Where capital P meets little p:Translating Policy to practice

Scott V. Joy, MD, MBA, FACPChief Medical Officer

HCA Physician Services Group, Continental DivisionDenver, Colorado

Learning Objectives

• Understand the building blocks and forces in play to change health care reimbursement from volume to value based

• List two challenges a general internist may face by being in an Accountable Care Organization (be prepared to share with the group)

• Create an advocacy statement to use at your organization in support or in opposition of being part of an Accountable Care Organization (be prepared to share with the group)

“The way physicians are organized and reimbursed in the United States is undergoing a once-in-a-generationtransformation from a fee-for-service system to alternative payment models.”

N Engl J Med 375;2: 104-105

Health Policy Progress toward Value over Volume• The shifting definition of ideal medical practice is a fundamental

challenge in health policies that are always at risk of promoting standards that are outdated.”*

• Health Maintenance Organization Act 1973• American Recovery and Reinvestment Act (ARRA, HITECH), 2009

*J Gen Intern Med 30(6): 848-52

https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2014/09/deciphering-the-reform-alphabet. Accessed December 7, 2017

March 23, 2010

https://innovation.cms.gov/. Accessed December 7, 2017

“The shifting definition of ideal medical practice is a fundamental challenge in health policies that are always at risk of promoting standards that are outdated.” J Gen Intern Med 30(6): 848-52

Accountable Care Organizations

CMS Definition of ACO

• ACOs are groups of doctors, hospitals and other healthcare providers, who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending healthcare dollars more wisely, it will share in the savings it achieves for the Medicare program.”

https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2014/09/deciphering-the-reform-alphabet. Accessed December 7, 2017

https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/index.html?redirect=/PhysicianSelfReferral/95_advisory_opinions.asp. Accessed December 11, 2017

https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/remarks-on-primary-care-and-value-based-transformation.html

Medicare Shared Savings Program

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about.html. Accessed December 11, 2017

• Focus on Transitions of Care• Focus on Preventive Services (Meet Quality Measures through

Preventive Visits)• Document Patient Complexity (HCC, ICD-10)

Building Blocks For Success in an ACO

https://theincidentaleconomist.com/wordpress/aco-calculations-explained/Administrative Lingo: “Open Gates”

ACO Calculations Explained

Four Ingredients for Engaging Physicians in a Network Setting

• Culture• Trust• Decision-Making• Local Infrastructure

https://catalyst.nejm.org/four-ingredients-independent-physician-network/. Accessed December 7, 2017

Risk Adjustment

Risk Stratification: Key Terms• Risk Adjusted Factor (RAF)• Hierarchical Condition Category (HCC)

a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) in 1997.The HCC/RAF (Risk Adjustment Factor) point system is a "shadow" calculation that affects every physician's reimbursement, no matter what goes on the bill. The HCC/RAF regulation assigns a point value to a relatively small number of ICD diagnosis codes that indicate serious disease

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Each HCC-RAF must be:

1. Documented, coded and submitted on a payment claim form during each ‘calendar year’.

2. Addressed on a ‘face-to-face’ encounter with a provider.

3. Supported by ‘medical decision-making,’ especially when certain conditions are linked based on ‘cause & effect’ and generally carry a higher RAF weight when linked, e.g., Diabetes Mellitus w/ manifestation/complication.

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HCC 17: Diabetes with Acute/Chronic Complications

HCC 22: Morbid Obesity

HCC 58: Major Depressive, Bipolar, Paranoid Disorders

HCC 111: Chronic Obstructive Pulmonary Disease

• 66 year old male presents for routine follow-up appointment for Type 2 Diabetes, Depression and Obstructive Sleep Apnea.

• Medication List• Insulin glargine• Oxygen 2L at night • Exam: BMI 41.0 kg/m2• PHQ9 score of 9(Mild depression)• Loss of monofilament sensation

bilaterally• Absent right great toe due to DM foot

ulcer in past

Condition ICD-10 Poor coding Appropriatecoding

66 y old male n/a 0.288 0.288

BMI 41.0 kg/m2 (morbid obesity)

E66.01 Not recorded 0.273

T2DM uncomplicated

E11.9 0.118 ----

T2DM with neuropathy

E11.40 ----- 0.368

Chronic Insulin Use

Z79.4 Not recorded 0.118

Depression, unspecified

F32.9 0.000 -----

Major Depression, single, mild

F32.0 ----- 0.330

Great toe amputation

Z89.419 Not recorded 0.779

Chronic respiratory failure, hypoxia

J96.1 Not recorded 0.329

RAF Score 0.406 2.485

PMPM Payment $325 $1,98826

Colorado Care Partners Market

Actual $$ $102.00 PMPM $100.00 PMPM

We are more costly in total dollars

Risk Score 1.05 1.00

Normalized $102/1.05 = $97.14 $100/1.00 = $100

Now we beat the market; cost gate opens

Risk Adjustment Financial Adjustment

Shared Savings Models Create Economic Winners and Losers• Whose revenue is lost to create savings• Who receives reduced expenses or proceeds• Who controls the flow of funds in these models

N Engl J Med 375;2: 104-105. July 14, 2016

Questions:

• Are you practicing in an ACO or Clinically Integrated Network?• What will be your advocacy talking points at the local level in regards

to Alternative Payment Models?

http://files.kff.org/attachment/Fact-Sheet-Medicare-Advantage

https://www.medicare.gov/find-a-plan/results/planresults/plan-list.aspx#Errors

https://www.healthcaredive.com/news/provider-groups-ask-medicare-advantage-be-counted-as-apm-under-macra-in-201/444194/

Administrative Lingo: “On Ramp”

http://www.ncqa.org/portals/0/Public%20Policy/VBID_Fact_Sheet.pdf. Accessed December 9, 2017

https://innovation.cms.gov/initiatives/vbid/index.html. Accessed December 7, 2017.

https://innovation.cms.gov/initiatives/vbid/index.html. Accessed December 11, 2017

https://www.civhc.org/shop-for-care/

Principles of Advocacy

• Find Your Message• Stay on Message• Take the High Road• Visibility Wins

Advocacy is relationship building

Compelling Narrative

Your Thoughts and Thank You!