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Opelika MGMA June 2014
1. Practice Assessments for the
Changing World of
Healthcare
Opelika – East Alabama MGMA
June 18,2014
William F. (Bill) Cockrell, FACMPE
Cockrell and Associates, LLC
2. 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 healthcare environment
Areas to assess to determine your practice’s readiness to remain viable
3.
4. Medical Practice Assessments – Why are
These Questions Important? – It’s All About
Planning and Preparing
Do you or have you?
Know your data
Know your referral network data
Know your sweet spot
Fully participate in incentive plans
Considered PCMH
Monitor patient Satisfaction
Utilize an EMR
Moved ahead on ICD-10
Participate in surveys
Manage your office processes (Co-Pays, HDHP, Bank fees)
6. “
”
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
7. 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
8. 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
9. 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
10. Healthcare Costs – The Rest of the Story
Below 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. An issue for practices dealing with high deductibles.
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
12. 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
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)
13. “
”
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, 2014
Jeb Shepard
Government Affairs Representative
Midwestern and Southern Sections
Medical Group Management Association
14. 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
15. 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
16. 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)
19. npi
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line_srvc
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1639125222SINGH BK 93458 L hrt artery/ventricle angio 92 89 $279.82 $1,650.00 $218.12
1639125222SINGH BK 93459 L hrt art/grft angio 11 11 $317.80 $2,700.00 $241.15
1639125222SINGH BK 93460 R&l hrt art/ventricle angio 12 12 $353.73 $2,000.00 $268.84
1639125222SINGH BK 93922 Upr/l xtremity art 2 levels 12 12 $11.31 $32.67 $8.30
1639125222SINGH BK 99204 Office/outpatient visit new 75 75 $117.74 $255.00 $92.70
1639125222SINGH BK 99204 Office/outpatient visit new 32 32 $146.89 $246.28 $90.73
1639125222SINGH BK 99205 Office/outpatient visit new 33 33 $151.49 $318.00 $118.28
1639125222SINGH BK 99214 Office/outpatient visit est 733 519 $71.43 $165.00 $55.50
1639125222SINGH BK 99214 Office/outpatient visit est 343 310 $95.57 $160.79 $49.45
1639125222SINGH BK 99215 Office/outpatient visit est 176 133 $100.46 $222.00 $78.33
1639125222SINGH BK 99215 Office/outpatient visit est 55 47 $128.73 $216.87 $71.79
1639125222SINGH 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 $199.05
1053384974CONLEY THOMAS 93460 R&l hrt art/ventricle angio 17 17 $343.33 $2,000.00 $274.66
1053384974CONLEY THOMAS 93571 Heart flow reserve measure 26 26 $85.62 $321.00 $68.50
1053384974CONLEY THOMAS 93922 Upr/l xtremity art 2 levels 18 18 $11.31 $37.56 $9.05
1053384974CONLEY THOMAS 99204 Office/outpatient visit new 25 25 $117.74 $252.80 $90.73
1053384974CONLEY THOMAS 99204 Office/outpatient visit new 15 15 $146.89 $250.20 $105.76
1053384974CONLEY THOMAS 99205 Office/outpatient visit new 18 18 $151.49 $318.00 $117.80
1053384974CONLEY THOMAS 99205 Office/outpatient visit new 13 13 $183.29 $311.77 $120.90
1053384974CONLEY THOMAS 99214 Office/outpatient visit est 791 671 $71.43 $165.00 $54.72
1053384974CONLEY THOMAS 99214 Office/outpatient visit est 487 429 $95.57 $161.42 $52.67
1053384974CONLEY THOMAS 99215 Office/outpatient visit est 73 67 $100.46 $222.00 $78.78
1053384974CONLEY THOMAS 99215 Office/outpatient visit est 58 54 $128.73 $216.83 $72.92
Medicare Data Excerpt
20.
21. 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)
22. 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
24. 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).”
25.
26. 2015 Changes
All three factors worth 10% - 30% total
Fewer options in the Administrative section
Adding specialty
Cardiology
Ortho
Others
27. 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
28. What Base Do We Use for Bonuses
Cognitive encounters for Primary Care
Major surgery codes for general surgeons
Specialty codes
New measurements
Quality
Cost
29. 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
30. 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
31. BCBS Sample Primary Care Value-
Based Payment Program Benefit
4 Internists
Busy Practice
25 % BCBS
57% Medicare
4% Medicaid
35. 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.
36. 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
37. 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 3
Policy needed; After hours call log created to track
and document; Don't offer extended hours
Element C Electronic Access 2 1
Overlap with Meaningful Use; Other factors require
patient portal
Element D Continuity 2 2 All factors met
Element 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 1
Policy needed; Need to have regular team meetings;
Designated PCMH roles for staff
38. 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 2
Meets 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
39. 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
41. Medicaid in Alabama
Transitioning to a Regional Care Organization (RCO)
Probably hospital led
5 Regions – Huntsville Hospital / Sentera just announced
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?
42. 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%
44. Data Sources for Patients, Payers and
Providers
Physician Compare
Other Payer Sites
Healthgrades
Angie’s List
Facebook
Why Not The Best
Other Sources
45.
46. 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?
48. Assessments for Primary Care
Do you or have you?
Know your data
Know your referral network data
Know your sweet spot
Fully participate in incentive plans
Considered PCMH
Monitor patient Satisfaction
Utilize an EMR
Moved ahead on ICD-10
Participate in surveys
Manage your office processes (Co-Pays, HDHP, Bank fees)
49. Assessments for Specialists
Do you or have you?
Know your data
Know your sweet spot
Educated your referrers and your patients
Participate in incentive plans
Been watching for the Specialty Centered Medical Home
program
Monitor Patient Satisfaction
Utilize an EMR
Moved ahead on ICD-10
Participate in surveys
Manage your office processes (Co-Pays, HDHP, Bank fees)
