1 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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Medical Home Medical Home Payment: It's Not Just Payment: It's Not Just

About Coding AnymoreAbout Coding Anymore

C4K December Monthly Clinical C4K December Monthly Clinical Team Call/Webinar Team Call/Webinar December 21, 2011December 21, 2011

Joel Bradley, MD, FAAPJoel Bradley, MD, FAAP

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Contact InformationContact Information

Email- [email protected]

Phone- 615-493-9529

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The Prevailing WindsThe 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 Filling Vacuums and Making Solutions-Making Solutions-

The PCMHThe PCMH

A complete patient centered A complete patient centered medical home program medical home program

combines-combines-

1. a quality service delivery 1. a quality service delivery model model

2. A reimbursement model 2. A reimbursement model that recognizes the care that recognizes the care improvementsimprovements

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The Agenda-Creating The Agenda-Creating ValueValue in Your Practice in Your Practice

1.1. The Triple Aim-The Triple Aim- Improving quality of Improving quality of care, the cost of care, care, the cost of care, and the general health and the general health of the populationof the population

2.2. Creating Value –Creating Value –

Value = Quality / Value = Quality / CostCost

3. 3. Payment will follow Payment will follow ValueValue

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PracticePractice TransformationTransformationRequirementsRequirements

The Medical Home Makeover is The Medical Home Makeover is transformation - an transformation - an evolutionevolution to an improved to an improved model of delivering health model of delivering health care, and creating value for care, and creating value for patients , payers, and your patients , payers, and your practicepractice

• Physician LeadershipPhysician Leadership• Subject Matter KnowledgeSubject Matter Knowledge• ResourcesResources

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Creating Value- What Creating Value- What Families WantFamilies Want

A personal physicianA personal physician

A place other than the A place other than the emergency room to emergency room to receive care (access)receive care (access)

Convenience (access)Convenience (access)

A Navigator (Care A Navigator (Care Coordination)Coordination)

Lower costs of insurance Lower costs of insurance and drugsand drugs

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Creating Value- What Creating Value- What Employers WantEmployers Want

A healthy workforceA healthy workforce

Easy employee access to Easy employee access to care care

Controlled Cost of health Controlled Cost of health insurance- stable insurance- stable premiumspremiums

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Creating Value- What Creating Value- What Payers WantPayers Want

A Network of Providers who A Network of Providers who can partner to-can partner to-

Improve Quality- measured (HEDIS)Lower Cost – inpatient, emergency, and pharmacy servicesUse Evidenced Based MedicineCreate and maintain Access for their membersReceive and Use data to improve care

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Accountable Care-Here We Go…… Accountable Care-Here We Go……

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A Key Concept-A Key Concept-Accountable Accountable CareCare

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 Medical Home Program- Core Attributes with Attributes with ValueValue

1. Access- Improved Access to Care – same day , walk-in, afterhours, preventive care , proactive approach to a population of our patients within a practice

2. 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

3. Health Information Technology- (HIT)-Use of Data to Improve care- The providers act on patient care registries (data driven care opportunities)

4. Evidenced Based Medicine- Adoption and Adhenrence to proven diagnosis and treatment guidelines

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National Payment Models – National Payment Models – Multimodal and Evolving to Risk Multimodal and Evolving to Risk

ModelModel• 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

Linkage of PCMH to ReimbursementOne Model

Fee Schedule for Visits/Procedures

Payment per Patient for Qualified Medical Homes

(services not normally reimbursed)

Pay for PerformanceQuality, Resource Use and Patient Experience

Linkage of PCMH to Reimbursement

Ongoing- Fee Schedule for Visits/Procedures)

Retrospective Pay for ValueQuality, Utilization, Patient Experience

Prospective- Care Coordination /Infrastructure

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Improving the Fee Schedule Improving the Fee Schedule for Key for Key

Medical Home ServicesMedical Home Services

Non-Face-To-Face Services

•Care Plan Oversight•Special Services –Afterhours

Care•Team Services

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Care Plan Oversight- Care Plan Oversight- Why a Key ServiceWhy a Key Service

for the Medical Home?for the Medical Home?

1. Allows reimbursement for managing chronic illness and behavior

2. Pays for all non face to face time not billed with other nftf codes

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Care Plan OversightCare 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 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 ServicesThe Key Servicesfor the Medical Homefor the Medical Home

Expanded Access: After Hours Codes

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After Hours CodesAfter 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 ServicesThe Key Servicesfor the Medical Homefor the Medical Home

Team CareNon-Physician Services

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USEFUL USEFUL Non PhysicianNon Physician SERVICESSERVICES

– 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 The “NEW” Pay For Performance-Performance-

PAY FOR VALUEPAY FOR VALUE

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Review of P4P Programs- the PastReview 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 PastReview 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 PastReview 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- Review of P4P Programs- Physician Physician PerspectivePerspective

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- Evolution of P4P Programs- Payment for ValuePayment 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

plusMeeting 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 Evolution of P4P Programs- the Present and near futurePresent and near future

Example- 500 patients under one payer- Quality Scores1. Adolescent well care- 100% of target2. Asthma care –controller medication-

90%3. ADHD Medication follow up- 65%Composite score= 85%

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Evolution of P4P Programs- the Evolution of P4P Programs- the Present and near futurePresent 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 Evolution of P4P Programs- the Present and near futurePresent and near future

Your Gain Share payment for value is ….

Quality score X Savings85% 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 Payer Engagement-The First MeetingFirst 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 Resources- The First MeetingMeeting

• 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……….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

patient’s winning will be good

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Change…Is Constant in Change…Is Constant in Health CareHealth 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 ResourcesPCMH Resources

1. AAP National Center for Medical Home 1. AAP National Center for Medical Home ImplementationImplementationhttp://www.medicalhomeinfo.org/http://www.medicalhomeinfo.org/Mentors, ToolkitMentors, Toolkit2. Center for Medical Home Improvement2. Center for Medical Home Improvementhttp://www.medicalhomeimprovement.org/http://www.medicalhomeimprovement.org/Medical Home Index, Role of FamilyMedical Home Index, Role of Family3. NCQA- 3. NCQA- http://www.ncqa.org/tabid/631/default.asphttp://www.ncqa.org/tabid/631/default.aspxxPatient-Centered Medical Home (PCMH) Patient-Centered Medical Home (PCMH) 2011 Recognition Program2011 Recognition Program

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PCMH ResourcesPCMH Resources

4.PCPCC- Patient Centered Medical Home 4.PCPCC- Patient Centered Medical Home CollaborativeCollaborativehttp://www.pcpcc.net/http://www.pcpcc.net/Subject Matter- How and Why It worksSubject Matter- How and Why It works

Payment Rate Brief- 2010 –a survey of pcmh reimbursement modelsOutcomes Report- 2010- a summary of quality and cost improvement made by exiting PCMH programs

5. Commonwealth Fund5. Commonwealth Fundhttp://www.commonwealthfund.org/http://www.commonwealthfund.org/The national perspective on PCMH,ACO, The national perspective on PCMH,ACO, and Health Careand Health Care

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AAP Coding ResourcesAAP Coding Resources

• AAP Coding Hotline ([email protected]) is a resource for practitioners to submit coding questions and receive a response from AAP coding specialists.

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AAP Core Coding AAP Core Coding ResourcesResources

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Upcoming Webinars

• ICD-10-CM Transition: It’s Not Just a Myth…It’s 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!