Medical Home Payment: It's Not Just About Coding Anymore

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Medical Home Payment It's Not Just About Coding
Anymore

• C4K December Monthly Clinical Team Call/Webinar
• December 21, 2011
• Joel Bradley, MD, FAAP

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Contact Information

• Email- joel_bradley_at_uhc.com
• Phone- 615-493-9529

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(No Transcript)
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The Prevailing Winds

• The U.S. health care delivery system continues to
  be fragmented- but now acknowledged.
• Even when the individual health care services
  provided to a patient meet high standards of
  clinical quality, the coordination of care, which
  may be delivered by multiple providers in
  multiple settings, often is lacking.
• Inadequate communication among providers, and
  between providers and patients and their
  families, is also common.
• There is a vacuum of accountability for the total
  care of patients, the outcomes of their
  treatment, and the efficiency with which medical
  resources are used-but all vacuums get filled
• There will be no new dollars for health care-
  likely overall cuts- new funding opportunities
  will be from cost savings by changing our systems
  of care

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Filling Vacuums and Making Solutions-The PCMH

• A complete patient centered medical home program
  combines-
• 1. a quality service delivery model
• 2. A reimbursement model that recognizes the care
  improvements

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The Agenda-Creating Value in Your Practice

• The Triple Aim- Improving quality of care, the
  cost of care, and the general health of the
  population
• Creating Value
• Value Quality / Cost
• 3. Payment will follow Value

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Practice TransformationRequirements

• The Medical Home Makeover is transformation - an
  evolution to an improved model of delivering
  health care, and creating value for patients ,
  payers, and your practice
• Physician Leadership
• Subject Matter Knowledge
• Resources

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Creating Value- What Families Want

• A personal physician
• A place other than the emergency room to receive
  care (access)
• Convenience (access)
• A Navigator (Care Coordination)
• Lower costs of insurance and drugs

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Creating Value- What Employers Want

• A healthy workforce
• Easy employee access to care
• Controlled Cost of health insurance- stable
  premiums

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Creating Value- What Payers Want

• A Network of Providers who can partner to-
• Improve Quality- measured (HEDIS)
• Lower Cost inpatient, emergency, and pharmacy
  services
• Use Evidenced Based Medicine
• Create and maintain Access for their members
• Receive and Use data to improve care

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Accountable Care-Here We Go
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A Key Concept-Accountable Care

• An Accountable Care Organization (ACO) is defined
  as a group of physicians, other healthcare
  professionals, hospitals and other healthcare
  providers that accept a shared responsibility to
  deliver a broad set of medical services to a
  defined set of patients across the age spectrum
  and who are held accountable for the quality and
  cost of care provided through alignment of
  incentives.

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Medical Home Program- Core Attributes with Value

• Access- Improved Access to Care same day ,
  walk-in, afterhours, preventive care , proactive
  approach to a population of our patients within a
  practice
• A New Care Model Office based Care
  Coordination/Management- The Chronic Disease
  Model, active patient Care Plans, Personnel and
  Processes for Patient Care Management and Care
  Coordination
• Health Information Technology- (HIT)-Use of Data
  to Improve care- The providers act on patient
  care registries (data driven care opportunities)
• Evidenced Based Medicine- Adoption and Adhenrence
  to proven diagnosis and treatment guidelines

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National Payment Models Multimodal and
Evolving to Risk Model

• Enhanced Fee for Service
• Typically higher rates than non PCMH
• Payment policy (afterhours care, care plan
  oversight)
• Evolution to risk global payments /capitation
• Prospective Payments- funding infrastructure
• Care coordination
• EHR
• NCQA certification costs
• Evolution to risk based on outcomes
• Retrospective Payments- For Performance or Value
  (new)
• Utilization (cost)
• Quality Indicators
• Patient experience
• Evolution to risk based on a Gain Share

Prospective- Care Coordination /Infrastructure
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Improving the Fee Schedule for Key Medical Home
Services

• Non-Face-To-Face Services
• Care Plan Oversight
• Special Services Afterhours Care
• Team Services

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Care Plan Oversight- Why a Key Servicefor the
Medical Home?

• Allows reimbursement for managing chronic
  illness and behavior
• Pays for all non face to face time not billed
  with other nftf codes

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Care Plan Oversight

• Review of subsequent reports of patient status,
• Review of related laboratory and other studies,
• Communication (including telephone calls) for
  purposes of assessment or care decisions with
  health care professional(s), family member(s),
  surrogate decision maker(s) (eg, legal guardian)
  and/or key caregiver(s) involved in patient's
  care,

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Care Plan Oversight

• ?99339 Individual physician supervision of a
  patient (patient not present) in HOME,
  domiciliary or rest home (eg, assisted living
  facility) 15-29 minutes- Calendar Month
• ?99340 30 minutes or more

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The Key Servicesfor the Medical Home

• Expanded Access After Hours Codes

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After Hours Codes

• 99050- when the office is normally closed
• 99051 "during regularly scheduled evening,
  weekend, or holiday office hours, in addition to
  basic service.
• Expect to see increase in payer recognition of
  this add-on service in support of Medical Home
• Adds additional revenue for visits on weekends
  and evenings after 5pm

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The Key Servicesfor the Medical Home

• Team Care
• Non-Physician Services

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USEFUL Non Physician SERVICES

• NURSE VISITS 99211 (19.71 for one visit)
• HEALTH BEHAVIOR ASSESSMENT INTERVENTION CODES
  96150-96155 (21.07 per 15 min)
• MEDICAL NUTRITION SERVICES 97802-97804 (31.94
  per 15 min)
• PATIENT EDUCATION (new in 2006) 98960-1 (26.16
  per 30 min)
• CMS 2011 Fee Schedule for Medicare

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Prospective Payments

• Payment provided in advance of the work
• Typically directed for infrastructure support
• Care Coordinators/ Care Managers
• Implementation of EHR
• PCMH Certification (e.g. NCQA)
• Name varies- care coordination payment , clinical
  integration grant
• Basis varies- per member per month or pmpm-
  range of 1.50 upward- for all patients or for
  those with special needs
• May be a grant to begin your program and evolve
  over time to become performance based

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The NEW Pay For Performance- PAY FOR VALUE
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Review of P4P Programs- the Past

• Typical- payment at the end of a measurement
  period (in addition to the fee schedule) for
  meeting targets for selected HEDIS quality or
  efficiency measures
• ( By in large, most first generation P4P programs
  were not successful in making substantial gains
  in quality or in cost savings )

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Review of P4P Programs- the Past

• Examples- HEDIS Measure- Adolescent Well Visits
• Threshold is 60 of all your teen patients need
  to have received by one year
• Once threshold is met, a payment is triggered (no
  threshold, no payment) of 40 per patient who
  received the service

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Review of P4P Programs- the Past

• Examples- HEDIS Measure- Adolescent Well Visits-
  Target for payment is 60
• Your practice has 100 teen patients
• By December, 62 (62) had their preventive visit,
  for a payment of 62 x 40 2480.

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Review of P4P Programs- Physician Perspective

• What makes a good measure from your
  perspective?
• Can you Impact?
• Can you efficiently do the extra work needed to
  improve rates?
• How much incentive is needed to sign onto a
  program?
• Are there any incentives beside money?

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Evolution of P4P Programs- Payment for Value

• Payment at the end of a 12 month measurement
  period (in addition to the fee schedule) for
  meeting targets for quality- selected HEDIS
  measures
• plus
• Meeting threshold targets for Efficiency measures
  creates a cost savings pool (the gain) that can
  be shared

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Evolution of P4P Programs- the Present and near
future

• Example- 500 patients under one payer-
• Quality Scores
• 1. Adolescent well care- 100 of target
• 2. Asthma care controller medication- 90
• 3. ADHD Medication follow up- 65
• Composite score 85

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Evolution of P4P Programs- the Present and near
future

• Example- 500 patients under one payer-
• Your Efficiency Scores-
• -10 reduction in ER visits over the past 6
  month reporting period and
• - 20 reduction in admissions and
• - 10 reduction in Pharmacy cost through
  generic conversions
• Total savings 50,000

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Evolution of P4P Programs- the Present and near
future

• Your Gain Share payment for value is .
• Quality score X Savings
• 85 x 50,000 42,500
• Your group divides up the money by its own rules,
  or if part of an ACO, by ACO rules

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Payer Engagement-The First Meeting

• Survey your practice- pick the top 4 or 5 payers
• Create the Framework for the Value discussion
• Request a meeting to present your PCMH
  transformation plan
• Best payer contacts-
• (door openers)- your provider service rep, the
  medical directors, and the directors of care and
  disease management

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Resources- The First Meeting

• Present Your PCMH Program and Implementation Plan
• Request a partnership to improve care (4
  attributes)
• Your request from the payer-
• Data- utilization, quality, and patient risk
  profile
• A Second Meeting
• Then develop a population based plan for your
  members

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So.

• Develop the practice infrastructure which
  provides the best care for your patients AND take
  advantage of the payment opportunities ( PCMH )
• Engage your payers- new payment opportunities
  should follow over time
• You will have the option to play
• The chances of both you and your patients
  winning will be good

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ChangeIs Constant in Health Care

• It is not necessary to change Survival is not
  mandatory
• Edward Deming
• Speaking to a group of Detroit automaker
  executives 1970s-

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PCMH Resources

• 1. AAP National Center for Medical Home
  Implementation
• http//www.medicalhomeinfo.org/
• Mentors, Toolkit
• 2. Center for Medical Home Improvement
• http//www.medicalhomeimprovement.org/
• Medical Home Index, Role of Family
• 3. NCQA-
• http//www.ncqa.org/tabid/631/default.aspx
• Patient-Centered Medical Home (PCMH) 2011
  Recognition Program

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PCMH Resources

• 4.PCPCC- Patient Centered Medical Home
  Collaborative
• http//www.pcpcc.net/
• Subject Matter- How and Why It works
• Payment Rate Brief- 2010 a survey of pcmh
  reimbursement models
• Outcomes Report- 2010- a summary of quality and
  cost improvement made by exiting PCMH programs
• 5. Commonwealth Fund
• http//www.commonwealthfund.org/
• The national perspective on PCMH,ACO, and Health
  Care

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AAP Coding Resources

• AAP Coding Hotline (aapcodinghotline_at_aap.org) is
  a resource for practitioners to submit coding
  questions and receive a response from AAP coding
  specialists.

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AAP Core Coding Resources

• AAP Pediatric Coding Newsletterproven coding
  solutions you cant afford to miss!
• Month after month, AAP Pediatric Coding
  Newsletter helps you maximize payment, save
  time, and implement best business practices to
  support quality patient care. Included in this
  annual subscription product is print and online
  access to broad coverage of coding for pediatric
  primary care and subspecialty services.
• Coding for Pediatrics 2012new 17th edition of
  the number 1 pediatric coding and billing
  resource!
• For beginners and advanced coders alike,
  this is the first place to look for
  pediatric-specific, AAP-endorsed, peer-reviewed
  coding solutionsall new and updated Current
  Procedural Terminology (CPT) and International
  Classification of Diseases, Ninth Revision,
  Clinical Modification (ICD-9-CM) pediatric
  codespractical recommendations, tips, and
  techniquesand much more.
• 2012 Pediatric ICD-9-CM Coding Pocket
  Guideconvenient go-anywhere format!
• Streamline pediatric diagnosis coding with
  this newly revised reference. Here are the basic
  guidelines for selecting appropriate codes for
  commonly encountered pediatric diagnoses and
  diseases.

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Practice Management Online

• Practice Management Online (PMO)
  (http//practice.aap.org) supports pediatricians
  in running a practice that is fiscally sound and
  efficient and provides quality health care to
  children and families.

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• Upcoming Webinars
• ICD-10-CM Transition Its Not Just a MythIts
  Coming! (February 9, 2012)
• Newborn and Neonatal Coding Issues (April 19,
  2012)
• Evaluation and Management Documentation
  Guidelines and Pitfalls of Electronic Medical
  Records (June 7, 2012)
• Visit www.aap.org/webinars/coding for additional
  information or to register!