Payment Reform: An Innovative Approach to Advanced Physical Therapy Practice Elise Latawiec, PT, MPH Senior Specialist, Payment and Practice Management American Physical Therapy Association Lindsay Still, JD Specialist, Payment and Practice Management American Physical Therapy Association
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Payment Reform: An Innovative
Approach to Advanced Physical
Therapy Practice
Elise Latawiec, PT, MPH
Senior Specialist, Payment and Practice Management
American Physical Therapy Association
Lindsay Still, JD
Specialist, Payment and Practice Management
American Physical Therapy Association
Session Learning Objectives
After this session, you will be able to:
• Describe why the current procedural based reporting and payment system is an unsustainable model in the third party pay environment.
• Describe the various types of payment models being implemented by payers and the results they have generated to date.
• Utilize tools to help you navigate the changing payment landscape.
Payment Reform
The Big Picture Change Method of Payment
4
Health Care Reform: Triple Aim
Improved Access
Improved Quality
Accountability/ Cost
Containment
Value-Based Health Care Payment Systems
Source: Miller HD. Creating payment systems to accelerate value-driven health care: issues and options for policy reform. Commonwealth Fund pub no. 1062, September 2007; http://www.commonwealthfund.org
• Taking page out of Medicare’s playbook in setting fees and developing utilization strategies
• MPPR and Sequestration being applied - List of payers who have implemented MPPR on APTA’s Payment (www.apta.org/Payment) webpage under “Private Insurance.”
• Audit Activity – UM/UR
• Value based payment
• Network Adequacy
• Benchmark Plans
• Direct Access
• Data Collection and Metrics
• Telemedicine
8
Making the Case for Payment ReformRecommendations from “Phasing Out Fee for Service” (NEJM)
• Transition to Quality and Episodic methodologies should begin with “Blended” approaches
• Site Neutral Payments / Provider Neutral Payments
• Majority of 97000 CPT codes describing interventions collapsed
into per session code structure
• Select services remain as “separately reportable” (~14 services)
• Bundling of high volume procedure codes into one code with
Provider reporting a level (1-5) that their clinical work reflects
• Levels of intervention, reported based on complexity/severity of
patient and intensity of therapist work
PT, OT Evaluations 3 Initial, Development of POC 1 Re-Eval, est. POC
Level of Evaluation
Clinical
Considerations &
Complexity of the
Examination
Problem - Focused Expanded Comprehensive
Limited 1
Moderate 2
Significant 3
Established POC 4
Evolution of ModelCollapsing Levels of Interventions
Severity of Patient @ Visit / Intensity of Intervention
Low/Low Moderate/LowModerate/Moderate
High/Moderate High/High
1 2 3 4 5
• Patient’s presentation• Clinical decision-making• Selection of interventions / Risk to the patient
Current CPT PerspectivesReporting Under a Per Session Payment Methodology
Characteristics of Reporting Elements: Level 1
Severity
• Patient presentation: Stable and uncomplicated
• Personal/environment: No impact on management
• Function: Per assessment instrument, minimal restrictions
• Prognosis: certain, predictable
Intensity
• Straightforward clinical decision-making
• No to minimal adjustment to supervised management
• Minimal risk
23
Current CPT PerspectivesReporting Under a Per Session Payment Methodology
Characteristics of Reporting Elements: Level 3
Severity
• Pt. Presentation: Condition/complaints actively evolving, but predictable,
with impact from co-morbidities
• Personal/environment: Present some challenges to pt. management
• Function: Per assessment instrument, moderate restrictions
• Prognosis: predictable but with risk for delayed progress
Intensity
• Straightforward clinical decision-making
• Intermittent adjustment required based on patient response
• Elements of supervised and direct contact management
• With risk factors taken into consideration through plan
24
Current CPT PerspectivesReporting Under a Per Session Payment Methodology
Characteristics of Reporting Elements: Level 5
Severity
• Pt. Presentation: Condition/complaints actively evolving, in an
unpredictable manner, with unstable co-morbidities
• Personal/environment: negatively impact pt. management
• Function: Per assessment instrument, significant restrictions
• Prognosis: variable, requiring prioritization of objectives
Intensity
• Complex clinical decision-making
• Immediate response to management of response to treatment
• Continual adjustment of elements of treatment provided in direct contact
with patient
• Risk factors influencing development and management through plan of
care
25
Timeline to Implementation:
June-Sept. 2014
Pilot testing -
CPTGathering of data
Sept.-Dec.
Analysis of data
Report to APTA-AOTA
Nov.-Dec.
Interim report to APTA
Discussion of revisions to potential Proposed
revisions to model
Feb. 2015
Presentation to CPT editorial Panel
Upon approval, referred to Relative Value Committee
Jan. 2017
Potential implementation through Medicare Fee
Schedule
OverviewAlternative Payment Methodology
Significantly change the model of payment:
• Demonstrates use of clinical judgment
• Payment is influenced by patient characteristics, intensity of
clinical work with reporting of outcomes that help
demonstrate value
• Administratively burdensome policies lessened with focus
moving away from control of utilization and towards managing
patient progress towards functional change and outcomes
A “Value” MindsetNeed to Prove Value of PT
• Value-based health aims to improve quality, lower cost, and drive toward value in healthcare delivery
• The demand for value requires greater accountability on the part of all stakeholders within healthcare
• To deliver on value, the current “sick care model,” which focuses on disease management, must be replaced by a true “healthcare model,” which focuses on health management
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New Payment Model: Innovative Approach to Advance PT Practice
Profession will either drive change or…it will be driven by others!
Payment Trends
Network Adequacy
Provider Networks
• Consumers choose health coverage based on:
• COST of insurance
• CHOICE of provider
• Network Adequacy Standards established for Marketplace Plans
• Definition:
• “Network of providers sufficient in number and type to assure all services will be accessible without unreasonable delay.”
• States may have more stringent Network Adequacy standards
Insurer Perspective
• Provisions of the Affordable Care Act increased cost/risk:
– No medical exclusions
– No increased premium based on medical status
– Limited premium increase w/age
– Cover children to age 26
– Cover EHB
– No lifetime cap
Insurer Response
• Narrow/ ultra narrow networks
– Limit provider participation
– Selective contracting
– Drive volume to “value” providers
• Broad network = higher premium
– Premium 5 to 20% less in narrow network
• Limit out-of-network benefits
• Increase out-of-pocket costs
Who does this affect?
• Healthcare Exchange enrollees
–McKinsey report:
•Narrow network plans available to 92% customers
•Broad network plans available to 90% customers
• Medicare advantage
• Commercial
Possible Benefits of Narrow Networks
• Integration of services
• Coordination between payer/provider
• More available data
• Better adherence to protocols
• Reduced duplication/testing
• Reduced fragmentation
Issues• Adequate coverage?
• Patient Access?
• Availability of provider listings?
• Consumers informed?
• Premium vs out of pocket
• Affordability vs choice
• Bills for out of network services
• Numerous lawsuits
Regulatory Changes
• National Association of Insurance Commissioners (NAIC) developing model network adequacy regulations– Balance needs all stakeholders–General vs. quantitative standards– Likely to address provider directory timeliness/accuracy– Likely to address tiered networks
• Role of Health Human Services (HHS) uncertain• Federally Facilitated Marketplace regulation/guidance for 2015:
– FFM plans must submit list of certain in network providers: • Hospitals• Mental health• Oncology• Primary Care
Opportunities for the States
• States introducing new Network Adequacy regulation
• Network adequacy legislation/ guidance to address:
–Transparency: accurate and accessible consumer information on network status of providers
–Monitoring of network provider capacity
–Speedy exceptions mechanism for specialized needs
–Risk selection strategy based on limited coverage of some specialties
What APTA and Chapters are doing:
• Advocate on behalf of the profession
• Advocate on behalf of patients
• APTA monitors Federal regulations
• Chapters monitor state specific NA standards
• APTA/ chapters comment on proposed NA regulations
• Align with other stakeholders
• Keep members informed
Provider Tips
• Check to see if more stringent network adequacy standards apply in your state
• If your facility is seeing narrow networks, collect anecdotal evidence of patient access issues
– Document all reported access issues
– Ask consumers to report concerns to insurer, employer, Office of the Insurance Commissioner (OIC)
• Use outcome data, cost data, and niche services to leverage in-network contracts
–UM/ quality management for prospective and concurrent review included in medical
–Outsourcing allows payer to fix cost
–Reduces administrative/increases medical spend
–Reduces rebates
Insurer Goals
• Reduce cost
• Control utilization
• Address outliers
APTA Mission
• Do its due diligence in advocating on behalf of the profession to ensure physical therapists are able to treat patients based on their clinical judgment and decision making and full scope of licensure, not based on arbitrary policies and protocols.
Value-Based Utilization Management
APTA Response
• Develop viable alternatives
– Value based (value= outcomes/cost)
– Patient centered
– Meet the Triple Aim of the Affordable Care Act
• Lower cost, improve patient experience, improve population health
• Cost stability structure benefits all stakeholders
• Develop consistent message
• Collect data demonstrating ST/LT affect of PT on outcomes and total cost of care
What needs to change
• PT must assume identity of a VALUE to be leveraged in driving positive outcomes to meet the “triple aim”… not a COST to be contained by counting procedures
• Need data to demonstrate VALUE of PT services
• Need to facilitate Direct Access
• Must collaborate w/insurers
• Get PT out of the silo and into total episodic cost of care
• Proactively facilitate alternatives to UM
Current APTA Activities
• Developing UM strategy
• UM Tool Kit for chapters
• UM member resources
• Developing online UM data collection tool
• Integrity in Practice Campaign
• Registry
• CPG development/ The Guide to Practice
• Innovations 2.0 models of care delivery templates
• In dialogue / educating / developing relationships with payers and self insured companies on better models of care
Where to go from here
• Be the driver of change
• Be part of the solution
• Demonstrate measurable value
• Assume risk/ innovate
• Identify opportunities
• Consider needs all stakeholders
Grace Period
Grace Period
• Provision of the Affordable Care Act
• Grace period: 3-month period of nonpayment of premiums before discontinuing coverage
• Plans required to pay appropriate claims for services during first 30 days of the 3-month period
• Plans may pend claims for services during the last 60 days
– Unpaid premiums by subsidized beneficiaries could mean 60 days of uncompensated care
• APTA CMS comment letter for 2015 exchanges
• Making Sense of Health Reform Series: Grace Period: