The document discusses the future of physician payments and the transition away from fee-for-service towards value-based and accountable payment models. It outlines emerging accountable care organization models including single-provider, multi-provider, insurer-led, and insurer-provider partnership models. It also summarizes Medicare and private payer initiatives focusing on shared savings programs and population-based payment approaches. Finally, it provides best practices for physicians and practices to position themselves for success under new payment reforms.

1. present
The Future of Physician
Payments
Presented by
David J. Zetter,
PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
Presented by
David J. Zetter,
PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
1
© 2012 Zetter HealthCare

2. Disclaimer
2
• No copyright claimed on government material or
information. This material is designed to offer basic
information. The information presented is based on
the experience, training and interpretation of the
author. Although the information has been carefully
researched and reviewed for accuracy and
completeness, neither the author, DecisionHealth or
Part B News accept any responsibility or liability with
regard to errors, omissions, misuse or
misinterpretation.
2
© 2012 Zetter HealthCare

3. Takeaways
State of Healthcare
SCOTUS
Capital Hill & Emerging Opportunities
Accountable Care Models
Private Payer Initiatives
Medicare Initiatives
Payment Reforms
3
© 2012 Zetter HealthCare

4. State of Healthcare
 Healthcare Reform/Transformation
• 27.4% 2012 Medicare rate cut averted for 12 months
• 2012 “doc fix” cost $21.1B
• MedPAC recommendations to realign fee-schedule to
support primary care and ACOs, bundled payments,
capitated models & shared savings programs
• MedPAC SGR recommendation slides –
http://tiny.cc/u58qv
• SCOTUS on ACA Legislation/Regulation
4
© 2012 Zetter HealthCare

5. State of Healthcare
 National & Global Efforts
• Create efficiencies, increase access & stabilize rocketing
costs
• As compared globally, we ranked #1 on costs, but 20-40th on outcomes
 Beginning the Shift to Paying for Reporting & Quality
• 27+ legislatures have proposed bills on accountable care
• 221 known ACOs active in 45 states
• Physician-led ACOs nearly double; from 38 to 70
5
© 2012 Zetter HealthCare

6. SCOTUS Observations
 Upheld the individual Mandate through Congress’
taxing authority
• Result = $1 Trillion tax bill
 Rules that HHS can’t put sanctions on states’ existing
Medicaid funding if the states decline to go along
with the Medicaid expansion
 Most States now will quickly implement Health
Insurance Exchanges & Medicaid expansion
strategies
 Still some legal challenges – Medical loss ratios & rate
reviews
6
© 2012 Zetter HealthCare

7. SCOTUS Observations
 Amplified movement away from FFS towards Shared
Savings
 Increased momentum and security for care
coordination strategies and more pressure for
aligning incentives and creating efficient care models
 Could see stabilization of insurance premiums now
• Not the 10%-17% annual increases of the past
 Full repeal will be nearly impossible by next President
of Congress
7
© 2012 Zetter HealthCare

8. Capital Hill Update
 Meaningful Use Stage 2
• Final Rule for MU Stage 2 – Out anytime this fall
• ONC discussions at AMIA Annual Symposium 11/3-11/7
Chicago
 White House
• Heavily engaged in HITECH progress w/ frequent panels &
town halls lately
• REC, HIE, Beacon, Standards, Interoperability, etc.
 FDA, ONC & FCC
• FDA Safety and Innovation Act, S 3187
• Prescription Drug User Fee Amendments Act of 2012
• Requires the HHS w/i 18 months to publish report “that
contains a proposed strategy & recommendations on an
appropriate, risk-based regulatory framework pertaining to
health IT, incl. mobile medical applications, that promotes
innovation, protects patient safety and avoids regulatory
duplication 8
© 2012 Zetter HealthCare

9. Emerging Opportunities
 EHR Meaningful Use Stages 2 & 3
 Regional Extension Centers
 Health Information Exchanges
 ACOs
 Accountable Care
 Medical Home Models
 Patient-Centered Medical Home
 Communities of Health
 EHR-enabled Clinical Research
…..Navigating Payment & Delivery Reform
9
© 2012 Zetter HealthCare

10. State of ARRA & HITECH Act
 EHR Meaningful Use
• Over $27B available w/ no cap (protected in Medicare Trust
Fund)
• As of May – over 248,000 care providers registered for MU
• Over 102,000 care providers achieving incentive payments
• Over $5.76B in incentives paid to EPs & hospitals already
• Over $152M just to nurses & PAs under Medicaid
• Meaningful Use Stage 2 Overview Chart – http://bit.ly/z0MHUC
10
© 2012 Zetter HealthCare

11. State of ARRA & HITECH Act
 EHR Certification
• 6 ONC-ATCB certifying entities
 CCHIT remains industry gold standard
 Regional Extension Centers
 Operations underway at various levels of execution
 Find your local REC – http://bit/ly/zUb3O9
 Health Information Exchanges
 Operations underway at various levels of operation
11
© 2012 Zetter HealthCare

12. The Evolution
…essential building blocks for a sustainable healthcare system
12
© 2012 Zetter HealthCare

13. Accountable For What?
 Electronification / Health IT & EHR Utilization
 Interoperability
 Coordinating Care (with Care Team)
 Best Practices
 Quality Improvement / Outcomes Improvement
 Patient Education
 Patient Satisfaction
 Cost Containment
 Cost Reduction (to increase Shared Savings)
13
© 2012 Zetter HealthCare

14. Accountable Care Models
14
© 2012 Zetter HealthCare

15. Accountable Care Models
29 4
118
70
In the past 8 months, the numbers of ACOs
sponsored by physician groups has almost doubled.
15
© 2012 Zetter HealthCare

16. ACO Organization Types
 Single Provider ACO: Usually an integrated delivery
system that receives payment for a population and
takes on the responsibility of providing accountable
care
 Multiple-Provider ACO: Two or more entities have
partnered to provide accountable care for a population
 Insurer ACO: A regional or national insurer who
organizes providers so that the insurer bears the
burden of assuring accountable care
 Insurer-Provider ACO: The insurer and the provider are
equal partners in providing accountable care
16
© 2012 Zetter HealthCare

17. Accountable Care Models
17 13
43
148
The dominant model for ACOs is largely single provider groups,
however, there is an increasing interest to share the risk.
17
© 2012 Zetter HealthCare

18. Private Payer Initiatives
 Every major carrier has an ACO-type plan
 Aetna, Blue Cross Blue Shield, CIGNA, and Anthem/Wellpoint
 Various approaches utilized across the board
 Shared Savings, Shared-Risk, Partial Capitation
 Real world example – CIGNA
 22 programs in 13 states; 270,000 customer/patients
 Primary care focus, open to multi-specialty, IDNs, physician-
hospital organizations
 Must meet quality improvement and cost reduction criteria to
receive benefits
18
© 2012 Zetter HealthCare

19. Medicare ACO Initiatives
 Medicare Shared Savings Program (MSSP)
 Initial 27 Medicare ACOs announced in April
 Next round of Medicare ACOs slated for July
 Pioneer ACO Model
 32 chosen to improve patient care and save $1.1B over five
years
 Rapid movement from Shared Saving to population-based
payment model
 Offers heightened risk/reward with more flexible payment
methods
 Advance Payment ACO Models
 Initial 5 organizations named in April; more schedule to being
in July
 Upfront payments awarded to design care coordination
infrastructure
*All programs found at http://innovations.cms.gov 19
© 2012 Zetter HealthCare

20. Medicare ACO Initiatives
 Major goal: Reduce the inappropriate utilization of
high-cost emergency care by Medicaid recipients
 Many state Medicaid programs are forming ACO
Models
 Colorado’s Accountable Care Collaborative
 New Jersey Demonstration Project
 Varying structures influenced by
 Individual states’ experience with managed care
 Existing delivery arrangements
 Serving low-income and chronically ill populations
20
© 2012 Zetter HealthCare

21. Integrating the Patient
 Combining care processes with patient expectations
 Improves patient adherence, satisfaction & enrollment
 Care processes: Evidence-based team plan for:
 Surgical procedure, care transition, preventive care, cost
containment, low readmission
 Utilizing EHR, PHR, and case management software
 Example: EHR clinical extracts & HIE for specific reporting
requirements (home health, skilling nursing) CMS data
 Beacon Community Model – information systems supporting
care processes matched with performance goals exist
21
© 2012 Zetter HealthCare

22. Managing the Patient
 Patient Engagement, Empowerment & Management
Strategies
 Produce analytics on patient/ consumer population
 Sample Functionality
 Phone & “text” reminders
 eMail calendar invites
 Customized (automatic) patient education materials that
incorporate video and “smart” self-help tools
 Robust Patient “CRM” –type Strategies & Functionality
 Analytics comparing and contrasting outcomes & quality
reports
 eMail marketing tools & “smart” patient education materials
22
© 2012 Zetter HealthCare

23. Payment Reform Trends
 The transition from fee-for-service to risk-based
reimbursement is inevitable
 The most important clinical components of managing
risk-based payments are patient care coordination &
population care management – with robust use of data
aggregation, analytics & shared information
 Innovation will fuel health IT adoption and usability
 Payment reform will fuel health IT usability as well
• Pay for quality, not for “clicks”
23
© 2012 Zetter HealthCare

24. Payment Reform Trends
 Consumers will drive change as tools and incentives
become readily available
 Government will likely follow rather than lead the
transition to risk-based payments as we witnessed
 Macro variables like economic growth and the ability of
the federal government to borrow capital will greatly
impact the transition to risk-based payment, but to
varying degrees.
24
© 2012 Zetter HealthCare

25. Practice or Community Strategy
 Ensure 3-5 year Operating or Growth Plans
 If you are approached by a local Accountable Care Plan
or ACO…
 Financial incentives to join ACO?
 Strategic incentives to join ACO?
 Access to bi-directional data/ interoperability?
 Legacy vs. Innovation
 Standards-based interoperability
 What data requirements are they requesting?
 Binding?
 Non-binding?
25
© 2012 Zetter HealthCare

26. Accountable Care Positioning
 Assess EHR, interoperability & overall technology
infrastructure
 Assess beneficiary patient volume; patients can opt
in/out voluntarily
 Engage peers, associations, payers, employers & health
systems in your community
 Identify CMS, private payer or combined care
coordination/ACO opportunities
 ACOs, Accountable Care & “At-Risk” communities are
forming today around the country 26
© 2012 Zetter HealthCare

27. Accountable Best Practices
 Pinpoint patients for clinical teams at the point of care
 Engage & educate patients to hold them accountable
for outcomes
 Identify reporting requirements which will include a key
focus on patient satisfaction, screenings and
assessments
 Utilize Health IT to increase the velocity of coordination
in your community by placing a focus on the
importance of EHRs and meaningful use
 Develop care management resources to monitor
delivery and ensure that patients receive appropriate
follow-up care
27
© 2012 Zetter HealthCare

28. Additional Resources
Important Government & HHS Sites
CMS Innovation Center (http://www.innovations.cms.gov)
HHS Breach Notification Rule (http://tiny.cc/xytq5)
HHA Privacy Rule (www.hhs.gov/healthprivacy)
Agency ACO Sites
Medicare ACO Final Rule (http://tiny.cc/pem0cw)
CMS Educational events Page (http://tiny.cc/aszkn)
CMS ACO/Shared Savings Page (http://www.cms.gov/sharedsavingsprogram)
28
© 2012 Zetter HealthCare

29. For Follow-up & Further Questions
Contact:
David J. Zetter,
PHR, CHCC, CHCO, CPC, CPC-H, PCS, FCS, CHBC
717.691.7100
Email: djzetter@zetter.com
Subscribe to our newsletter at
Follow us on
www.twitter.com/djzetter
and
www.linkedin.com/in/djzetter
29
© 2012 Zetter HealthCare