sink or swim - creating opportunities to thrive in new environment - steve owen

© Copyright Summit Leadership Strategies | 2013 All Rights Reserved

Sink or Swim: Creating Opportunities to Thrive in

this New Environment

2nd Alabama Rural Health and TeleHealth Summit 2013

Steve Owen Summit Leadership Strategies


“A mind, once stretched by a new idea, can never again retain its original dimensions.”

Oliver Wendell Holmes, Jr.


Institute for Healthcare Improvement (IHI) 2008: “Triple Aim” for Improving U.S. healthcare

McCarthy D, Klein S. http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2010/Jul/Triple%20Aim%20v2/1421_McCarthy_triple_aim_overview_v2.pdf. Accessed April 21, 2011

• Quality, access, reliability

Improving the patient’s experience of care • Healthy life

expectancy

Improving the health of populations

• Or at least controlling or slowing cost growth

Reducing the per capita cost of health care

Berwick D et al. Health Aff (Millwood). 2008;27(3):759-769.

“Pursuit of these interdependent goals is an exercise in balance.” Donald Berwick, MD


The “New” Provider Environment

Increased alignment between physicians and hospitals

The focus on “quality” of care as a metric for value-reimbursement strategies.

Services provided are viewed as “costs” instead of revenue generators.

If it can be measured, it will be collected.

Critical role of technology.

Emergence of new care models emphasizing a network approach to care coordination.


2014 Sink or Swim: Creating Opportunities

1. Ensure organizational understanding of value-based reimbursement policies and provisions contained in the PPACA.

2. Position services to align with commercial and Federal value-based reimbursement initiatives.

3. Assess opportunities created by recent 2014 Proposed Physician Fee Schedule Rules regarding Telehealth Services.

4. Seek partnership opportunities with emerging care models endorsed by the PPACA and CMS IPPS/PFS Rules.


2014 Sink or Swim: Opportunity - 1

1. Ensure organizational understanding of quality reimbursement policies and provisions contained in the PPACA .


2014 Sink or Swim: Opportunity - 1

1. Ensure organizational understanding of quality reimbursement policies and provisions contained in the PPACA .

Hospitals: Inpatient Quality Reporting System (IQR)

Value-Based Purchasing (VBP)

Hospital Readmission Reduction Program (HRRP)

Hospital Acquired Condition Reduction Program (HACRP)

Physicians: Physicians Quality Reporting System (PQRS) Value-Based Modifier (VBM) Electronic Health Records (EHR)

Emerging Care Models Endorsed by PPACA: Accountable Care Organizations (ACO) Patient-Centered Medical Homes (PCMH) Medicaid Medical Homes


2014 Sink or Swim: Opportunity 2

2. Position services to align with commercial and Federal quality reimbursement initiatives.

Example: The Hospital Readmissions Reduction Program (HRRP) Reducing 30-day Hospital Readmissions for Congestive Heart

Failure, Pneumonia and Acute Myocardial Infarction.

Incentive/Penalty Programs Impacted: Medicare Hospital Readmissions Reduction Program

(HRRP) “Mortality Outcomes” Measures of Hospital Value-Based

Purchasing (HVBP) Program.“Efficiency” Measures of HVBP.Hospital Acquired Conditions (HAC) Payment Modification

and HAC Reduction Program Penalties.Composite Cost Score for Physician Value-Based Modifier.



2. Position services to align with commercial and Federal quality reimbursement initiatives.

Example: Hospital Readmissions Reduction Program (HRRP)Reducing 30-day Hospital Readmissions for Congestive

Heart Failure, Pneumonia and Acute Myocardial Infarction.

Alignment Opportunities: Home Health Services:

Transitional Care Management; Disease-Specific Clinical Initiatives; Skilled Nursing Services; Intensive Rehabilitation

TeleHealth Services: Initial inpatient consultations; Follow-up inpatient

consultations; Office or other outpatient visits; Pharmacologic Management; Transitional Care Management.



3. Assess opportunities created by the recent FY2014 Proposed Physician Fee Schedule Rules regarding Telehealth Services.

a. Proposed Rule 1: To add Transitional Care Management (TCM) to Medicare-covered TeleHealth services.

b. Proposed Rule 2: To adopt a new definition of “Rural” in determining allowable locations for originating sites.


2014 Sink or Swim: Opportunity 3a

3a. Proposed Rule 1: To add Transitional Care Management (TCM) to Medicare- covered TeleHealth services.

2 new CPT codes (99495, 99496) for providing Transitional Care Management from day of discharge through day 29 post-discharge, were proposed to be added to allowable Telehealth services.

CPT 99495-GT Transitional Care Management Services (Medical Decision Making: Moderate Complexity): Communication within 2 business days post-discharge; Face-to-face visit,

within 14 calendar days post-discharge. Average Reimbursement Rate: $163.00

CPT 99496-GT Transitional Care Management Services (Medical Decision Making: High Complexity): Communication within 2 business days post-discharge; Face-to-face visit,

within 7 calendar days post-discharge. Average Reimbursement Rate: $231.00

• Codes are billable by physicians or other qualified healthcare professionals under the physician’s supervision.


2014 Sink or Swim: Opportunity 3b

3b. Proposed Rule 2: To adopt a new definition of “Rural” in determining allowable locations for originating sites.

Medicare currently limits Telehealth originating sites to those “located in an area designated as a rural Health Professional Shortage Area (HPSA), in a county that is not in a Metropolitan Statistical Area (MSA).”

Currently, 29 of 67 Alabama counties are contained within MSAs and are not eligible for Telehealth originating sites.

The Office of Rural Health Policy (ORHP) uses the Rural Urban Commuting Areas (RUCAs) as a means to classify areas within MSAs according to the degree to which they are Urban or Rural.

Medicare is proposing to modify allowable originating site rules to include RUCA-classified “rural census tracts” contained within MSAs.

Result of Change:58 additional rural census tracts would be added for 14 of

29 Alabama MSA counties.


Proposed Additional Rural Tracts CY2014 Alabama MSA County Number of RUCA (4 – 10 Classification)

Autauga 2 Bibb 2 Blount 4 Calhoun 2 Chilton 6 Etowah 1 Geneva 4 Greene 2 Hale 4 Henry 3 Lawrence 1 Limestone 10 St Clair 2 Walker 14


Box Elder County, Utah

49003 UT Box Elder County 49003960100 10











4. Seek partnership opportunities with emerging care models.

a. Medicaid Medical Homes

b. Patient Centered Medical Homes (PCMH) –

c. Accountable Care Organizations (ACOs) –Medicare or Commercial

d. Alabama Regional Care Organizations (RCOs) (Medicaid)



4. Seek partnership opportunities with emerging care models endorsed by the PPACA.

4a. Medicaid Medical Homes: April 9, 2013 – CMS approval for “Medical Home” status for four pilot

Alabama Medicaid Primary Care Networks (PCNs) serving over 80,000 patients

As a Medical Home, PCNs will coordinate comprehensive care for: Beneficiaries with two chronic health conditions or one chronic health

condition and be at risk of developing another condition. Approved conditions include asthma, diabetes, heart disease,

cardiovascular disease, chronic obstructive pulmonary disease, cancer, HIV, mental health conditions, substance abuse disorder, sickle cell anemia and transplant patients.

Physicians who oversee medical care will receive enhanced fees. Patients will be identified monthly using claims data and referred for

services. The effort also includes transitional care services. PCNs are the implementation foundation for Regional Care Organizations

(RCOs).

2014 Sink or Swim: Opportunity 4a


Medicaid Medical Homes

CMS approves “Health Homes” for Alabama Medicaid networks

May 7, 2013

Care coordination for patients with high cost, chronic health conditions has been the foundation for the early success of Alabama Medicaid’s four pilot Patient Care Networks (PCNs). Now, federal approval of a new “health home” program will provide extra funding and support needed to improve patients’ health outcomes while reducing overall expenditures to the state.

The Centers for Medicare and Medicaid Services (CMS) notified the Agency on April 9 that it had approved the Agency’s request to implement comprehensive care management in the four networks, also known as health homes. Federal approval will allow the state to draw down 90 percent federal matching funds for a two-year period between July 1, 2012, and June 30, 2014.


4. Seek partnership opportunities with emerging care models.4b. Patient Centered Medical Homes (PCMH):

The PCMH is a care delivery model designed to strengthen the patient-provider relationship by moving from reactive episodic care to proactive coordinated care

Cornerstone of the model is an ongoing relationship with a “care team” who is responsible for providing all the patient’s health care needs, including: Appropriate referral to other qualified physicians as needed. Emphasis

is placed on open scheduling, expanded hours Strong communication between patients, healthcare providers and

staff. Technology plays a key role

EMR E-prescribing Disease registry Quality reporting and improvement





4b. Patient Centered Medical Homes (PCMH):

70% of surveyed primary care physicians and non-physicians are either actively transforming their practices into a PCMH or are interested in doing so.

The National Committee for Quality Assurance (NCQA) has recognized over 6,000 physician practices as PCMHs involving over 29,000 physicians in 49 states.

Alabama has 227 NCQA PCMH-recognized physicians, 97 of which are Level 3.

Commercial Payers have 63 PCMH pilot programs in effect.

CMS is involved in multi-payer PCMH projects in 8 states.

The Veterans Health Administration plans to incorporate over 900 PCMHs over the next three years.

BC/BS of Alabama pays an additional 5% to physicians achieving the highest NCQA (Level 3) Certification as part of its value based purchasing program.


NCQA Recognized PCMH Locations




4b. Patient Centered Medical Homes (PCMH):

Proposed addition of Complex Chronic Care Management Services.

PCMHs can collaborate with Health Plans and Hospitals on initiatives to: Reduce re-admissions Capture accurate diagnostic codes and HEDIS measures Improve quality scores Improve patient satisfaction Empower patient/PCP relationship Participating in bundled payment demonstrations and ACO

formation.


4. Seek partnership opportunities with emerging care models.4c. Accountable Care Organizations. (ACOs) (Medicare Shared Savings Program (MSSP)

• An organization of health care providers that agrees to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-for-service program who are assigned to it.

Focus is on care coordination, reduced patient costs, and increased patient satisfaction.

New model of population-based care delivery. Thus, ACOs are seeking home and community-based partners to provide care management services for their patients.

Provides care for Medicare FFS beneficiaries or Dual Eligible Medicaid/Medicare patients.

ACO models can be organized around: Hospital System Physician Groups Independent Practice Associations (IPA) Community-Based Organizations Insurers

2014 Sink or Swim: Opportunity 4c



4c. Accountable Care Organizations. (ACOs)

There are 253 ACOs participating in under the Medicare Shared Savings Program (MSSP) across the country serving Medicare and Dual-Eligible Medicare/Medicaid beneficiaries. In addition, there are over 300 ACOs operating under Commercial Insurers.

40% (104 of 253) of MSSP ACOs operate in the states of Florida, California, New York, Texas and Massachusetts

No MSSP ACOs are headquartered in Alabama at this time.

Only two MSSP ACOs operate in a limited fashion in Alabama in counties bordering Mississippi and Georgia. (Accountable Care Coalition of Western Georgia, LLC. and Medical Mall Services of Mississippi)

2014 Sink or Swim: Opportunity 4c



4d. Alabama Medicaid Regional Care Organizations(RCOs)

Alabama Act 2013-261became law in June 2013:

Calls for Alabama to be divided into 5 regions and that a community-led network (Regional Care Organization) coordinate the health care of Medicaid patients in each region, with networks ultimately bearing the risks of contracting with the state of Alabama.

Networks are to provide care for 800,000 Medicaid-only beneficiaries. Dual Medicare/Medicaid eligible beneficiaries, those in long term care facilities or utilizing home and community-based waiver services, and the developmentally disabled would be excluded from the initiative.

2014 Sink or Swim: Opportunity 4d


Section 9. A regional care organization shall contract with any willing hospital, doctor, or other provider to provide services in a Medicaid region if the provider is willing to accept the payments and terms offered comparable providers. Any provider shall meet licensing requirements set by law, shall have a Medicaid provider number, and shall not otherwise be disqualified from participating in Medicare or Medicaid.




4d. Alabama Medicaid Regional Care Organizations(RCOs)

Initiative would utilize a payment model that includes capitation with care management payments.

The State has submitted a 1115 waiver to CMS to gain permission for implementation of RCOs between now and October 2016.

The current PCN network (Medicaid Medical Homes) will serve as a transition to implementation of RCOs.



2014 Sink or Swim: Creating Opportunities

1. Ensure organizational understanding of value-based reimbursement policies and provisions contained in the PPACA.

2. Position services to align with commercial and Federal value-based reimbursement initiatives.

3. Assess opportunities created by recent 2014 Proposed Physician Fee Schedule Rules regarding Telehealth Services.

4. Seek partnership opportunities with emerging care models endorsed by the PPACA and CMS IPPS/PFS Rules.


Conclusion:

“Things that one day seemed impossible seem inevitable in

retrospect.” Condoleezza Rice

sink or swim - creating opportunities to thrive in new environment - steve owen

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