New News You Can Use

James L Sublett MDPresident, Joint Council of Allergy, Asthma, & Immunology

Clinical Professor & Chief, Allergy & Immunology

University of Louisville School of Medicine

Managing Partner, Family Allergy & Asthma

Louisville, KY

Disclosures

• None related to today’s topic

• Stockholder– AllergyZone LLC

• Advisory Board/Research/Speaker– ALK– GlaxoSmithKline– sanofi-Adventis– Merck– Novartis– Greer– ISTA – Planet Biopharma

Objectives

•To update you on recent regulatory changes that may affect the allergist’s practice

•To review the Patient Protection and Affordable Care Act and the potential effect on the practice of Allergy & Immunology

Joint Council of Allergy, Asthma, & Immunology

Mission Statement

The Mission of the JCAAI is to act on behalf of the specialty of allergy-immunology and the patients it serves; and to provide a unified voice in medical socio-economics which will enable patients to receive the highest quality allergy-immunology care.

Who is the JCAAI?

• Leadership–Jim Sublett MD – President (2 yr term)

–Dick Honsinger MD, Pres-Elect (2 yr term)

–Steve Imbeau MD – Past-President

–J. Allen Meadows, MD - Secretary

–Stan Goldstein MD, Treasurer

–Don Aaronson MD, JD, MPH – Exec. Dir.

–Gary Gross MD, MBA – Exec. VP

Who is the JCAAI?

• Board

–Pres. & Pres Elect of AAAAI & ACAAI

–Board Members include equal representation of both ACAAI & AAAAI

–Board Members include FIT/Young Physicians & Training Program Directors

• Staff

–Sue Grupe, Director of Operations

YOU!

Who is the JCAAI?

JCAAI Membership

• Fellows-In-Training

–Free

• Practicing Physicians

–$175 annually

–Staff - $25

JCAAI Benefit

Allergy Practice Infringement

by Chiropractors

JCAAI Action on Chiropractic Laser Centers

• White paper in progress addressing issue

• JCAAI board requested GAO investigation of laser treatments for allergies as provided by over 400 “allergy care relief centers”.

CPT Changes

• Testing Codes-Descriptor Change (95004, 95024, 95010, 95015)

• 95004 – Percutaneous tests (scratch, etc.)…including test interpretation and report by a physician.

• All other test codes have same descriptor change

• Reason – JCAAI effort to obtain physician work

Practice Parameter Forms

• Clinical Indications for IT- Pt with AR or BA

–Poor response to meds or allergen avoidance

–Unacceptable adverse effects to meds

–Desire to avoid long term meds/reduce med costs

–Co-existing AR and BA

–Possible prevention of BA

Practice Parameter Forms

• Indications for Continuation of IT >5 years–Informed consent necessary

–History of failure of previous discontinuation of IT after minimum 3 year course

–Continued need for venom IT

–Risk/Benefit assessment favors continued IT

–Other extenuating medical circumstances

Proposed 2011 Medicare Physician Fee Schedule

• Released on June 25, 2010

• Many of the changes result from requirements of the Patient Protection and Affordable Care Act (PPACA)

Elimination of Consultation Codes

• CMS eliminated consultation codes in 2010 fee schedule• RVU’s from consultation codes redistributed to E/M codes

– will result in a 6% increase in outpatient E/M reimbursement and a 0.3% increase in inpatient E/M reimbursement

• JCAAI survey of allergy practices– up to 40% of new patients were considered consultations.

• Allergy and many other specialties opposed• You should NOT bill Medicare for any consultation

codes - outpatient (99241 – 99245) or inpatient (99251 – 99255)

• Unclear what private carriers will do long term – some appear to be considering adopting this.

Medicare Fee Schedule 2010

Code 2008 RVU

2009 RVU

2010 RVU

2011 RVU*

3 Year

% Change

95004 Percutaneous 0.15 0.16 0.16 0.19 +26.67

95010 Perc Titration 0.45 0.47 0.48 0.53 +17.77

95015 ID Titr Drug/Bug 0.32 0.36 0.36 0.42 +31.25

95024 IDs 0.18 0.19 .19 0.21 +16.67

95070 Inhal Challenge 1.57 1.18 1.07 1.10 -29.94

95075 Food Challenge 1.57 1.72 1.73 1.88 +19.75

95115 Itx. Single Inject 0.33 0.29 0.27 0.30 -09.09

95117 Itx. Multi Inject 0.41 0.36 0.33 0.36 -12.19

95165 Multi-dose vials 0.29 0.31 0.33 0.37 +27.59

*proposed for 2011

Increases for Venom Immunotherapy

• JCAAI submitted request for increase

• RVUs for these codes(95145-149) are proposed to increase by 30 – 38 percent over current values:

–1 ml dose of venom from $10.70 to $16.67

–3-vespid mix from $21.26 to $30.22

MEI Rebasing/Revising

• CMS is proposing to rebase the Medicare Economic Index to 2006 from 2000.

• MEI is supposed to reflect the annual price changes for various inputs needed to provide physician services.

• Comprised of two categories:– physician work

–physician practice expense & malpractice

MEI Rebasing/Revising

• To be done in a budget neutral manner without decreasing work RVUs

• Will offset the adjustments made to PE and malpractice RVUs by a reduction in the overall conversion factor.

• Expected impact for allergy/immunology is +4 %.• Allergy supports the proposal.• We believe the AMA will oppose this.• We have sent a letter requesting the AMA remains

neutral.

Primary Care and General Surgery Bonuses

• PPACA mandated that, beginning in 2011, Medicare pay bonuses of 10% for primary care services who practice in health professional shortage areas (HPSAs)

• Physicians designating a primary care specialty should be furnishing complete primary care services to their patients.

• CMS will be watching for physicians changing their specialty designation inappropriately.

Potentially Misvalued Codes

• Congress specifically directed CMS to examine potentially misvalued services in seven categories:– Codes for which there has been the fastest growth– Codes experiencing substantial changes in practice

expenses– Codes for new technologies or services– Multiple codes billed in conjunction while furnishing a

single service– Codes with low relative values, especially if frequently

billed multiple times– Codes not valued since implementation of the RBRVS – Other codes as determined by the Secretary

Potentially Misvalued Codes

• A/I CPT codes under review:

–95165 - allergy immunotherapy

–94060 - evaluation of wheezing

–95004, 95010, 95015, 95024, 95027 - allergy skin testing

–95148 - venom immunotherapy with 4 venoms

–95144 - used in off-the-board treatment

Disclosure by Physicians When Referring for Advanced Imaging Services

• PPACA requirement • Directed at physicians who perform in-office advanced

imaging services (PET, CT and MRI)• Must inform the patient in writing at the time of a referral

for these services that the patient may obtain the same service from other at least 10 other suppliers (if available) located within a 25-mile radius of the physician’s office

• CMS is considering whether the list may include hospitals or other institutional providers of the service or whether it must be limited to free-standing “suppliers.”

• Disclosure be documented by obtaining a signed copy of to keep in the patient’s file.

IVIG

• IVIG Survey August 2009–30 completed surveys–53% Medical Center Faculty–25% of patients receive in-office infusions

• Subset of patients who receive IVIG who are not "typical" and require more work than the "usual" patient.

• RUC values a code for the "typical" patient who receives the service.

• Unlikely RUC would approve new codes

Food Allergy Challenges

• JCAAI Survey April 2010• Costs for application to RUC for coding

change approximately $30,000• Responses don’t support request for

change with CMS• Agreed to develop arguments focusing on

the fact that food allergy challenges in children and young adults are substantially more complex than food allergy challenges in Medicare patients

Food Allergy Challenges

Xolair

• CPT code request considered–Some carriers pay chemo code – 96401,

96402

–Some pay injection code only – 96372

• Strong opposition by several medical specialty societies

• Ask each carrier how to bill for Xolair. If told to bill that way, OK to bill.

USP 797

• Pitched that we, as a specialty, can self-govern and “rule ourselves.”

• Resulted in “USP 797 Sterile Preparation of Allergy Vial Guidelines”

• Test for vial preparers– Test prepared by Academy and College

Immunotherapy committees– Free to members of JCAAI on website

• Media Fill Test– Order from Valiteq (link on JCAAI web site.)– Test performed annually by all staff who prepare vials– Will contain instructions for use

USP 797

• Results as of July, 2010–Less than 30% of the practicing allergists have

had their staff take the test

–Recent state audit of allergy office (NN 7-10-10)

• What can you do?–Take the test

–Have your vial preparation staff take the test

–Perform an annual fill test

The JCAAI has made it easy:

Meaningful Use

• Final Rule released July 13, 2010

• Provides details on how eligible providers (EP) can qualify for the Medicare and Medicaid incentive payments

• Establishes standards and certification criteria for EP’s

Meaningful Use

• Generally rule reduced and relaxed proposed criteria

• HITECH act provided for possible $44,000 or $66,000 incentive payments to assist physicians in implementing HER in their offices–$66,000 only if 30% of your practice is

Medicaid (20% if you are a pediatrician – but if you do not meet 30% you only get 2/3) – choose one payment only

Meaningful Use (cont)

• Phase in – can qualify for phase 1 ($18,000) 2011 through 2014

• Phase 2 – ($12,000) effective year after Stage 1

• Phase 3, 4, 5 ($8,000, $4,000, $2000) each of next 3 years

• Final Rule only addressed criteria for Phase 1

• Meaningful use criteria after 2014 to be announced at a later time

Meaningful Use (cont)

• Stage 1– EP’s must meet criteria for 15 core measures plus– Choose 5 other “menu” measures from list of 10

potential measures– Reporting period is for 90 days for stage 1 and for all

other stages is 365 days– Reporting for 2011 is via an attestation

• This attestation will probably be in effect for all stages

• Hospital based physicians, NP and PA are not eligible

• EP’s that are not meaningful users by 2015 will be subject to annual penalty

Meaningful Use – Mandatory Criteria

• Use CPOE for at least one medication for at least 30% of patients

• Implement drug-drug and drug-allergy interaction checks

• 40% of prescriptions transmitted electronically

• Record demographic info for 50%+ of patients

Meaningful Use – Mandatory Criteria

• Maintain up to date problem list for 80%+

• Maintain drug allergy list for 80%+

• Record vital signs for over 50%

• Record smoking status for 50% over age 13

• Provide more than 50% with electronic copy of health information within 3days of request

Meaningful Use – Mandatory Criteria (cont)

• Implement one clinical decision support rule and track compliance

• Report clinical quality measures to CMS

• Maintain active medication list for 80%

Meaningful Use – Mandatory Criteria (cont)

• Provide clinical summaries for each office visit to over 50% within 3 business days

• One test + of ability to transmit PHI electronically to another provider

• Protect PHI by doing security risk analysis and implementing security updates

Meaningful Use- EP Menu – pick 5/10

• Implement drug formulary checks• Incorporate labs into EHR as structured

data• Generate lists of patient by specific

conditions for QI or outreach• Send reminders to patients per patient

preference for preventive/follow-up care• Provide patients with electronic access to

their PHI within 4 business days of it being available to EP

Meaningful Use – EP menu – 5/10 (cont)

• Use certified EHR technology to identify specific education resources and provide that information to patients if appropriate

• Perform medication reconciliation when appropriate on transfer of patient to your care

• Provide summary care record on each transition of care or referral

Meaningful Use – EP menu – 5/10 (cont)

• Capability to submit electronic data to immunization registry

• Capability to submit electronic syndromic surveillance data to public agencies and actual submission if required

e-Prescribing

• Medicare fix established bonus payment for using e-prescribing– 2% in 2009 and 2010– 1% in 2011 and 2012– 0.5% in 2013

• Use mandated starting 2011• Penalty for non-use

– 1% in 2012– 1.5% in 2013– 2% in 2014 and beyond

• Measure will be %Part D drugs ordered via e-prescribing – if under 10% no bonus

Allergists Use of e-Prescribing

• JCAAI Survey – 203 responses

–41% use e-prescribing

–59% do not

• Of the 41 % - 47% use it for 70% or more of their prescribing

• Multiple programs used

ICD-10

• CMS moving towards transition to ICD-10

– ICD-9 has 17,000 codes

– ICD-10 will have approximately 210,000 diagnosis and

procedure codes

– Would need new software (and possibly hardware)

• Standards for electronic health care transactions change from Version 4010/4010A1 to Version 5010 on January 1, 2012

• Version 5010 accommodates the ICD-10 codes, and must be in place first before the changeover.

• ICD-10 goes into effect October 1, 2013

Health Care Reform – Where are we?

THE AFFORDABLE CARE ACT (ACA)

• Passed March 2010

• Timeline highlights

–June –high risk pools mandated for uninsured due to pre-existing conditions

–Oct – no denial of coverage of children with pre-existing conditions; no lifetime caps; first dollar coverage for preventive care

THE AFFORDABLE CARE ACT (ACA)

• 2012 – requires many demonstration projects

• Accountable Care Organizations (ACO)

• Medical Homes

• Bundling for hospitals and doctors

• Other payment approaches

• P4P projects

ACA (cont)

• 2013 – your taxes increase to fund this–SGR to include value based purchasing

concepts

• 2014 – major changes occur–Subsidies for low income patients

–Insurance mandate for most people

–Limitations on pre-existing exclusions

ACA (cont)

• 2015–Independent Payment Advisory Board

(IPAB)

• 2018–40% excise tax on high end insurance

policies

• 2019–Fully extends coverage to 32 million people

Health Care Reform – Where are we?

Issues of concern:• No funding for training of allergy and immunology

fellows

• Lack of a permanent, or even a multiple-year-fix for the SGR – Medicare’s physician fee schedule formula

Health Care Reform – Where are we?

Issues of concern:• Lack of malpractice reform

• Institution of an Independent Payment Advisory Commission (IPAC) - a panel that will set physician’s fees without a provision or any right of appeal to Congress;

• Alternative payment mechanisms (such as bundling, accountable care organizations, and medical home).

Sustainable Growth Rate

• 2008 Congressional Budget Office (CBO) Analysis

–Freezing physicians’ Medicare payment rates at 2009 levels cost $318 billion next 10 years

–Growth at current medical inflation rates $556 billion

• One year patch $15 billion.

Comparative Effectiveness Research

• Compares clinical outcomes of therapies or strategies used to prevent, treat, diagnose, and manage the same condition.

• Purpose is to assist patients and clinicians in making informed health care decisions

• Better evidence on what works will lead to better health care choices and thus to improved quality of care and improved efficiency.

• JCAAI supports concept.

Comparative Effectiveness Research in Allergy

• Hankin C, Cox L, et al. J Allergy Clin Immunol. 2008;121:227-32) – 6 months preceding versus following IT among children (<18 years) newly

diagnosed with allergic rhinitis. – 6-month total cost savings of $401– offset the average total cost of immunotherapy ($424 per patient).

• Hankin C, Cox L, et al. Ann Allergy Asthma Immunol. 2010;104:79–85) – 10 years (1997-2007) of Florida Medical data– compared health services use and costs between children newly diagnosed

with AR who received IT to matched controls with AR who did not receive IT.– Children who received IT had significantly lower 18-month total health care

costs ($3,247 vs $4,872), outpatient costs exclusive of immunotherapy-related care ($1,107 vs $2,626), and pharmacy costs ($1,108 vs $1,316) than matched controls

– Savings were evident as early as 3 months following IT initiation, and increased throughout the study period.

• JCAAI/ACAAI/AAAAI boards approved funding for adult data to be reviewed and published.

Payment testing has begun

Pay for Performance

P4P – starts 2015 – different from PQRI– Physician payments will be based on quality

and cost of care they deliver – budget neutral payments

–Based on current studies of physician resource use• Will look at outcomes of care as a measure

• Quality will be measured against cost

• 2012 HHS will publish measures for quality and cost

Health Care Reform & Allergy

• Bundled Payments – combining payments for physicians and hospitals into one payment to hospital • Plan for bundled payments if pilot improves quality

and reduces costs (2016)• Applies to hospitalization payments only• Allergists do not work in hospitals• No reason to put hospital between us and our

payment

• Gainsharing – hospital focused reduction in costs of care – reductions shared by hospital and physicians

Health Care reform (cont)

Medical Home–Primary care physicians will become care

coordinators

–Issues• Not enough PCP’s

• Most small PCP groups cannot deliver all services

• Care Coordination studies – 40 different definitions

• No demonstration of cost savings vs. specialty care

Medical Home

• “Partnerships with key players…and reimbursement aligned to reward practices… with physician support and measurement of results” – AHP-Hi Wire

• “the specialist-dominated US health care system produces care of mediocre quality, with excessive use of costly services that have little marginal benefit. Within this context the PCMH has become the shorthand for rebuilding US primary care capacity.” – Landon et al Health Affairs 2010

Principles of the PCMH

• Personal Physician (PP) – each patient has ongoing relationship with personal physician

• Physician directed medical practice – leads team all of whom collectively take responsibility for ongoing care of patients

• Whole person orientation – PP responsible for providing for all the patient’s healthcare needs or takes responsibility for appropriately arranging care with other qualified professionals – at all stages of life

• Joint Principles of PCMH – AAFP ,AAP ,ACP, AOA 2007

The Medical Neighborhood

• PCMH cannot exist in a vacuum

• Look to control costs by reducing hospital readmissions, ED use for non-emergent conditions and control alleged overuse of specialists

• Need to align specialists, hospitals and PCMH goals–Need to define roles with appropriate incentives

–Need to coordinate care across the continuum• Includes shared accountability for outcomes

Accountable Care Organization

• A combination of primary care, hospitals, and possibly specialists

• Physicians and hospitals have for quality and cost of care

• Bonus for high quality and low cost

• Possible penalty for low quality or high cost

ACO – Value Proposition

• Huge variation between cost and quality

• Create local accountability for cost, quality and efficacy

• Measure defined population performance

• Share savings: positive incentive

Accountable Care Organization

• Establishes a spending benchmark based on expected spending.

• Payments are bundled

• If an ACO can improve quality while slowing spending growth, it receives shared savings from the payers.

• Demonstration projects funded

ACO: Types of Organizations

• Primary Care Physicians: Medical Home• Primary Care Physicians and selected

Specialists• Primary Care Physicians, Specialists,

Hospital – PHO• Multi-Specialty Group Practices• Multi-Specialty Group Practices and

Hospitals• Integrated Health Systems

ACO Conclusions

• ACO – will not be easy to implement

• Success depends on common vision

• Aligning financial interests in non-group environment will be very hard

• Will require many demonstration projects

• When this will be implemented is unclear

• Medicare may mandate ACO membership

PQRI

• PQRI – extends 1% bonus for 2011, 0.5% 2012-2014

–2015 penalty for non-participation 1.5% 2015 and 2% 2016 and after

• Report on at least 3 measures (unless there are not at least 3 measures applicable)

PQRI – Allergy Measures

• 52 – Percent of Patients over 18 with diagnosis COPD, FEV1/FVC <70% prescribed inhaled bronchodilator

• 110 - % patients over 50 given flu shot during flu season

• 111 - % patients over 65 who received on pneumonia shot

• 114 - % patients over 18 queried about tobacco use at least once in past 24 months

PQRI – Allergy Measures

• 116 - % adults 18-64 with diagnosis acute bronchitis not prescribed antibiotic

• 129 - % patients over 50 screened and counseled on need for flu vaccine during Flu season

• 130 - % patients over 18 with written medication reconciliation verified with pt

• 132 - % patients over 18 with evidence of active participation in development of their treatment plan

PQRI - Proposed Allergy Measures

• 7 measures in pipeline – 5 apply to asthma

• No rhinitis measures in approval process yet

• Measure #1 – Assessment of Asthma Control

• Measure 2 – Tobacco Use: Screening

• Measure #3 – Tobacco Use: Intervention

• Measure #4 – Pharmacologic Therapy for Persistent Asthma

• Measure #5 – Management of Asthma controller and reliever medications

• Measure #6 Assessment of Asthma Risk in ED

• Measure #7 – Asthma Discharge Plan ED/Inpatient

Graduate Medical Education (GME)

• Funding for primary care only• Unused medical residency training slots to

be allocated to primary care • Ignores the immediate need of other

specialties facing workforce shortages.• Established a National Commission to

study and make recommendations in future years.

• JCAAI supports funding for specialty training

Lobbying Strike Force

Each society will identify three interested members who….

• will be effective lobbyists

• willing to work both locally and nationally, to lobby allergy issues with their individual representatives, as well as with appropriate Congressional committee chairpersons.

• capable of making their own appointments with their local Federal legislators.

Identification of appropriate lobbyists could become a responsibility of the RSL and HOD.