Strategies for Success in the Changing World of HealthcareMGMA – Morgan / Lawrence CountiesJune 17,2014

William F. (Bill) Cockrell, FACMPE

Cockrell and Associates, LLC

Who we are – What we do – What we’ll do today Healthcare management and resource organization

Research

Plan

Manage

Services

Credentialing

CME

Today

Overview of the environment and some programs

Review of the Medical Home concept

Other Issues

Summary of options

“

”

How the Fee For Service Model is Viewed by Policy Advisors

“There’s a trend in youth sports. We don’t keep score and everyone gets the same size trophy at the end of the season. Well, that’s been the basic model for the healthcare system in the United States. We didn’t keep track of how well providers were doing their jobs and we gave them all the same size trophies. We called it “fee-for-service”…”

“Will Pay-For-Performance Pay Off”, Gary Young, Director of the Center for Health Policy and Healthcare Research at Northeastern University

The Evolving World of Healthcare

Affordable Care Act It’s Not Going Away The ACA will get modified, not scrapped

Modern Healthcare, January 8, 2014 – “The U.S. Chamber of Commerce has accepted that the Patient Protection and Affordable Care Act is here to stay and, rather than continue calling for its complete repeal, will work this year to change what it sees as flaws in the 2010 law, the business group's president and CEO said Wednesday.”

Continued pressure to find new delivery models to drive down physician and hospital costs

Medicare is already making changes independent of the ACA Commercial payers are already on board with new models Medicaid has to change The number of beneficiaries can sway an election – taking something

away loses elections

RAND Corporation – ACA Impact Survey – Thru March 28, 2014

Net gain of 9.3 million with healthcare coverage

From

ACA

Employer sponsored coverage (ESI)

Medicaid

Of the first 3.9 million in the ACA market plans only 1.4 were uninsured

Margin probably decreased with late surge.

As a result of the ACA plans, ESI and Medicaid growth, the number of uninsured dropped from 20.5% to 15.8%

Total voters in the 2012 election – 130 million

Healthcare Costs

Even as his health care law divided the nation, President Barack Obama's first term saw historically low growth in health costs, government experts said in a new report Monday. The White House called it vindication of the president's health care policies, but it's too early to say if the four-year trend that continued through 2012 is a lasting turnaround that Obama can claim as part of his legacy. For the second year in a row, the U.S. economy grew faster in 2012 than did national health care spending, according to nonpartisan economic experts at the Centers for Medicare and Medicaid Services.

Associated Press, January 6, 2014

Healthcare Costs – The Rest of the StoryBelow the topline figures, spending grew faster in some areas and more slowly in others,

making it more difficult to piece the puzzle together.

Spending for hospital care and doctors' services grew more rapidly.

So did out-of-pocket spending by individuals. That reflects the trend of employers increasing annual deductibles and copayments to shift a greater share of medical costs directly on to employees and their families.

Spending on prescription drugs barely increased, reflecting an unusual circumstance in which patent protection expired for major drugs like Lipitor, Plavix and Singulair. Generic drugs accounted for an ever-increasing share of prescriptions.

Medicare spending grew more slowly, reflecting a one-time cut in payments to nursing homes and some of the spending reductions in Obama's health care law.

Spending for private insurance also grew more slowly, reflecting the shift to high-deductible plans that offer lower premiums.

Associated Press, January 6, 2014

Medicare

Medicare SGR – What was proposed

Three Congressional Committees combined efforts

”SGR Repeal and Provider Payment Modification Act”

Repeal SGR – 23% cut in 2014

Annual Update of 0.5% from 2014 to 2018

Frozen rates from 2013 thru 2018

Cost of $126 Billion (down from $230+ Billion)

Starting in 2018

Merit Based Incentive Payment System

Replaces e-Prescribe, PQRS, other

5% Bonuses Starting in 2018

Alternative Payment Model (25% of Medicare funds through APM)

Shared Savings (ACO, etc.)

Patient Centered Medical Home (PCMH)

“

”

A lot of thought went into crafting the repeal and replace law, with MGMA and others in the healthcare community working with key staffers to reach a bipartisan, bicameral repeal solution so it is very likely that should comprehensive reform arise again next year, many of the same provisions would be retained. Value and cost based reimbursement is the way that CMS has been moving with their reimbursement models as evidenced by the ACA’s Value Based Payment Modifier, the Medicare Shared Savings Program (ACOs) and other various quality reporting programs (PQRS, MU) – all of which are required to be implemented by law.  

April 14, 2014Jeb ShepardGovernment Affairs RepresentativeMidwestern and Southern SectionsMedical Group Management Association

Medicare Value Based Modifier 2013 – Focused on groups with 25 or more

eligible providers filing under a single tax identification number (TIN) who will receive QRURs

2015 – Groups with 100 or more eligible providers filing under the same TIN will be subject to the modifier based on their performance in 2013

2017 - Expands to all physicians who participate if FFS Medicare (3 years)

Alternative Payment Model (APM)

Professionals who receive a significant share of their revenue through a qualifying APM would be paid an incentive payment equal to 5% of covered professional services from 2017 (3 years) to 2022. APMs include

A model under the Center for Medicare and Medicaid Innovation definition (PCMH)

A Medicare Shared Savings Program ACO Bundled Payments

ACO’s and Shared Savings Shared savings are starting on the hospital

level but can include physicians Accountable Care Organizations (ACO’s) (3

year terms) Not any real traction in Alabama, yet

Primary care driven but control could be through a hospital or large specialty network

Medicare Advantage Plans

Example - BCBS Blue Advantage 2013 $3.6 million paid out 2013 $ 4.9 million left on the table

HRAs HEDIS gap in care closure Other

Approximately 1,900 BCBS PCP’s eligible Reporting issues (i.e. Blood pressure)

Medicare Physician Payments

npi

nppes_provider_last_org_n

ame

nppes_provider_first_name

hcpcs_code hcpcs_description

line_srvc

_cnt

bene_unique_cnt

average_Medicare_allowed

_amt

average_submitted_chrg_a

mt

average_Medicare_paymen

t_amt1639125222SINGH BK 93458 L hrt artery/ventricle angio 92 89 $279.82 $1,650.00 $218.121639125222SINGH BK 93459 L hrt art/grft angio 11 11 $317.80 $2,700.00 $241.151639125222SINGH BK 93460 R&l hrt art/ventricle angio 12 12 $353.73 $2,000.00 $268.841639125222SINGH BK 93922 Upr/l xtremity art 2 levels 12 12 $11.31 $32.67 $8.301639125222SINGH BK 99204 Offi ce/outpatient visit new 75 75 $117.74 $255.00 $92.701639125222SINGH BK 99204 Offi ce/outpatient visit new 32 32 $146.89 $246.28 $90.731639125222SINGH BK 99205 Offi ce/outpatient visit new 33 33 $151.49 $318.00 $118.281639125222SINGH BK 99214 Offi ce/outpatient visit est 733 519 $71.43 $165.00 $55.501639125222SINGH BK 99214 Offi ce/outpatient visit est 343 310 $95.57 $160.79 $49.451639125222SINGH BK 99215 Offi ce/outpatient visit est 176 133 $100.46 $222.00 $78.331639125222SINGH BK 99215 Offi ce/outpatient visit est 55 47 $128.73 $216.87 $71.791639125222SINGH BK 99223 Initial hospital care 191 173 $182.15 $308.00 $142.38

1053384974CONLEY THOMAS 93458 L hrt artery/ventricle angio 108 108 $253.18 $1,650.00 $199.051053384974CONLEY THOMAS 93460 R&l hrt art/ventricle angio 17 17 $343.33 $2,000.00 $274.661053384974CONLEY THOMAS 93571 Heart flow reserve measure 26 26 $85.62 $321.00 $68.501053384974CONLEY THOMAS 93922 Upr/l xtremity art 2 levels 18 18 $11.31 $37.56 $9.051053384974CONLEY THOMAS 99204 Offi ce/outpatient visit new 25 25 $117.74 $252.80 $90.731053384974CONLEY THOMAS 99204 Offi ce/outpatient visit new 15 15 $146.89 $250.20 $105.761053384974CONLEY THOMAS 99205 Offi ce/outpatient visit new 18 18 $151.49 $318.00 $117.801053384974CONLEY THOMAS 99205 Offi ce/outpatient visit new 13 13 $183.29 $311.77 $120.901053384974CONLEY THOMAS 99214 Offi ce/outpatient visit est 791 671 $71.43 $165.00 $54.721053384974CONLEY THOMAS 99214 Offi ce/outpatient visit est 487 429 $95.57 $161.42 $52.671053384974CONLEY THOMAS 99215 Offi ce/outpatient visit est 73 67 $100.46 $222.00 $78.781053384974CONLEY THOMAS 99215 Offi ce/outpatient visit est 58 54 $128.73 $216.83 $72.92

Medicare Data Excerpt

Physician Payment Initial Observations High drug prices skewing payouts to some physicians

(Modern Healthcare April 10, 2014)

Could expose fee-for-service models that reimburse sub-specialists at a higher rate that PCPs. (Medical Economics April 9, 2014)

Medicare Pulls Back The Curtain On How Much It Pays Doctors (NPR April 9, 2014)

Data trove shows U.S. doctors reap millions from Medicare (USA Today April 9, 2014)

Doctors in McAllen Texas perform 5 times the CABG volume as in Pueblo Colorado yet patients are no sicker. (USA Today April 9, 2014)

Birmingham News

“Why Medicare Paid One Doctor $4.8 M” The Birmingham News – April113, 2014 The “headline society” issue Lists doctors Highlights a Huntsville Oncologist It does disclose AMA’s “9 Cautions” To look up your doctor go to

www.tinyurl.com/MedicareMapAL Or www.cms.gov

Commercial Payers

Other Payers United Healthcare

July 10, 2013

UnitedHealth Group on Wednesday announced that it expects to double its accountable care contracts over the next five years across employer-sponsored, Medicaid, and Medicare plans. Currently, more than $20 billion in United Healthcare reimbursements to hospitals, physicians, and other providers are paid through contracts linking pay to quality and efficiency measures. Those contracts include more than 575 hospitals, 1,100 medical groups, and 75,000 physicians nationwide.

Humana May 17, 2012

Humana has begun working with providers on several new, collaborative delivery system models that already have yielded successful results, the insurer told a Senate panel Wednesday. “the insurer is working toward aligning payment and care through its different accountable care organizations (ACO) and patient-centered medical homes (PCMH).”

2015 Changes

All three factors worth 10% - 30% total

Fewer options in the Administrative section

Adding specialty

Cardiology

Ortho

Others

BCBS Qualifiers

PMD doctor for at least one year in good standing Must practice Geriatrics, Family Practice, Internal

Medicine, General Medicine or Pediatric Medicine Must utilize ETF Must file claims electronically Must have 24 hour on call coverage Must be Board Certified Must participate in all applicable BCBS of Alabama

Networks

What Base Do We Use for Bonuses Cognitive encounters for Primary Care Major surgery codes for general surgeons Specialty codes New measurements

Quality Cost

Primary Care Base for Bonuses Typically, Primary care bonuses are based on

these: Office/outpatient visits, CPT 99201-99215; Nursing facility services, CPT 99304-99318; Domiciliary, rest home, or custodial care

services, CPT 99324-99340; and Home services, CPT 99341-99350.

In many cases, surgery and other non-diagnostic codes are included BCBS list is 20 pages long

BCBS Primary Care Value Based Payment Program

Current Participants (April 2014) 1,783 (of roughly 2,500 eligible)

5% 919 10% 602 15% 104 20% 158

BCBS Sample Primary Care Value-Based Payment Program Benefit

4 Internists Busy Practice 25 % BCBS 57% Medicare 4% Medicaid

BCBS Financial ImpactCode Volume BCBS Fee Base 5% Extension 10% Extension 15% Extension 20% Extension

90471 252 $21.61 $5,445.72 $5,718.01 $5,990.29 $6,262.58 $6,534.8690472 1 $11.50 $11.50 $12.08 $12.65 $13.23 $13.8096372 461 $17.00 $7,837.00 $8,228.85 $8,620.70 $9,012.55 $9,404.4099201 5 $37.00 $185.00 $194.25 $203.50 $212.75 $222.0099202 24 $49.00 $1,176.00 $1,234.80 $1,293.60 $1,352.40 $1,411.2099203 96 $73.00 $7,008.00 $7,358.40 $7,708.80 $8,059.20 $8,409.6099204 60 $104.00 $6,240.00 $6,552.00 $6,864.00 $7,176.00 $7,488.0099205 1 $155.00 $155.00 $162.75 $170.50 $178.25 $186.0099211 11 $26.00 $286.00 $300.30 $314.60 $328.90 $343.2099212 30 $39.00 $1,170.00 $1,228.50 $1,287.00 $1,345.50 $1,404.0099213 690 $62.75 $43,297.50 $45,462.38 $47,627.25 $49,792.13 $51,957.0099214 2680 $95.00 $254,600.00 $267,330.00 $280,060.00 $292,790.00 $305,520.0099217 43 $63.00 $2,709.00 $2,844.45 $2,979.90 $3,115.35 $3,250.8099218 9 $74.00 $666.00 $699.30 $732.60 $765.90 $799.2099222 50 $107.00 $5,350.00 $5,617.50 $5,885.00 $6,152.50 $6,420.0099223 68 $139.00 $9,452.00 $9,924.60 $10,397.20 $10,869.80 $11,342.4099224 13 $28.50 $370.50 $389.03 $407.55 $426.08 $444.6099231 62 $39.00 $2,418.00 $2,538.90 $2,659.80 $2,780.70 $2,901.6099232 407 $59.00 $24,013.00 $25,213.65 $26,414.30 $27,614.95 $28,815.6099233 136 $86.00 $11,696.00 $12,280.80 $12,865.60 $13,450.40 $14,035.2099234 31 $116.00 $3,596.00 $3,775.80 $3,955.60 $4,135.40 $4,315.2099235 7 $192.00 $1,344.00 $1,411.20 $1,478.40 $1,545.60 $1,612.8099238 106 $72.00 $7,632.00 $8,013.60 $8,395.20 $8,776.80 $9,158.4099305 1 $91.00 $91.00 $95.55 $100.10 $104.65 $109.2099306 4 $114.00 $456.00 $478.80 $501.60 $524.40 $547.2099307 1 $30.00 $30.00 $31.50 $33.00 $34.50 $36.0099308 20 $50.00 $1,000.00 $1,050.00 $1,100.00 $1,150.00 $1,200.0099309 6 $70.00 $420.00 $441.00 $462.00 $483.00 $504.0099310 6 $87.00 $522.00 $548.10 $574.20 $600.30 $626.4099316 0 $64.00 $0.00 $0.00 $0.00 $0.00 $0.0099385 3 $86.00 $258.00 $270.90 $283.80 $296.70 $309.6099396 1 $78.00 $78.00 $81.90 $85.80 $89.70 $93.6099406 166 $13.90 $2,307.40 $2,422.77 $2,538.14 $2,653.51 $2,768.88

$401,820.62 $421,911.65 $442,002.68 $462,093.71 $482,184.74

$20,091.03 $40,182.06 $60,273.09 $80,364.12

BCBS Financial Impact

Base 5% Extension 10% Extension 15% Extension 20% Extension

$401,820.62 $421,911.65 $442,002.68 $462,093.71 $482,184.74

$20,091.03 $40,182.06 $60,273.09 $80,364.12

Patient Centered Medical Home (PCMH)

Definition

The patient-centered medical home is a way of organizing primary care that emphasizes care coordination and communication.

National Committee for Quality Assurance (NCQA) has documented that medical homes can lead to higher quality and lower costs, and can improve patients’ and providers’ experience of care.

NCQA Patient-Centered Medical Home (PCMH) Recognition is the most widely-used method to transform primary care practices into medical homes.

Levels of Participation

NCQA National 6,800 locations as of March, 2014 33,000 PCMH Clinicians as of March, 2014

BCBS Data for Alabama PCMH 190 Locations(164 Physicians )

Level 1 84 Locations Level 2 42 Locations Level 3 64 Locations

Growing interest in Patient Centered Specialty Practice Recognition

PCMH Scoring

Levels of Recognition PCMH Level 1: 35-59 points PCMH Level 2: 60-84 points PCMH Level 3: 85-100 points

Based on cumulative score from seven elements

Sample Scoring Elements

PCMH Standard/Element

Points Possible

Points Earned

Explanation

PCMH 1: Enhance Access and Continuity 20 14

Most policies will need to be created, but most elements are being done in spirit

Element A Access During Office Hours 4 4 Need policy

Element B After-Hours Access 4 3Policy needed; After hours call log created to track and document; Don't offer extended hours

Element C Electronic Access 2 1Overlap with Meaningful Use; Other factors require patient portal

Element D Continuity 2 2 All factors metElement E Medical Home Responsibility 2 1

Factors being met in spirit; Can advertise PCMH status on TV in lobby

Element F Culturally and Linguistically Appropriate Services (CLAS) 2 2 All factors met

Element G Practice Team 4 1Policy needed; Need to have regular team meetings; Designated PCMH roles for staff

Sample Scoring Elements

PCMH Standard/Element Points Possible

Points Earned

Explanation

PCMH 3: Plan and Manage Care 17 11.25

Generally meeting requirements; Requires patient chart audits

Element A Implement Evidence-Based Guidelines 4 4 Overlap with Diabetes Recognition Program

Element B Identify High-Risk Patients 3 0 Need policy and report; can be done easily

Element C Care Management 4 2Meets a lot of the factors, but can improve communication/visit preparation

Element D Medication Management 3 2.25 Completing half of the factors, but must document

Element E Use Electronic Prescribing 3 3 Meeting all factors

Sample Scoring Elements

PCMH Standard/Element Points Possible

Points Earned

Explanation

PCMH 5: Track and Coordinate Care 18 13.5

Generally meeting requirements; Need work on referral tracking/follow-up

Element A Test Tracking and Follow-Up 6 6 Need to create policy, but all factors met otherwise

Element B Referral Tracking and Follow-Up 6 1.5

Meeting one factor because it is a Meaningful Use Objective

Element C Coordinate with Facilities/Care Transitions 6 6 Need to create policy, but generally meeting factors

Medicaid

Medicaid in Alabama Transitioning to a Regional Care Organization (RCO) 5 Regions – Huntsville Hospital / Sentera just

announced Probably hospital led Multiple RCO’s Uses the Medicaid fee schedule How does it save money

Better sharing of data (diagnostics) Eliminating high cost providers through steerage Steerage through shared savings?

Questions MASA can help answer

Oregon Results

Known as Coordinated Care Organizations (CCO)

Include capitated (PMPM) and non-capitated

Goal is better health, better care and lower costs (Triple Aim)

Focused on the use of Medical Homes

One year results include

Primary care utilization up 18%

ED utilization down 13%

CHF hospitalization down by 32%

COPD hospitalization down 36%

Thirty day readmissions down 8%

PCMH enrollment up 51%

Data Sources

Data Sources for Patients, Payers and Providers

Physician Compare

Other Payer Sites

Healthgrades

Angie’s List

Facebook

Why Not The Best

Other Sources

Other Items to Be On Top Of EMR and Meaningful Use

If you don’t do it it’s more than just a 1% penalty. It affects your ability to participate in delivery in the future.

ICD-10

It’s going to happen sometime so go ahead and get ready

Medicare PQRS and ePrescribe

Keep participating but these will roll into some other program

Surveys

MGMA – The data is great in that it helps point you in the right direction

HDHP

Do you know what it costs to collect on credit / debit cards and how to improve you opportunities?

Summary of Strategies

Strategies for Primary Care Know your data Know your referral network data Find your sweet spot Use physician extenders where possible Participate in incentive plans Become a PCMH Monitor Patient Satisfaction Utilize an EMR Move ahead on ICD-10 Participate in surveys Manage your office processes Look for ACO and carve-out opportunities

Strategies for Specialists Know your data Find your sweet spot Educate your referrers and your patients Participate in incentive plans Watch for the Specialty Centered Medical Home program Monitor Patient Satisfaction Utilize an EMR Move ahead on ICD-10 Participate in surveys Manage your office processes Look for ACO, bundled payment and carve-out opportunities

Webinars and Slides

Webinars PCMH

Tools we have identified

Leave your business card or sign the list with your name and e-mail and we'll keep you posted on dates and times

Slides www.caahms.com

Links - Slideshare

Questions

Contact Us

Bill Cockrell bcockrell@caahms.com (205) 637-6880 (Ext 1)

Rodger Egeland regeland@caahms.com (205) 637-6880 (Ext 2)

www.caahms.com