Affordable Care Act - Impact on Provider Reimbursement SLIDES

Affordable Care Act – Impact
on Provider Reimbursement

Adele Allison
National Director of Government Affairs

August 16, 2012

ACA and Provider Reimbursement

• Evolution - Reimbursement Models
• ACA and The Big Picture
• ACA and Health IT
• PQRS and Value Modifiers
• Questions

888.879.7302 • www.SuccessEHS.com

The Cycle of Reimbursement Models

2010 1917
2000-Present Health Care Lumberjacks
Costs > Inflation Reform Full Risk, Community-
Boomers, Increased Based Care
Patient Portion

1929-1939
2012
The Blues
3rd Party FFS,
Community-Based
1980-1990s ACOs and PCMH being Rating
Partial-Full Risk implemented;
Capitation, HMOs,
PPOs A return to
Community-Based Care
1940-1960s
1974-1989 Commercial FFS
Fee Schedules 1965 Employer-Sponsored
Defined Provider and Health Coverage
Hospital Payment
Gov’t FFS
Medicare and Medicaid

Reimbursement Strategies
• Government Payer
o Legislation & Policy – “Pay-for-Service” to “Pay-for-Value”
• 1997 – BBA → Sustainable Growth Rate (SGR) Formula
• 2006 – TRHCA → Physician Quality Reporting Initiative (PQRI) – Define “Value”
• 2009 – ARRA → EHR Adoption, Clinical Data Reporting and “Evidenced-Based”
Care
• 2010 – ACA → Value-Based Modifiers, Episode Groupers, Bundled Payments
o Issue – Medicare Sustainable Growth Rate (SGR) Formula → 27% Adj.
• Commercial Payers
o Reimbursement Models – Capitation, Withholds, FFS, Bundling
o Pilot Programs – P4P, PCMH, ACOs

• Providers
o Defensive Strategies
o Large Group Practice, Employment, Concierge Practice

Full Risk – Capitation / Provider Risk
ABC Health Plan Enrollees

Dr. PRIMARY Dr. CARE
 1,000 Patients  500 Patients
 Median Age 27  Median Age 58
 100 have Chronic Dz.  350 have Chronic Dz.
 $10 PMPM  $10 PMPM
1,000 Patients 500 Patients
X $10 PMPM X $10 PMPM
$10,000 / Month $5,000 / Month

20 Pts. Per Month 100 Pts. Per Month
X $75 Avg. Coll. Per Visit X $75 Avg. Coll. Per Visit
$1,500 FFS Cost = GOOD $7,500 FFS Cost = BAD


Fee-for-Service – Health Plan /
Employer Risk
Episodic Care Over Utilization
 Disjointed Care  Provider Paid Fee for
Continuum every Service
 Limited Prevention  Incents unnecessary
 Inadequate Chronic treatments
Dz. Management  No Accountability
 Unengaged Patient  No incentive to
 Conflicting Care Plans manage Chronic Dz.
 Treatment Duplication  “Take what I can
 Poor Quality & Safety get” mentality


Calculating Fee Schedules
• Pay-for-Service – Risk Management Critical
o Clinics - Productivity Reporting
o Payer - Utilization Reporting
• Limited Data Standards – CPT and ICD9, E&M Coding
• Health Insurance Claims – paid as a % of MDR/HIAA
o Commercial Pricing Data
o 80th - 85th Percentile of Claim Charges by Zip Code
o Usual, Customary and Reasonable (UCR) Rates
o Databases:
– Prevailing Healthcare Charges System (PHCS) – Health Ins. Assn. of Am.
(HIAA) –1974
– Medical Data Research (MDR) – Medicode – 1987
– Fee Analyzer – Medicode – 1991


Claims Paid on HIAA / MDR
100% $100 CPT Code: 99212
$98 Zip Codes: Atlanta
$95
$92
$89
$87
$85
85% $82
$85 = UCR
$79

$75 Issues:
$73 • Fees are Charge Driven
$70 • Unscientific / Arbitrary
50%


Calculating Fee Schedules
• Claims paid by RBRVS – Resource-Based Relative Value Scale
o 1985 – Secretary commissions Harvard School of Public Health
o 1988 – Phase 1 RBRVS issued to Health Care Financing Administration (HCFA)
o 1989 – Omnibus Budget Reconciliation Act → Create Medicare RBRVS Fee
Schedule
o 1992 – RBRVS Medicare Fee Schedule Implemented
• RBRVS uses weighted, 3-part formula:
o Physician Work (e.g. skill, time, effort, stress, etc.) = 52%
o Physician Expense (e.g. supplies, Rx, devices, etc.) = 44%
o Malpractice Risk (e.g. Office Visit vs. Brain Surgery) = 4%


Measuring Knowledge


Statutory Law vs. Case Law
100 435 30

APPOINTED OFFICIALS → LIFETIME
Lawsuits
CONGRESS
ELECTED OFFICIALS → TERMS

Appeals

Act 2 Cases

Statutory Law

Health Care Policy Case Law


Supreme Court of the U.S. - SCOTUS

Chief Justice John Justice Antonin Justice Anthony Justice Clarence Justice Ruth
Roberts Scalia Kennedy Thomas Ginsburg

Justice Stephen Justice Samuel Justice Sonia Justice Elena
Breyer Alito Sotomayor Kagan


Legislation and Health IT
• 2 Major Health IT Legislations under Obama
• ARRA – Meaningful Use of Certified EHR Technology (CEHRT)
o ARRA → 1,400 Pages; HITECH → 60 Pages
o Enacted February 17, 2009
o Stage 1 MU → Adopt / Capture Data; Stage 2 MU → Move / Report Data
o Goal: Reward and Accelerate Adoption of Interoperable CEHRT
• ACA – Affordable Care for All Americans
o ACA → 2,700 Pages (U.S. Constitution is 8 Pages)
o Enacted March 23, 2010
o Goals: Reduce the number of uninsured Americans and Make Care Affordable
• Gov’t to become a purchaser of Value


Reimbursement Reform

• Change the Paradigm
o Patient-Centered Medical Home (PCMH) & Prevention
 Shift focus to prevent and chronic disease management
 Patient Engagement and Accountability
o Redesign the way care is compensated
 Discontinue blanket fee-for-service reimbursement
 Must define value

888.879.7302 • www.SuccessEHS.com Source: Arrow - AAMC, 2012 Medicare Physician Fee Schedule Proposed Rule, July, 2011

The HIPAAMIPPACHIPRAARRAPPACA
Era!
Status Quo VBM
New Status Quo
Pay-for-Value
Pay-for-Service

ARRA – Meaningful Use
Data Provider
eRx CEHRT
Provider CEHRT
Performance
Data

PQRS HIPAA – ICD-10 Educate Measures CDS
HHS Factory

ACA – Define “Value”
Comparative
Effectiveness
Guidelines
Research


ACA and Providers – Prevention
• 2011 – Annual “Wellness” Visit (AWV) for Medicare
o Goes beyond the “Welcome to Medicare” check-up
o 2 New AWV codes created – G0438 (Initial), G0439 (Subsequent)
o AWV codes billed with E&M (-25 modifier) = Paid for both
 Establish/Update medical and family history (MU2)
 List of providers, suppliers and Rx
 Measure height, weight, BMI, BP, etc. (MU1)
 Determine cognitive impairments
o Details: http://go.cms.gov/R0aLyj
• 2011 – No Patient Cost-Sharing for:
Colorectal Screening Cholesterol / Other CAD
Annual Mammo (Ages 40+) Cervical Cancer Screening
(Flex-sig / Colonoscopy) Screenings
Nutrition Therapy Prostate Cancer Annual Flu, Pneumonia
Diabetes Screening
(Diabetics / Kidney Dz.) Screening and Hep B Vaccines
Abdominal Aortic HIV Screening for High
Bone Mass Measurement
Aneurysm Screening Risk Patients


ACA and Providers – Prevention
• 2011 – 2015 – Primary Care Incentive Payment Program
o MDs, PAs and NPs 10% Medicare B on top of MPFS
o Quarterly payments by CMS
o Must be Self-designated PCP (IM, FP, Peds or Geratrics)
o 60% of Medicare “Allowables” must be for designated PCP services
o CMS will assess eligibility by:
 Checking Provider’s specialty self-designation
 Looking back on % of designated services performed
o Medicare contractor has more information: http://go.cms.gov/OrxT9y
• 2013 – 7% FP, 3-5% other PCP pay increase for TOC
• 2013 / 2014 – Medicaid pay to PCPs to reach Medicare levels
(Average 34% Increase)


Polling the Audience


ACA and Health IT – By the Numbers
• 73 Times ACA mentions Accountable Care Organizations
• 15 Times the Medical Home is talked about
• 36 Times Patient-Centeredness is referenced
• 84 Times Value-Based is mentioned as relates to reforming hospital
and provider reimbursement
• 12 Times Payment Modifier is referenced as relates to MD
reimbursement for Medicare Part B
• 29 Times Quality Reporting is discussed related to clinical data
• 58 Times ACA references FQHCs (27), RHCs (14), and CHCs (17)
• 26 States enjoined the lawsuit over the Medicaid expansion
• 12 SCOTUS Opinion mentions broccoli


ACA and Health IT – Key Provisions
• Medicaid Eligibility expanded to 133% of FPL as of 2014
• Medicaid Expansion Ruling → States can Opt-in or Opt-out
• 351,576 more AL Medicaid Enrollees by 2019
• AHA supports Medicaid expansion → ENROLLNOW
• Opt-out of State Insurance Exchange = Feds
• Other Coverage Keys
o No Lifetime Insurance Caps
o Parental coverage to Age 26
o No pre-existing denials
o Independent Payment Advisory Board (IPAB) → 15 Members for
Medicare Cost Containment Actions


ACA and Health IT
• 4 Marks of the Affordable Care Act (ACA)
1. Report Quality Data → CQMs and PQRS
2. Knowledge Transfer to Providers
3. Measure Provider Performance → PQRS
4. Purchase “Value” → Value Modifier
• Driving linkage between performance and reimbursement
• ACA Ruling →
o Solidifies Federal Gov’t defining Quality
o Provisions funding to make it happen

• Remember that MU is under separate legislation


ACA and Health IT – Report Data
• §2717 – Establishment of quality reporting for insurers
o CMS is an insurer (‘Care and ‘Caid), extends to private insurers
o Priority given to:
 Health Care Outcomes
 Management across episodes of care / transitions of care
 Use of Health IT
 Informed treatment decisions and shared decision-making
o “Preference-Sensitive Clinical Care” must be defined by HHS
 Use of CDS to guide “preference-sensitive” treatment choices
 Drives reimbursement
 Gov’t defining “value” based on evidence / data
 Controversial for Gov’t – “My doctor should decide, not my government.”


ACA and Health IT – Report Data
• §3004 and 3005 – Submission of quality measures to
HHS
o Affects LTC, Hospitals, Inpatient Rehab, Hospice and Cancer
Hospitals
• §3013 – Grant awards for purposes of developing
Health IT Quality Measures
o Focus on where no measures exist
o Seeks to create standards for measuring population improvement
o Quality Reporting becomes a broad federal initiative
• §4302 – Federal data collection at the smallest level
possible
o HHS/ONC to develop national standards for data collection,
interoperability and security for data management
o Includes federally conducted/supported health care programs or
surveys


ACA and Health IT – Knowledge Transfer
• §6301 → Communication and Knowledge Transfer (ARHQ)
o RFP issued for preferred vendors for Knowledge Transfer
o $150M in Grant awards earmarked
• §10332 → Medicare A, B, and D Claims Data
o Probabilistic Matching between unrelated databases → Leveraged with ACOs
o Impact Physician Compare rating website
o Patient Privacy issues? → Challenged in other courts (Patient de-identified,
Provider Identity intact)
• §10333 → Grants for Community-based Collaborative Care
Networks (E.g. telehealth services)
• §10109 → HHS to receive input (From NCVHS, HIT Policy Committee,
HIT Standards Committee, Standards Orgs and Stakeholders)
• §4103 → Annual Wellness Visit for each Medicare Patient
o Increase Self-Management through use of Health IT


ACA and Health IT – Knowledge Transfer

• §5405 → Primary Care Extension Programs
o Education / Technical Assistance in Evidence-based Practices
o HHS to consults with agencies experienced in health care / prevention,
including ONC
• §934 → Technical Assistance Grants
o Provide education / technical assistance to health care providers
o Must coordinate with RECs regarding quality improvement, reform and best
practices
• §2401 → Home / Community-based services and support
o To help eligible patients with care such as daily living
o Includes back-up systems for Continuity-of-Care


ACA and Health IT – Measure
• §10305 → Public Reporting of Performance Data
o Requires alignment with other Health IT efforts
• §1323 → Community Health Insurance a/k/a Exchanges
o Use Health IT for real-time data for investigation of fraud/abuse
• §2703 → Chronic Condition Consumers receive payments
o Provision for home health services
o Includes use of Health IT for care management


ACA and Health IT – Pay-for-Value
• §1311 → Reformed Provider Reimbursement – Ind. & SBA
o Increased pay for best practices, evidence-based medicine and use of Health IT
• §2706 → Pediatric ACO Demonstration – Incentives for Quality
• §3002 → PQRS integration with MU CQMs
o Establishes informal review process
• §3021 → CMMI Created ($10B in funding)
o Innovative payment and service delivery models
o Includes ACOs and Health IT enabled networks
• §3007 – Value-based payment modifier for Physicians


Value Modifier (VM) under ACA
• 2 Established Federal Quality Measure Programs
o PQRS Performance on Core Measure Set
o Meaningful Use EHR Incentive Program Measures
• CMS Final Rule – Performance Resource Measures (Nov. 28, 2011)
o VM → composite of Quality and Costs
o Quality: PQRS and MU used to create 62 preliminary VM measures for P4P
o Costs: Total per capita costs for target populations → COPD, Heart Failure, CAD,
and Diabetes
• Data published publically on “Physician Compare” website at
www.medicare.gov/find-a-doctor/provider-search.aspx
• CMS issued 23,730 Physician Feedback reports
o 2010 Quality and Resource Use Report (QRUR) for Medicare FFS
o Sent to MDs in 4 states → Iowa, Kansas, Missouri, Nebraska
o Sample Copy Available at http://go.cms.gov/NPoBTC


EHR Direct Reporting & CMS
• CMS wants EHR Direct Submission of Quality Data
• Claims-based / Registry-based = bit of data only
• EHR-based = Continuity of Care Document (CCD) on each
individual Patient
• Stage 1 MU Final Rule:
“… the HIT Policy Committee proposed the goal as, ‘Report to patient registries
for quality improvement, public reporting, etc.’ We have modified this care goal,
because we believe that patient registries are too narrow a reporting requirement
to accomplish the goals of quality improvement and public reporting.”

• 20 Vendors CMS EHR Direct Qualified → 15 ONC CEHRT as
Complete EHRs → Only 9 eRx Incentive Program through
EHR Direct
Aprima Medical Software, Inc. ASP.MD, Inc. AZZLY™
Digital Medical Solutions, Inc. e-MDs Epic
LSS Data Systems Medical Informatics Engineering SuccessEHS, Inc.

Value Modifier (VM) - Timeline
• 2012
o eRx Penalties for 2011 unsuccessful eRx begin
o 2011 Feedback reports to 100K physicians
o Identification of specific measures of cost and quality
o CMS initiates plan to align PQRS, MU and EHR reporting
o ISSUE: Only 3,300 of 23,730 have downloaded QRUR
 MDs unengaged
 GAO to CMS → MD awareness must be heightened!
• July 6, 2012
o NPRM → first VM for 2015 based on 2013 performance
o Applies to:
 Physicians billing Medicare Part B FFS , and
 Threshold of 25+ PQRS EPs
o Avoid Penalties → CMS PQRS self-nominate by January 31, 2013


Future – Value Modifier (VM)
• 2013
o Performance period for 2015 VM begins
o VM implemented more fully through rulemaking
o Physician Compare (website) has performance data published
• 2015
o CMS applies VM to select physicians/physician groups (TBD Rulemaking)
o Penalties for non-adopt of PQRS and EHR under MU begins
• 2017 – Full Payment Reform
o VM is applied to ALL physicians/physician groups


Registry vs. EHR Direct Reporting
“We are aware of many oftoo narrow a reporting encounter to
“… patient registries are the infrastructure for
“We envision a single reporting issues registries requirement
during the collectioninofdata they receivestrive to public
accomplish the goals the future and will from and
electronic submission of quality improvement eligible
professionals for whom they provide services. … As we
reporting.”
align the EHR incentive program and PQRI [a/k/a
move towards develop the reporting framework for
PQRS] as we implementing the Value-Based Modifier, the
-Final Rule Stage 1 Meaningful Use
collection of accurate data will become increasingly
clinical quality measures to avoid redundant or
important. reporting. Further, we alsofuture rulemaking
duplicative We anticipate adopting in note that the
the option of disqualifying a registry from future PQRS
Affordable Care Act requires that the Secretary
reporting if theirto integrate the EHR incentive of the
develop a plan data is inaccurate for future years
program.”and PQRI by January 1, 2012.”
program
-Final Rule Medicare Program; Payment Policies Under the Physician Fee
-Final Rule Stage 1 Meaningful Use
Schedule, 5-Year Review of Work RVUs, Clinical Laboratory Fee Schedule,
and Other Revision to Part B for CY2012


Transformation – Your IT Vendor
• Meaningful Use and other Dashboards?
o Metrics / Analytics by Provider
o Facilitates quick numerators/denominators for MU attestation
o Practice analytics with drill-through details
• Patient Portal Inherent with System?
o Additional license or support fees
o Additional vendor and integration considerations
• Single database solution = Always certify as a “Complete EHR”
• EHR Direct PQRS?
• More than just first call support?
o Initiative Toolkits (E.g. MU, PCMH)
o Consulting Support with domain experts
• Ongoing Client Educational Offerings
• QIO Alignment

Added to The BRIEF,
Questions:
adelea@successehs.com
Follow me on Twitter:
www.twitter.com/Adele_Allison


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