's the first recap, right, message. And also looking at the Medicare patients with secondary insurance. And as Nicole alluded to, it's about the copay, right? So you're trying to make this as easy as possible, not only for you guys, for the patient. So we're starting off with the least amount of activity here. So once you identify your patients, and then it was figuring out the programs. Again, you don't have to do any of these programs. You can do one of them. You can do both of them. It's really just to wrap your brain around the options that you have. TCM, the transitional care management, was one of them that we talked about. Again, a lot of you guys are already doing this work. And these are the patients that are transitioning from the ED inpatient to home. So it's that 30-day after discharge, right? You want to avoid the readmission. So we've been talking about this for years. A lot of your nurses are already calling these patients. So we want to find those patients, right? And then most importantly are the details, right? So two days after discharge, somebody's calling them, somebody's calling to check in on them and making an appointment, a follow-up appointment, that 7 to 14 calendar days. So that's the transitional care management. Again, very popular. You guys are already doing the work. How do we formalize it? And then we jumping into TCM, principal care management. This one's a little bit more complicated, but complicated often means more money. So keep that in mind. We're talking about the patients, the patients that have a lot of issues going on, right? And these are truly your frequent flyer folks, right? They have a lot of conditions, COPD, diabetes, hypertension, heart failure. So they come in often. You try to avoid them coming in often. There's a lot of phone calls. You want to manage these. And again, there's already a plan for most of these patients in place already. You guys are checking in on them. So one of the details with regarding PCM is time-based services. So you want to be really careful about tracking the time in order to bill for it. And then it also requires the face-to-face once a year, which in most cases is easy, right? They're coming in more than once a year, but at minimum. So again, two great options. And now what do you do, right? How do you decide how you're going to move forward? So again, these slides look familiar. I'm not going to lie. I borrowed them from Denise and Nicole, because they were fabulous and really to the point, right? So their key recommendations for success, obviously, was the documentation, critical for billing, obviously. And then to consider time-tracking software, because that's really the meat and the potatoes of being able to prove activity, review existing workflows to identify staff. And actually, this is the bulk of what Joel and I are going to be talking about today really, right, is identifying those workflows, more specifically, the resources that go into those workflows that you guys are probably already expensing and aren't even realizing. And then Nicole and Denise talked about scripting for the team for communication. Obviously, consistency, structured communication is always critical. And then collaboration with everybody involved, front-end, back-end, inpatient, outpatient. It really does take a team to do this properly. So really quick, we're going to talk about your existing current state. You want to really just, you know, be thoughtful about this, right? And first of all, as we know, it takes a team, right? And although we think, we feel like cardiovascular service is the most importance of specialty in the entire hospital, and everything should really revolve around us, at least I often felt that way. But the reality is, there's a lot else happening in the hospital, right? Especially these complicated patients with the diabetes, COPD, renal disease, hypertension, heart failure, they could be all over the place. So you really, before you get too deep into that, you want to take a step back and inquire what's happening in the system. And the reason is, because there's only one of these charges can't be dropped by all the subspecialties plus primary care for these same patients. So if the primary care is already managing it and already dropping the charges, unfortunately, that means you can't and that's okay, as long as someone's, you know, capturing those dollars. But again, we want to make sure nobody else is already tapping into these charges. So I would take a step back and depending on what kind of system you belong to, whether you're private practice, a little easier to manage, figure out who's charging. At the same time, if you're part of a large system, figuring out all the other players, right? For me, it would have been going to the billing office and saying who else is dropping these codes, right? Anybody else in the family that's under the same tax ID, but for every single one of you could potentially be a different setup. So figuring out who else is dropping these charges, again, it could be another subspecialty, could be primary care, but you need to ask. And unfortunately, because you don't have access to all of that, it takes time. So again, before you get too deep into it, because it could potentially be a deal breaker, you want to ask that question upfront. And then from there, we want to think about existing workflow. Again, I apologize, my mouse is just being very tricky there. So existing workflow, what services are you providing? And I feel pretty confident that many of you guys are already providing these services. One, because it's the right thing to do for the patient. Two, because a lot of us have been working, dealing with the 30-day readmission, right? The penalties for that for years now. So it's the same workflow, right? So we've had a lot of people doing this, but just informally, right? You have nurses, the ones that work on Monday, or somebody comes in on Wednesday, somebody takes the weekend activity. You guys have already been utilizing a ton of your resources to take care of this. Again, but you just haven't been dropping the charges and that's okay. So the good thing is that you already have some of the process in place, right? So again, you want to ask your MDs, your PAs, everybody involved, right? And really drill down on activity and see what's happening. And for some of the bigger systems, you really want to be thoughtful about it because it could be, you know, your inpatient nurses or your outpatient nurses calling the heart failure. It could be, again, a lot of these large systems, just because they sit on somebody's budget, that's not necessarily where the activity is happening. So just take a step back and think about, you know, work with your docs, work with your physician extenders, even the admins, right? To figure out if there's already a process in place, if they know what's happening, starting again with these certain patient populations, the EP folks, heart failure, very popular. So figuring out what's happening, right? And then, obviously, once you figure out what's happening is figuring out the inventory of the services you're not going for, right? Because it's really manpower, obviously, that's the big expense. And for a lot of people, again, it's been become part of their job, but just not, it just hasn't been formalized, right? So figuring out who are those people involved? Are they the nurses, inpatient nurses, outpatient nurses could be a combination, right? Depending on the subspecialty. So really wrapping your hands around those, those FTEs, and then the space, we all know space is critical. There's not enough space anywhere for anybody. So is this happening in the clinic? Is it happening in the office? Does it happen virtually? So figuring out what exactly that encompasses, then is it the same for everybody? Because in the end, you want consistency, right? And you want to be able to, again, tell your story. So figuring out where these activities are happening, and it sounds silly, but supplies and equipment, believe it or not, somebody's paying for those phone bills, right? And is it happening on, you know, again, in the clinic? Is it happening at home? You know, is there, is there a cell phone associated? Is there a pager associated with the, with those folks who are taking care of those patients? So again, just understanding everything that it entails. Because again, you ultimately, you want to put a dollar figure on that, because you want to show, you know, what you need versus what you've already been paying for. So you're going to do all of that. And then, then you're going to actually reply dollars to it, right? And again, we're not looking for overly complicated. And we're definitely, we know that this is not going to be an exact science. These are all going to be approximate. So it's really for you to feel comfortable with the story that you're telling, because it could be 12 different nurses, a little bit of all of them, right? 5% of the heart failure nurse, 20% of the EP nurse, who knows, right? But in the end, you want to quantify all of these people that are critical to this program, right? So the staffing, how many people, their salaries, and if you can, obviously the friends, the more you can tell, that's fabulous. At the same time, we don't want to get too caught up in details. So once you have your staffing, and again, space, are you renting space? Is it part of the hospital? For some of you guys, it's very specific numbers. And for others, you have no idea, and that's okay. But if you're able to quantify it all the more better. Supplies and equipment. And again, I'm going to keep repeating this about the resources that you're utilizing, and how we're going to apply dollars to that in order to tell the story, right? You may not be using anything, and you may be using a ton of stuff indirectly. And that's okay. But again, if you can quantify the computers, the pagers, whatever it is that you're using, that would be fabulous. Especially if in the end, you decide you want to use a third party vendor, to be able to quantify some of this stuff. So that's the first part, right? You want to wrap your brain around what's happening, what you're already paying for without billing, to start telling the story. And with that, I'm going to pass it off to my colleague, Joel, who will start to dive a little deeper into the details. Thank you, Anna. And thank you, everyone, for attending this afternoon, or this morning, depending on where you are. Anna, there's a something on the screen. I don't know if it's from your mouse or what, but yeah, there you got rid of it. Thank you. If you want to go to the next slide, please. We're now going to talk about how to kind of project the volumes that you could expect in each of these two areas. We're going to focus on TCM and PCM. And as Anna mentioned, this is not an exact science. You're going to have to let good enough be okay, because there's no way for any of us to predict the future with certainty. If we could, we probably wouldn't be doing the jobs we're doing. So if you want to go to the next one. So I'm going to give you some real practical guidance on how we can predict the future, or project both the patients that we could potentially garner, and then what the financial performance would be on that. So we're kind of building a stepwise case to that. So zeroing in now on transitional care management, or TCM, as Anna mentioned, in the recap, these are patients coming out of the hospital. So a logical place to start would be with your inpatient volumes. And you can measure that either through your admissions, or your discharges. Now, many of you are probably consultative, so you may not have discharges, but you do know how many patients you were rounding on and things in the hospital, and that would be your population. So if you take the total population, now we're going to do some rule outs. There are some people we know we won't get, as has been mentioned, it may be financial ability to pay, or it may be, look, there's a certain number of admissions we had in the prior year that we're never going to see again. They're from other states, they were passing through, whatever. Those would be easy rule outs. Then you would have those that don't meet the requirements. And again, this is not perfect, but you're just trying to do some rational criteria that would help you make the case for your decision makers on budgets and things. And then you may say, look, we can only offer TCM in one or maybe two locations. So if a patient is too far away from that location, through some sort of mile radius, we're going to rule those out as well. Now we're going to turn over to social determinants of health. That's a big one. I mentioned the ability to pay. It may be that you know that a certain population of patients in your panel does not have transportation. Those would be a rule out. It was mentioned in the first webcast, focusing on those patients that have both Medicare and a supplement because then they would have no copays. That's another rational way for you to take the whole available and winnow it down to what you could expect. And then Anna mentioned only one of you can bill for these services if your primary care physicians are already doing that. That may be something you want to avoid for logical reasons, I think. But again, that would be another area to kind of winnow it down. And then those patients, you know, would actually show up for these visits. So here's just an example. We took a group, fictitious groups, discharges from their trailing 12 months. And that's a logical time frame to look at, by the way. It's the most recent time period that you can get a full 12 months data. I'm not a fan of taking partial years and annualizing because whatever aberrations are in that time period, you're magnifying through that annualization process. So if you can get 12 months of data, I think that's the best advice to you. Here, we're saying about one in six of those we determine through our logical process. These are rule outs. We're not going to be able to expect them. So now we get to a net population of about 5,000 patients. And notice across the columns, I think this is also a good way to do financial projections when you're trying to make decisions. We have low, expected, and high. And then typically the decision would be made based on the low because that would kind of be your worst case scenario. But we would tell our uplines, we expect the middle column, and we may just hit it out of the ballpark, and then we would get to the high. Very rarely are people upset when they exceed projections. Usually where the anxiety comes is when you are below. So this gives you a nice way to forecast that. These percentages, keep in mind, for the most part, nearly all of your admissions slash discharges would be eligible for TCM services, but we are projecting, obviously, significantly lower than that, even within the population, the net population after those rule-outs, just to be safe. And then you can see the resulting figures. These need to be tailored. Those percentages need to be tailored to your specific circumstances. We, as MedAxium, would argue these are in the ballpark for what you could probably expect from our experience with cardiology practices across the country. Next slide. Oh, can you go back one to get that off? Thank you. You might use your keyboard instead of the mouse. It would be a lot easier. There you go. Okay, now I'm going to turn over to principal care management. And remember, again, these are not all the criteria, but just in quick review, these are high-risk patients, have chronic conditions lasting at least three months. So probably not difficult in our cardiology practices. But unlike TCM, now the patients that we would look to as the starting point would be your patient panel, your active patients. And those are defined as unique patients that were seen in a face-to-face E&M encounter in the last 18 months. It's a metric MedAxium tracks as part of our MedAccess database, and you would have access to that through that database. We do the same process as before. Now we're ruling out patients who we don't think would merit these services. And then we also go to those social determinants of health. And here, because this is a monthly billing, it gets much more serious. It's one thing for a patient to be able to afford one TCM visit, it's a whole nother thing for them to be able to afford monthly principal care management where they have that 10, 20% co-pay on a continuing basis. And even though we may feel like the amounts are small, it adds up and you will find quite a few people who will rule that out from a financial perspective. So again, good rule of thumb is to forecast based on those patients who have supplemental insurance. And then we talked about making sure you're not stepping on toes for other specialties who may be billing these services. Next. I'm sorry. Okay, now what you may on these, there is that monthly time requirement. You have to hit the minimum threshold in order to bill for it. And I'm going to cover that in another area. So if you were jumping ahead of me and going, yeah, but what about the times we don't get to the full 30 minutes, we'll cover that elsewhere. Okay, so now here's same exercise. We have our low expected and high, but now we're starting with our entire patient panel. So let's say this group of 20 some physicians has a patient panel of 40,000. They do their rule outs, which comes up to 10% of that population. We get to a net of 36,000. Now notice the TCM percentages, or I'm sorry, this should be labeled PCM. My apologies for that. These PCM percentages are significantly lower because of the requirements. And then because we have those monthly recurring charges that will rule out patients. The other thing with PCM is that, that same monthly encounter, even though it doesn't have to be live and in person, it can be delivered virtually. That may also widen the rule out spectrum. So you'll see much lower percentages here. And again, your circumstances will be unique to you, but these are in the ballpark of what an organization would expect for these types of services within that patient population. Next. All right, now we're gonna move from the population of patients into the payments. So this is critical. Now we're getting to a payment per encounter for each of these. So what I suggest is we start with what we know and we know Medicare. Medicare is a federally published fee schedule. So there's no guessing with this one. And we simply go to that. Now, what we will not know necessarily, unless you are in, when you did your current state analysis that Anna talked about, you found out what you are currently billing in terms of both TCM and PCM, and maybe you are doing some of it, then you will know those rates. If you don't, request them. There are specific CPT codes. Those were given to you in the first webcast, but you can ask of those from your non-Medicare payers. The other thing you can do then is index off of Medicare. And what I mean by that is, there's a certain level of detail when you're doing financial projections that was a lot of work for not a lot of value. So we're trying to do this in a simplistic fashion. If we know Medicare, and we consider that the index of one or 100%, then we take all other payers and we lump them together and say, well, if Medicare is 100%, what are those other payers as a percent of that fee? And the way to do that is you take your non-Medicare net revenue divided by the non-Medicare net units, and that gives you that calculation. And then you just compare that to what it was on the Medicare side. In most markets, not all, and you would have to look at your unique market, but in most markets, Medicare is one of our lower payers. So it would typically be that that other would be a higher than 100% percentage, but again, you have to do that specific to your market and your current world. And we're doing all of this to create a calculated weighted average, which I'll show you next. I'm gonna focus on PCM here, Principal Care Management, in part because it's more complicated. So if you take what you learn here, it should be very easy to apply then over to TCM. But these are the specific CPT codes that go with Principal Care Management. And you can see in the column, second column from the right, I've taken a stab at saying, well, we think about 90% of our encounters are gonna be those first 30 minutes because we would only have a small subset of our patients that would actually require more than an hour because you'd have to hit 30 times two in order to hit that second CPT code. We only think about 10% of our patients that are in PCM would hit that. And then we're looking at both provider time and non-provider time. That's the difference between these CPT codes. So if we go to the next, and what I did here is I simply took the physician fee schedule for Medicare and I've applied it to these weighted to get a weighted average on the difference between the first 30, the second 30, the provider based and the non-provider based time. And remember, if you're having APPs do the work, which we would strongly encourage you to do, they receive 85% of the physician fee schedule. So you'd have to multiply that by 0.85 in order to get to an APP rate. Now, next Anna. Okay. Most of the cardiology groups around the country are at about 60% of Medicare. So 40% would be other. Let's say in this fictitious group, Medicare is obviously 100%, but their other payers are at 175%. We're going to split the difference. Now, if you look, and I'm gonna ask Anna to go back, which I'm a little scared to do, but. Okay. If you see now we'll bring these amounts forward to the next sheet, if you go forward. And now we're saying the difference or the split between provider and non-provider is gonna be 70-30. So 70% of our work will be done by non-physicians, non-APPs. And we're further gonna presume that APPs do all of the provider work. This is not work that requires physicians in our mind, and you want to go to top of license. So we would funnel all this work to your APPs. So that 69-19 is 85% of what the physicians would receive for that work, which was calculated on that previous screen. And then the 60-40, $60 and 40 cents is the weighted average for the non-provider work. Now we show that based on 60% being Medicare fee schedule and 40% being other at 175% of Medicare, we take those amounts into consideration to create a weighted average across all payers and across all of those four CPT codes to get to a single weighted amount of $82, $81 and 95 cents. So we've taken the complexity of four CPT codes and we blended it down to a single rate weighted average across all payers. So it is considering your payer distribution. It is including your specific reimbursement amounts, and it's considering the distribution of work between your different caregivers. Next. All righty. So I swear that was the hardest part, was Joel's part. The most confusing part. It got a little wonky, I get it, but. But no, that's the reality of, you know, of wrapping your financials around the program, right? And necessary to understand those details. So really quick, we're gonna, oh, here I did it again. We are going to talk about, I totally just lost myself, my apologies. Building the right budget, right? A gap analysis. And I say building the right budget because we've become, you know, we've unfortunately have now, because of economic times, everything happening in the hospital, we build these budgets that are not ideal, right? They're basically shoestring budgets of what we actually need to do. And it's problematic, right? So, and I say right-sizing because we don't wanna also build a budget for the current state. We know that volume is growing. We know that this is the beginning. Potentially it's one program and you're building another program. So you want to have some ability to expand, right? So building the ideal state. So again, back to the staffing, making sure you have all the right staff on board. And who does that entail, right? Obviously you probably have an MD who's oversight over the whole program, coming up with the care pathways, and then you have your, whether it's a PA or MP, RNs, pharmacists, admin staff, you wanna make sure people are working up to their licensure, right? You don't want the RN calling a scheduled appointment if she doesn't need to. So making sure all the right people are in place for the program. Obviously consistency is great in the different programs, your AFib programs, your heart failure, but understandably things could be different. So again, wrapping your arms around all the right people that you need to build a solid program. And then the space, again, clinic space, hard to come by, you have to measure the ROI. Is it worth your nurses sitting in the clinic to do this? Or is it something they can do in office space? Or maybe it's virtual. Maybe they can do it from home. The same time you're, again, we keep talking about building for the future. Maybe you can do this at an offsite clinic somewhere, right? So when you do need to see these patients, that they can, you can make it as easy as possible for them. So keep all of this in mind. Again, we're building for the future. And then the supplies and equipment. Maybe it's a cell phone. So you have a number that the program is associated with. One for EP, one for a heart failure, who knows? And you can transfer it to other people's cell phones or to landlines, depending on what's happening. Again, we're thinking for the future. And then the supplies. Maybe it's a couple laptops so that we have consistency and there's certain laptops that go with certain programs, who knows? The point being, you want to make it easy for the staff. You want to make it sustainable. So what does that entail? And then we bring in the third-party software for IT. So there's a few companies out there that track the time for you. The time tracking is complicated, right? And you want to make sure that's properly done. So maybe you bring in a third-party to do that. Some people are doing it on their own. Some people are using third-party. So it's something to think about. See what your options are. So again, right-sizing, building for the future. And then obviously you want to formalize that activity. You need to spend money to make money. So we know a lot of this activity is already happening because it's been the right thing to do. We've been trying to deal with 30-day readmissions, trying to avoid those for years now. So you've already have people in place that are doing this. So what are you currently spending and not billing for? So it's already costing you. And again, keep in mind the separate budgets, right? Because it may not, all these expenses may not sit on one budget, but you want to still quantify all the expenses that you're expensing now. And then come up with that ideal state. We know that ideally, you're probably going to need more staff to do this properly, right? Because now you have billing, you have a lot more documentation, you may have more visits. So make sure you bill for the ideal state. Increase your FTE, vacation, sick time. We often don't do that, right? We don't account for the bandwidth that's needed for vacation time. And then the space, centralized space would be ideal, but maybe that's not the case. But maybe as you build out this ideal state, build it in. And then the equipment supplies. Again, we talked about this, the cell phones, the laptops. Often it's going to be a negotiation, the budget. So my thought is always you ask for ideal state, you ask for more knowing that you're probably not going to get it all. And then again, the IT tracking software system, which can be costly, but ideal, right? It's more of the easy button for the team. So again, these details are critical. They're not complicated to come up with. It's just a little bit labor intensive, right? You need to do some digging around to get all this information. But once you've done that, you have it in place, right? And then from there, we're going to pass it back off to Joel where he can talk about putting dollars onto those resources. Yeah, and so we're going to get more wonky now here and I will try to go as slow and detailed as possible recognizing that there are people out there who do this work, including MedAxiom and our care transformation team. So you can always bring in a third party if it gets overly complicated. But I hope what we're leaving you with are some of the tools, kind of the high level tools for you to consider when you're putting the pieces together. And that's what we're doing now. So we've estimated our volumes. We know what we're going to get paid or what we can expect to get paid. And now we've done the analysis of the current state, what we have in the gap analysis to know what's required and then estimating the expenses of those gap resources that we'll need to put in play in order to achieve these two different billing codes, these care management services. Next. All right, so here we go again. And some of this should be a little bit familiar now. But I'm going to focus on principal care management because it's the more complicated. So I wanted to give that one as the example just because I figured it would be more valuable to you. So once again, we're looking at a payer split of 60% Medicare, 40% everybody else. Medicare at 100% of itself, and then everything else at 175%. I am not the complexity to go into provider based is way beyond the scope of an hour long webcast. But these services can be done in an HOPD setting. And there is a completely different fee schedule for that for those hospital based services. I am presuming we're looking at the physician fee schedule or the PFS. So all of these are predicated on being in the physician's office, which is where we see this most often given the monthly recurring fees that HOPD can get very expensive quickly for your patients. I'm not telling you that's what you have to do. I'm just pointing out that we are going to stay in the PFS world for this illustration. Recall that principal care management, as Anna noted, is time based and that you have to get at least 30 minutes in the month in order to be able to drop a charge. So the odds of you being able to get to exactly 30 minutes all the time to drop that charge are pretty remote. So we built in a five minute hedge, which means you're giving away five minutes. I realize that sounds kind of silly to say, but it also is part of what we're going to have to factor into our resource estimates because you're going to have to give away certain amount of care in order to be able to build those 30 minute increments going forward. So for our projections here, we're going to say, on average, we're having to hit 35 for each billable encounter. 2080, 2080 is a pretty standard calculation of the work year for your employees and FTEs. 8% of net revenue for your collection and billing costs, also pretty straightforward, but you would put in whatever you believe it should be for your organization. Now, the EMR software that Anna mentioned, I left blank because that's an unknown cost. You may have it or you may not. You may be able to, you may feel comfortable tracking that time yourself, whereas others of you may say there's no way we're going to be able to do that accurately. We need something that's embedded in the EMR and tracking our phone calls, our emails, our communication with the patient. You would have to build that in depending on what your circumstances are. In this case, we're thinking this organization that I'm using in this example is not doing PCM currently, so they're probably going to have to designate some staff for it and maybe even hire staff, which requires some square footage for them to live in and to do their work. So we used a cost of about $1,500 for a computer, a desk, things like that, for each of those new staff people. They would take up a 10 by 10 area or 20 square feet, and the cost of that square footage at $40 a foot, and that's a fully loaded. These resources do not have to be in your clinic. They could be off site somewhere because most of this work can be pulled off remotely. And then we used a direct variable cost of about $3 a month for things like if you brought them into the office for the exam table paper, whatever you might use. You can see it's very low in terms of the estimate because these are mostly virtual services, so you're using things like electricity more than you're using EKG leads and things like that. Next. Go back to our calculation from earlier, a patient panel of about 36,000. We had a capture rate, a net patient population of 36,000. We had a capture rate 5% on the low, 10%, and then 15%, which translates into those unique patients. And let's say we think we can hit about eight months out of 12 in a year that we would hit that 35-minute threshold in order to be able to drop a charge for that month. So we're hedging our bets even a little bit more with that. We don't think we're going to achieve this every month, but these patients are sick enough and needing our care enough that we think we would hit them about 2 thirds of the time. That translates into these billable encounter months that you see then right under the patient billing, so 14,400 in our low estimate. That converts over to 8,400 billable hours, which is important because now that's what we're going to use to determine our staff resources. And we're going to even hedge that a little bit and say we think about 15% of the staff's time is going to be those patients where we hit 25 minutes, or 10 minutes, or 17 minutes, whatever below 30 that we did not get to the threshold in order to drop a charge. So that increases the number of hours. I'm only going to be able to bill for about 8,400, but I'm going to have to staff closer to 10,000 in order to hit that. And I'm following the low column right now just to keep these all on the same page. We said we did not want to use positions for this, so we put all of the provider time. And if you hit click one more time in, I think it'll bring up a bubble. Yeah. Recall that we said we wanted 30% of the work done by our providers and the rest by non-providers, so 30% of that 9,882 hours would be APP time, and then the non-provider just under 7,000. Next. So now we're taking that, those hours that we just projected, we're dividing by 2080 to get the FTE requirements for each of those thresholds of patients. So if we hit the low, we would need 1.43, just about 1 and 1 half FTEs of an APP. However, if we hit more where we think we're going to land, we would need three APPs. So this gives you an opportunity now to say, this is what I need, here's what we have, what's the difference? Then we project the costs. And I believe Anna mentioned it earlier, but don't forget fringe benefits because they're expensive. APP at 100,000 doesn't cost us 100,000, costs us more like 130,000. So we need to take that into consideration. And then you apply those costs to the FTE to get the total projection in terms of those staffing resources. And if you go to the next one, oh, go back, I'm sorry. There was something I missed. So over on the right-hand side, you will notice the percentages that have no label on them. Those are how we're going to project, not an exact science, we're using some of our logic and just trying to say, out of 100% of the care being delivered for these PCM, how much of it do we think is going to be APPs? Which we said 70% would be non-providers, so 30% for the APPs. But now we have to split that 70% between the nurse and a medical assistant resources because they have different cost thresholds. So we're going to say we're going to split it evenly. Is that exactly how it will work out? Undoubtedly not, but it's a logical place for you to start with respect to these projections. So now we'll go forward. All right, so now we see up here we have the low expected and high again. We're looking at our billable months based on those panel projections. Go back all the way to my explanation, my wonky explanation of how to get to a weighted average reimbursement per unit. And we just simply multiply those out, and you can get to a net revenue figure. Now, some of your organizations may require you to take some sort of hedge on bad debt. Some don't. Some are like, look, that's for the chief financial officer's office to do that. All our expectation coming out of cardiovascular services is get us to a contribution margin, and we'll take it from there. In this one, I didn't bake it in, but remember that the weighted reimbursement should be cash. It is not a fictitious charge amount. It is based on what we think the reimbursement will be. But it is dependent on patients making their co-pays and deductibles and things like that. So if you wanted to build in a hedge for bad debt, you could, and you would do that up here in the revenue calculation. Now we're going into the staffing expenses and these are simply taking those FTE calculations, multiplying by the FTE cost, fully loaded with the benefits in there. And we come up with the total cost for those services. Now, recall back to the other expenses. I mentioned 20 square feet per new person at $40 a square foot. The miscellaneous, that would be on a per episode basis. And then billing and collection costs, which are 8% of that net revenue figure, to get us to a contribution margin. This is not a profit calculation, and I can't stress that enough. We have not allocated any indirect overhead to these services, which your organization undoubtedly will. But in my experience with organizations, that is rarely the expectation when they are asking for resources. That comes later at a higher level. What everybody asks for is, can you tell me what the contribution of these new services will be to our overhead? And that's what we're calculating here. And then you can see, I've actually taken that contribution margin divided by the net revenue to come up with a contribution margin percentage. And what the expectations of your organization are in terms of hitting percentages. For instance, some organizations I've worked for actually had a minimum 30%. They did not entertain new services or resources allocated to new resources unless the contribution margin was in excess of 30%. Yours may not be. What I would say, and this goes back to what's been said in webcast one and what Anna mentioned earlier, these are really necessary services, and they are good patient care. I would hope that the expectation of your organization would be less than 30% because it's going to be difficult for this, particularly for PCM and CCM, to hit those kind of margins. I will say this, we did the calculation on transitional care management. And typically, because we're actually doing a lot of that care already, the contribution margin is significantly higher on a percentage basis, even if the revenue is lower. All right, we're wrapping up here. So hopefully, that was not overly detailed. And you could follow the logic of what we're doing in terms of trying to project what these populations and what our financial performance would be if we added these services. So we want you to leave with knowing that care management, as I said, is good patient care. It's often work that we're doing, but we are not tracking the time to sufficient levels that we could ever drop a bill for it. And you do not want to surprise your patients with these services and the bills. You want to let them know they're enrolled and that they are going to expect that to happen as part of what you're offering. I also just recently sat in on a webcast where the special guest was the head of CMMI's innovation. He was the chief transformation officer. And they were asking him, why are so many of the Medicare value-based payment models still heavily steeped in fee-for-service? And his answer was intriguing and fascinating, and we should all take note of it. He said, we are trying to teach our providers the skills they will need to take risk and perform well in a value-based arrangement. And care management, he even noted those specifically, are those good skills. So yes, we're paying for them on a fee-for-service basis, but eventually they will be expected, and skills we all need as providers in order to do well in mandatory risk arrangements. So it's somewhere out there. They are taking us through a logical path, and I think we need to keep that in mind. When we are reviewing services like this and saying, should we or shouldn't we? That needs to be in our calculus, because these are skills we'll need to know how to do and do very well. I also hope you left with some logical ways to estimate your patient volumes, that you will build your program with enough horsepower to succeed. If we try to cheap it out, you may artificially cause it to fail when that would have not been the outcome had you given it sufficient resources. There's a reasonable ROI. None of us are going to get rich on these services, but we can provide great patient care and not lose money, and in fact, contribute to our overhead. And I'll leave you with the last comment, which is don't let perfect be the enemy of good enough. We cannot get exact with this, and no one can expect us to be exact, because we're predicting the future. So we're just trying to use sound logic to come up with a rational range of performance expectations. So with that, I'll go to the last slide, which is to remind everybody our CVT is coming up. It's in Atlanta, April 18th to 20th. We have a huge attendance so far. I hope you add your name to the list if you're not on it. It's going to be a great meeting, and we'll hope to see you there. And with that, Arianna, are there any questions that came through the chat? We do. We have a question. Has this pro forma been borne out by partner entities that are already fully integrated around these billable activities? Yes. Now, their specific performance is going to be different than what we showed you, but these have been tested in real-life circumstances. Beautiful, and that was the only question we had. I just want to add, we did bring it up, but as you continue to hopefully build these programs for the work that you guys are already doing is to account for the activities in the job descriptions of the people who are doing the work, right? Because eventually, it should just be part of people's roles. And the problem is when it's not part of their job description, at times, people get pulled away to do other things. We learned that through COVID. We all had a bunch of staff that were redirected, so you never know what's going to happen. That being said, we just want to keep the books clean is what I always say, right? So just make note of that, updating job descriptions to reflect activity, especially if you're billing for it. So I apologize for not bringing that up earlier, but I hope you guys walk away with some understanding. And again, MedAxium is here for you guys. If you would like somebody to, specifically Joel, if you would like him to hash out your numbers for him, he'd be happy to. But we're here to help you grow these programs, because again, you guys are already doing this. It's the right thing to do, but in order to be able to bill for it. And with that, thank you, everyone. Yeah, we'll give you back five minutes, seven minutes. Thanks, everybody. Have a great day.

care management services

patient volumes

financial performance

budgets

staffing

FTE requirements

contribution margins

value-based payment models

CVT