Presentation by Dr. James Sublett Kentucky Society of Allergy, Asthma & Clinical Immunology Annual Meeting-September 2011

1. JCAAI: New News You Can UseKSAAI September 2011 James L. Sublett MD, FACAAI, FAAAAI President Joint Council of Allergy, Asthma, & Immunology

2. Disclosures None related to today’s topic

3. Objectives At the end of this discussion participants should be able to respond to recent regulatory changes that may affect the allergist’s practice to apply aspects of the Patient Protection and Affordable Care Act to the practice of Allergy & Immunology.

4. JCAAI Advocacy 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.

5. JCAAI Advocacy Process Continuum Identify an issue that may or has had a socioeconomic effect on “Allergy”. Does it fall within the mission of the JCAAI? Analyze the potential impact of the JCAAI acting upon the issue and determine whether it could make a difference. Obtain consensus from leadership of the ACAAI, AAAAI, & JCAAI Act on the issue

6. Who is the JCAAI? Staff Don Aaronson MD, JD, MPH – Exec. Dir. (Part-time) Gary Gross MD, MBA – Exec. VP (Part-time) Sue Grupe, Director of Operations Board Equal representation of both ACAAI & AAAAI President & President-Elect of AAAAI & ACAAI Executive VPs of both - non-voting members Appointed by AAAAI & ACAAI: 2 FIT/Young Physicians 2 Training Program Representatives

7. Current JCAAI Leadership? Jim Sublett MD (KY) – President (2 yr. term) Dick Honsinger MD (NM), Pres-Elect (2 yr. term) Steve Imbeau MD (SC) – Past-President J. Allen Meadows, MD (AL) - Secretary Stan Goldstein MD (NY), Treasurer

8. Who is the JCAAI? YOU!

9. Health Care Reform – Where are we?

10. Health Care Reform – Where are we? Issues of concern for allergists: Lack of a permanent, or even a multiple-year-fix for the SGR – Medicare’s physician fee schedule formula Alternative payment mechanisms (such as bundling, accountable care organizations, and medical home). 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; No funding for training of allergy and immunology fellows

11. SGR – Sustainable Growth Rate Under current SGR schedule Physician Reimbursement will decrease by 29.5% Jan 1 Likelihood of fix unclear Physician/House Republicans disagreement AMA supported/supports Obamacare House Republicans angry Net result possible – no SGR fox for 2012 Note only 15% of physicians belong to AMA

13. 2% in 2009 and 2010

14. 1% in 2011 and 2012

15. 0.5% in 2013

16. Use mandated starting 2011

17. Penalty for non-use

18. 1% in 2012

19. 1.5% in 2013

20. 2% in 2014 and beyond

22. ePrescribing (cont) Exemption Reasons Practice in rural area w/o high speed internet Practice area w/o sufficient available pharmacies Registered for EHR incentive Cannot prescribe electronically due to state regs (prescribing controlled substances) Infrequent prescriber - <10 Rx from Jan1-June 30 Insufficient opportunities to report (not Allergy)

23. ePrescribing (cont) Can receive incentive by Submitting G Code – G8553 (25 times in 2011) to Medicare on Claim form To CMS via QUALIFIED EHR To claim exemption must report G8644 at least once if you have no prescribing privileges or Report thru an as yet not established portal that you qualify for an exemption This incentive sunsets in 2014

24. ePrescribing for Groups Group practices that meet certain eligibility requirements can qualify for ePrescribing incentives Further details at www.cms.gov/ERXIncentive Pediatricians who have fewer than 100 medicare encounters per year will not be subject to the penalty

25. 5010 – ICD-10 5010 – HIPAA requires physicians to use certain mandated standards in electronic transmission of claims – 5010 will be required as of January 1, 2012 ICD-10 new diagnosis coding system – required by Oct 1, 2013

27. Could be part of new EHR or just the 5010 upgrade

28. Needed for ICD-10

29. Should already be in place (July 1, 2011) to give adequate time for testing and training your staff

30. IF you have not tested 5010 which is installed in your office – you must before Jan 1.

31. JCAAI will notify members when test dates announced

33. ICD-10 ICD-9 has 3-5 numeric characters – running out of numbers ICD-10 – all codes alpha-numeric – up to 7 characters Patient with Bronchial Asthma with asthma exacerbation: ICD-9: Code 493.92 asthma w/acute exacerbation ICD-10 J45.21–mild intermittent w/acute increase J45.41 – moderate, persistent with acute increase J45.51- severe persistent with acute increase

35. Depends on whether you purchase new EHR

36. Other costs:

37. Computer reprogramming, training coding staff and physicians

38. Loss of physician and coding staff productivity

40. Meaningful Use Registration is now open

41. Meaningful Use Eligibility Requirements for Professionals Medicare EHR Incentive Program Doctor of medicine or osteopathy Incentive payments ($27 Billion over 10 years) to drive adaptation 41% of physicians planning to become “meaningful users” 62 regional centers to provide assistance Participation began this year.

42. Must use certified EHR technology.

43. Validating Certification

44. Meaningful Use Eligibility Requirements for Professionals Incentive payments based on individual practitioners. If you are part of a practice, each eligible professional may qualify for an incentive payment if each eligible professional successfully demonstrates meaningful use of certified EHR technology. Each eligible professional is only eligible for one incentive payment per year, regardless of how many practices or locations at which he or she provide services. Hospital-based eligible professionals are not eligible for incentive payments

45. Meaningful Use Eligibility Requirements for Professionals Medicare EHR Incentive Program Eligible professionals can receive up to $44,000 over five years. Additional incentive for eligible professionals who provide services in a Health Professional Shortage Area (HSPA). To get the maximum incentive payment, Medicare eligible professionals must begin participation by 2012. For 2015 and later, those providers that do not successfully demonstrate meaningful use will have a payment adjustment in their Medicare reimbursement.

46. The Medicaid EHR Incentive Program Voluntarily offered by individual states and territories and may begin as early as 2011, depending on the state. Minimum 30% Medicaid patient volume (20% for pediatricians) Eligible professionals can receive up to $63,750 over the six years that they choose to participate in the program. There are no payment adjustments under the Medicaid EHR Incentive Program.

47. Meaningful UseCore 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 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 3 days of request Implement one clinical decision support rule and track compliance Report clinical quality measures to CMS Maintain active medication list for 80% 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

48. 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 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 refer Capability to submit electronic data to immunization registry Capability to submit electronic surveillance data to public agencies and actual submission if required

49. Laboratory Test Signature Requirement CMS had announced a policy to require physicians signatures on lab test orders for any test covered for Medicare patients effective 1/1/11 There was a good deal of protest CMS has retracted rule Rule should be formally retracted in September

50. Patients Access to Test Report Proposed New Rule Monday, September 12, 2011 Drafted jointly by CMS), HHS Office for Civil Rights (OCR), & CDC. Amendment to CLIA Would allow patients to access their test results directly from labs by request

51. Physician Compare Website Mandated by ACA – started December 2010 www.medicare.gov/find-a-doctor/provider-search.aspx To correct errors: qnetsupport@sdps.org or 866-288-8912 Many errors reported You should check your listing and correct if needed

52. 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

53. Physician Quality Reporting System Joint Task Force on Quality Performance Measures Co-Chairs: Michael Blaiss Michael Schatz MD CMS Public Forum February 9 Allergy represented by Richard Nicklas MD

54. Physician Quality Reporting System - 2011 Measures Measure #53: Asthma: Pharmacologic Therapy Percentage of patients aged 5 through 50 years with a diagnosis of mild, moderate, or severe persistent asthma who were prescribed either the preferred long-term control medication (inhaled corticosteroid) or an acceptable alternative treatment Measure #64: Asthma: Asthma Assessment Percentage of patients aged 5 through 50 years with a diagnosis of asthma who were evaluated during at least one office visit within 12 months for the frequency (numeric) of daytime and nocturnal asthma symptoms Measure #231: Asthma: Tobacco Use Screening - Ambulatory Care Setting Percentage of patients aged 5 through 50 years with a diagnosis of asthma who were queried about tobacco use and exposure to second hand smoke in their home environment at least once within 12 months Measure #232: Asthma: Tobacco Use Intervention - Ambulatory Care Setting Percentage of patients aged 5 through 50 years with a diagnosis of asthma who were identified as tobacco users (patients who currently use tobacco AND patients who do not currently use tobacco, but are exposed to second hand smoke in their home environment) who received tobacco cessation intervention within 12 months

55. Accountable Care Organization An ACO model establishes incentives for health systems to increase quality and efficiency, better coordinate patient care, eliminate waste, and reduce the overuse and misuse of care.

56. 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 Hospitals wary of ACO – will reduce admissions

58. Improve care coordination

59. Tie provider pay to quality and efficacy

60. Decrease regional variations

61. Dartmouth Atlas – 3 fold variation in per capita spending across US

62. Inverse relation between spend and quality

63. Develop range of innovative payment models and evaluate them for widespread implementation

64. ACA – demonstration projects begin Jan 1, 2012

67. Independent Payment Advisory Board (IPAB) Becomes effective 2015 15 member board –full time employees Will be composed of 15 members – physicians, health management experts, health economists, healthcare finance and consumer backgrounds Charge: Make spending recommendations to Congress if board determines long term spending growth will exceed targeted levels

68. IPAB (cont) If IPAB makes recommendations Congress can override but President can veto Congress override and then it takes 2/3 vote of each house to override If no Congressional Override that is sustained IPAB rules and IPAB recommendations become law

69. IPAB (cont) Legislation to repeal IPAB has been introduced 186 co-signers in House currently Probably no definitive action on the repeal will take place this year Expect this to be addressed in early 2013 and will be dependent on the election results JCAAI has sent letters to all Senators and Congressmen advocating repeal of IPAB

70. GME Various budget proposals have called for elimination of GME from Medicare Numerous groups oppose including all allergy organizations JCAAI drafted opposition letter for send out by strikeforce and others We have received good response to letter

71. Pediatric GME Obama budget proposed full elimination of Children’s Hospitals GME funding Allergy strongly opposed and we have sent letters to all senators and Congressmen in oposition HR 1852 and S.958 have been introduced to fund Pediatric GME Both bills pending

72. Recent JCAAI Initiatives USP 797/Allergy Extract Preparation Guidelines Physician work for skin testing codes MEI Rebasing/Revising of RVUs Expected impact for allergy/immunology +4% Business Associate Agreement Enable review & resolution for physician members of various state/regional claims issues Monitoring potential socio-economic impact of HCR on Allergy

73. Current JCAAI Initiatives Potentially Misvalued Codes Food Allergy Challenge Survey Comparative Effectiveness Research Remote Practice of Allergy RADAR initiative Lobbying Strike Force

74. Medicare Fee Schedule 2011

75. Direct Supervision of Vial Preparation Direct Supervision means a physician must be in the office anytime vials are prepared This applies to all vials – not only medicare paid vials Medicare Statute Medicare Regulations state that Medicare pays for antigens “furnished incident to a physician’s professional service” Incident to requires direct supervision

76. Requirements for Direct Supervision of Allergy Testing Medicare has rules for physician supervision of various in office procedures Allergy Skin testing – 2 Physician must be physically present in office suite and immediately available to furnish assistance Physician work for Allergy skin test codes requires “test interpretation and report by physician”

77. Comparative Effectiveness Research in Allergy December 2009: Discussion between Linda Cox & Jim Sublett on dissemination of study findings to MCOs March 2010: JCAAI Board meeting resulted in recommendation by JCAAI Board to ask ACAAI/AAAAI funding JCAAI/ACAAI/AAAAI boards approved funding for adult data to be reviewed and published. Nov 2010: Data presented at JCAAI Board meeting Dec 2010: JCAAI facilitating AHRQ funding requests March 2011: AAAAI abstract presentations and next steps with JCAAI board

78. Results: Median, Per-Patient, 18-Month Savings for Patients with Newly Diagnosed AR who Received versus Did Not Receive SIT 54

79. Payors Healthcare Delivery

80. The Data Opinion Research Corporation (ORC) asked a representative sample of 1,000 Americans What type of doctor or medical specialist treats allergies? 2007 Allergist 39% 1994 Allergist 36% What type of doctor or medical specialist treats asthma? 2007 Allergist 7% 1999 Allergist 13% * Results from an independent caravan survey (1994, 1999, and 2007)

81. The “Mr. Rogers Effect” The economics of allergy practice is local. Health care reform is local. Survival is local.

82. What is your neighborhood? Where do you practice? What is your catchment area? Have there been changes in your neighborhood’s: Economy? Population? Demographics? Health Care Delivery?

83. Neighborhood Economic Effects Factors we can’t directly control: Economic growth of community Unemployment Payors: Medicare, Medicaid, HCOs, Uninsured Demographics Competition

84. Neighborhood Economic Effects Factors we can directly control: Patient Experience – Is your practice patient focused? Facilities Location and number of facilities Facilities Cost Evaluate how space is utilized Evaluate facility appearance Payroll Hire for attitude Hire for success

85. What is patient-focused care? The care we want ourselves, or our families, to receive all of the time The care we want all of our patients to receive The care that would bring you, your family, and your patients back

86. Barriers to being patient focused As physicians, we …. Are prescriptive Like to be in control Have strong opinions Tend to be self-focused Can be dismissive

87. Barriers to being patient focused Office medical personnel are…. Busy Are required to multi-task Are conditioned to be protective of the physician Look at each patient as a potential disruption Good customer service is not intuitive, it requires training.

88. Who are your “customers”? Patients Potential Patients Current Patients Referring (and Non-Referring) Providers Pharmacists Hospitals Pharmaceutical Representatives Each other (within the office)

89. As allergists we…. Worry more about new referrals than taking care to keep great relationships with the current referral pattern. Forget the 80-20 rule. Value new patients more than established patients.

90. Customer Service

91. For great customer service ... Believe in it. Lead by example. Hire for attitude, train for technical skills. Be willing to put resources behind your plan…both personal time and money. Borrow from other examples of excellence: Southwest Airlines Starbucks Disney

93. Office

94. ProcessesOn-Stage/Back-Stage

95. Neighborhood Economic Effects Factors we can directly control: Marketing Direct-to-Consumer Costs not previously considered Take advantage of ACAAI Relief Team materials Referral Development PCPs Employers Alliances with Medical Homes, ACOs, other Allergists.

96. Neighborhood Effects Competition PCPs - see 60% of our potential patients How will the Medical Home effect referrals? Urgent Care Centers/ Emergency Departments – see about 18% of potential patients ENTs – see about the same number (16%) of allergy patients as allergists (18%) This is not new – ENTs historically have practiced allergy for over 60 years. The public (and many doctors) don’t know differences. Expanding their “allergy” scope of practice to include asthma, food allergy, and dermatology

97. Neighborhood Effects Competition Practice of Allergy – also not new. Pulmonology - See only about 10% of asthma Emphasis on sleep, critical care. Chiropractors, Naturopaths, etc. ther allergists We are not the enemy: work together to raise the awareness of the benefits seeing an allergists can bring.

99. Health Care Reform is Local “The recently passed health care legislation was much more about making changes in the systems we employ to pay for health services and less about reforms in how health care is delivered in the United States or how much health care costs us as a society.” Rick Ungar

100. Regional Advocacy Discussion andResponse (RADAR) Development of local, long-term liaisons with state allergy societies. Work with RSL/HOD to identify and train a designated liaison for each state/local society who could “be on the point” for local issues and serve as conduit to/from the JCAAI.

101. Remote Practice of Allergy Marketing of allergy testing & immunotherapy services to primary care physicians Avoid actions which might be considered restraint of trade. Healthcare Truth and Transparency Act of 2011 (HR451) – JCAAI supports Notify JCAAI of any known issues Will refer to office of the Inspector General (OIG) of Medicareif our legal counsel believes they cross the line

102. Remote Practice of Allergy Many different reports of varying kinds of remote practice Began with labs getting PCP’s to send blood samples for RAST and getting back allergenic extract for administration Allergy developed slide set for lectures to PCP’s and Allergy developed a paper on remote tests and their reliability – these are posted on JCAAI website

103. Remote Practice (cont) Companies setting up allergy testing and treatment labs in PCP offices We have noted this becoming more commonplace around the country There is nothing inherently illegal in this It may or may not represent what we consider the best practice It may or may not be consistent with the Practice Parameters

104. Remote Practice (cont) Best practice to deal with Remote Practice EDUCATION Describe complexities of allergy care Need for a trained physician to supervise and interpret skin tests (note CPT requires “test interpretation and report by Physician”) We believe that a physician must read the skin tests in order to comply with the above CPT descriptor language Trained physician shold make decision as to whether patient needs environmental controls, allergy immunotherapy, both or neither

105. Remote Practice (cont) EDUCATION (cont) Risks of misdiagnosis if no trained physician involved Potential increase in unnecessary costs Use of immunotherapy when environmental control is all that is needed Allergy standards for vial preparation are evidence based Failure to follow guidelines could result in extract which is too concentrated or too dilute Extract may not be prepared in accordance with Allergy guidelines

106. Remote Practice (cont) What should you not do DO NOT DISPARAGE – even if you disagree with the approach Take a positive approach as to what advantages trained allergists bring to the table Do not write letters to companies engaging in what you consider is remote practice Do not use you own stationery Do not use Allergy society stationery Do not engage in what could be called anticompetitive behavior – including recommending boycotts

107. Health Care Truth and Transparency Act Another tool to use in dealing with remote practice Introduced by Rep John Sullivan (R-Ok) – Bi-Partisan Support Prohibits health care professionals from making misleading statements or acting in a deceptive way Includes lying about education levels Also prohibits lying about healthcare license or board certification Bill pending in House

108. Health Care Truth and Transparency Act (cont) What can you do Write you Congressman and ask them to consider supporting and perhaps signing on as a co-sponsor to HR 451 Look for evidences of potential remote practice which you think crosses the line Notify JCAAI and we will evaluate and make recommendations for any action if any are indicated Any solicitations in writing would be most helpful

109. Lobbying Strike Force Each society will identify 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.

110. The Allergist’s Glass: half empty or half full? Allergy is a specialty best suited for Consumer Driven Healthcare: Our services potentially benefit 20 to 30% of the population People recognize they “may” have allergies The JCAAI has worked with CMS to include physician work in our key drivers: skin testing and allergen vaccines JCAAI remains proactive in developing outcomes data and comparative effectiveness studies.

111. Survival Tips for the Allergists Become more involved with your national organizations. Join the ACAAI “Relief Team”. Join the JCAAI & utilize the resources. Stay involved with local allergy societies – we speak stronger as a group. Do a practice check-up – remember “everything speaks” to your patients. Implement patient-focused service. Implement a marketing plan – utilize “Relief Team” materials from the College. Implement a referral development plan. Get to know your local hospital leadership, politicians, and MCO medical directors – become a resource to them. Be a good neighbor to all of the stakeholders who can influence the success of your practice.