Sink or Swim - Creating Opportunities to Thrive in New Environment - Steve Owen

Sink or Swim:
Creating Opportunities to
Thrive in this New Environment
2nd Alabama Rural Health and TeleHealth Summit 2013

Steve Owen
Summit Leadership Strategies

© Copyright Summit Leadership Strategies | 2013 All Rights Reserved

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

Improving the patient’s
experience of care

Improving the health
of populations

• Quality, access,
reliability

Berwick D et al. Health Aff
(Millwood). 2008;27(3):759-769.
McCarthy D, Klein S.
http://www.common
wealthfund.org/~/media/Files
/Publications/Case%20Study/
2010/Jul/Triple%20Aim%20v2
/1421_McCarthy_triple_aim_
overview_v2.pdf.
Accessed April 21, 2011

• Healthy life
expectancy

Reducing the per capita
cost of health care
• Or at least controlling
or slowing cost growth


“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 valuereimbursement 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 Medicarecovered 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.

Proposed Additional Rural Tracts CY2014
 Alabama MSA County
















Number of RUCA (4 – 10 Classification)

Autauga
Bibb
Blount
Calhoun
Chilton
Etowah
Geneva
Greene
Hale
Henry
Lawrence
Limestone
St Clair
Walker


2
2
4
2
6
1
4
2
4
3
1
10
2
14

Box Elder County, Utah
49003

UT

Box Elder County

49003960100

10

49003

UT

Box Elder County

49003960200

7

49003

UT

Box Elder County

49003960300

7

49003

UT

Box Elder County

49003960400

10

49003

UT

Box Elder County

49003960500

4

49003

UT

Box Elder County

49003960600

4

49003

UT

Box Elder County

49003960701

4

49003

UT

Box Elder County

49003960702

4

49003

UT

Box Elder County

49003960801

4

49003

UT

Box Elder County

49003960802

4


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)


2014 Sink or Swim: Opportunity 4a
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).


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.



4b. Patient Centered Medical Homes (PCMH):

 The PCMH is a care delivery model designed to strengthen the patientprovider 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


 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




 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.


2014 Sink or Swim: Opportunity 4c
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 communitybased 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 4d

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 communityled 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.


 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.


4.

Seek partnership opportunities with emerging care models.
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.


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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