1. Reimbursement Challenges and Solutions for Cardiovascular Specialists: Building Collaborative Payer Relationships to Support Quality Care Kathleen Flood Director, Payer Advocacy October 14, 2007

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3. 3 The “Crisis” Environment  Affordability Crisis:  Unsustainable cost trends  Quality Crisis:  Variation in medical practice  Limited scope of the “evidence” in evidence-based medicine  Gaps in quality / failure to implement what works  Medical errors  Information Crisis:  Limited information on performance  Numerous unrelated initiatives to address the issue Source: Steven Uderhelyi, MD CMO, IBC

4. 4 Health Care Largest Single Benefit Cost for Employers All Private Employees-March 2006 Source: Bureau of Labor Statistics, "Employer Costs for Employee Compensation-March 2006, Table 5" Health insurance is the most expensive employee benefit!

5. 5 Source: PriceWaterhouseCoopers. 2006. Factors Fueling Rising Healthcare Costs 2006. Page 13. National Health Care Cost Drivers ComponentShare of Insurance Premium Spending Growth Rate Percentage Point Contribution to the 8.8% Increase in Health Insurance Premiums Physician24%7.8%1.9 Outpatient22%13.6%3.0 Hospital Inpatient18%7.5%1.3 Prescription Drugs16%8.6%1.4 Other Medical Services*6%7.3%0.4 Growth in Health Insurance Premiums by Components, 2004-2005 *Other medical services include durable medical equipment, nondurable medical equipment, home health, other health professionals, and other personal care.

6. 6 Imaging: One of the top 11 medical developments of the past 1000 years - NEJM

7. 7 How can ACC and chapters address the crisis?  Lead (v): to influence the positions of others  Innovate (v): to recommend a new way of doing things  Advocate (v): to recommend, to be in favor of; to speak on behalf of another

8. 8 ACC-Chapter Opportunities to Influence Payers Imaging  Appropriateness Criteria--Pilots Measurement  NCDR/Registries Performance Assessment  PAR-3 - Strategy  Performance Measures—Cost of Care Measurement---Outcomes Measurement  Transparency—Rules of the Road Dialogue  Build on Chapter Relationships  Medical Directors’ Institute  Payer Roundtables  Second Wednesday Audio-conferences---2008 Patient – Centered Approach  Internal Review for Patient-Centered Approach  Patient-Centered Medical Home Initiative

9. 9 Cardiovascular Imaging The Issue: Imaging growth is complex and not always “black and white.” Claims of inappropriate imaging are largely unsupported and clinical benefits are often ignored in the growth debate. Patient care and access are at stake!

10. 10 Alaska Texas Utah Montana California Arizona Idaho Nevada Oregon Iowa Colorado Kansas Wyoming New Mexico Missouri Minnesota Nebraska Oklahoma South Dakota Washington Arkansas North Dakota Louisiana Hawaii Illinois Ohio Florida Georgia Alabama Wisconsin Virginia Indiana Michigan Mississippi Kentucky Tennessee Pennsylvania North Carolina South Carolina West Virginia New Jersey Maine New York Vermont Maryland New Hampshire Connecticut Delaware Massachusetts Rhode Island Diagnostic Imaging Prior- Authorization Programs Almost 70% of the nation’s health plans utilize RBMs for diagnostic imaging approval. UHC, Aetna, CIGNA and Humana have national programs

11. 11 Cardiovascular Imaging Payer Efforts  Released model LCDs for, SPECT, CCT, and CCTA.  Cardiac MRI Model LCD-Due Fall 2007  Developed RBM Talking Points to deliver consistent message.  MDI brings together payers and physicians to address appropriate use of imaging.  Working with UnitedHealthcare to develop pilot program using Appropriateness Criteria for SPECT- MPI.  Addressing the next generation of RBMs, specialty specific.

12. 12 Chapter Case Studies in Addressing Payer Issues: Keys To Success  Physician-Patient Relationship  Communication  Engagement – Advisory Committees  Role of the Specialty – Expertise  Take Charge – Lead - Innovate

13. 13 Impact on Diagnostic Imaging Programs  Pennsylvania-Highmark and IBC  Adjusted Highmark’s comprehensive prior-authorization and privileging program to reflect CV concerns  Almost 2 year process, confirmed PaACC appointments on Imaging Committees  Worked with IBC to ensure prior-authorization process for CV specialists was acceptable

14. 14 Highmark Issues Shared EquipmentMust be owned or leased fulltime - Appeals Process MR Accreditation – ACRIntersocietial Commission on Accreditation Nuclear Training Radiology 6mos Recognized differences in rigor by specialty Imaging Advisory CommitteesPaACC offered several seats on various committees

15. 15 Impact on Diagnostic Imaging Programs  North Carolina – BCBS  Engaged plan prior to launch of prior-authorization program  Worked with chapter to support communication  Program started in February 2007  Chapter is planning to regroup with plan Fall 2007 to review data and develop a “gold-card” program

16. 16 Impact on Diagnostic Imaging Programs  New York-GHI and HIP (downstate)  Working with Chapter to address alternative approach for SPECT-MPI  Proposing NY-ACC members be reviewers of SPECT-MPI - provide feedback to primary care.  Exploring development an educational module for PCPs ordering SPECT  Review of HIP prior-authorization program

17. 17 Impact for Diagnostic Imaging Programs  Idaho - Blue Cross  Proactively restructured privileging program to ensure appropriate CV training and accreditation standards  ACC Governor member of Imaging Committee  Participate in CCTA Focus Group

18. 18 Success Factors  Chapter Engagement – Key with local/Blue plans  Chapter and ACC Collaboration  Dialogue – Meetings and/or Conference calls  Scientific information source for plan Medical Director  ACC commitment to quality

19. 19 Clinical Policy Development-Issue  Scrutiny of the evidence base  Resulting in limited coverage policies and reimbursement  Redefine medically necessary services  Limited understanding of the science

20. 20 Clinical Policy Development  ACC working to review all major health plans clinical policies that affect cardiovascular specialists  UHC, Aetna, CIGNA  BCBSA TEC  WellPoint, Wellmark, Regence  More than 20 policies in 2006

21. 21 Aetna-Color Flow Doppler Policy  October 2005 - Aetna released revised CFD policy with limited diagnoses as medically necessary to reimburse 93325  ACC/ASE respond – meetings throughout 2006 to explain value of technology and the context of the guideline  Incremental changes throughout process

22. 22 Aetna-Color Flow Doppler Policy  Summer 2007-Aetna reverses its decision on unspecified murmur (785.2) – becomes a covered diagnosis.  ACC/ASE continue to challenge CFD policy for more diagnoses

23. 23 Action Steps to Engage  Establish formal communication with health plan  Update Plans of new governors  Have members appointed to CV committees  Invite to MDI and MDI at Scientific Session  Host quarterly/bi-annual meetings  Review medical policies  Coordinate with ACC

24. 24 Is the process worth it?  Yes!  Not always fast but results in change  Be engaged with health plans to prevent onerous restrictions and changes  Opportunities for innovation and leading change – Improving the system and delivery of CV care

25. ACC’s Appropriateness Criteria: SPECT-MPI Cardiac CT Cardiac MRI Echo: TTE/TEE & Stress Coronary Revascularization: PCI/CABG

26. 26 What are Appropriateness Criteria?  Define “what to do”, “when to do”, and “how often to do” in the context of local care environments combined with patient and family preferences and values  Address misuse, overuse and underuse  Connected to guideline content  Imply a level of detail and complexity that extends beyond the current recommendations

27. Pilot Study: Evaluation of Appropriateness of SPECT MPI The American College of Cardiology The American Society of Nuclear Cardiology

28. 28 ACC Pilot: Evaluation of Appropriateness SPECT MPI  Develop a data collection mechanism to evaluate appropriateness  Create a process to implement awareness of appropriateness criteria in practice  Provide feedback reports to improve both practice- level and individual physician-level adherence to the criteria  Establish benchmarks to guide performance improvement

29. Tools for Achieving Quality in Imaging Patient Test selection Image acquisition Image interpretation Results communication Better patient care ACC-Duke Think Tank 2006 JACC 2006 48: 2141 Registries Research Appropriateness criteria Benchmarking Provider education Lab accreditation Technologist cert. Lab accreditation Physician training Physician competency Key data elements Uniform structured reports Timeliness standards

30. 30 Project Timeline Month  develop algorithms select/train participating sites implement paper form develop and provide training on the electronic data collection tool implement electronic data collection tool Evaluate project Provide benchmark feedback reports

31. 31 How is this Project Different from RBM?  RBM  No Imaging results available  Focus solely on individual tests  Pilot Study  Imaging results are available  Focus on practices and practice patterns  Creates a feedback network for improvement with education component

32. 32 Why Will MDs Use the AC Implementation Tool?  Advance the science and improving care  “Connect the dots” between imaging and outcomes  Quality improvement  Payer Incentives:  Waive preauthorization  Recognition programs

33. 33 \ Appropriateness Based on Physician Ordering

34. 34 Next Generation RBM Specialty Management  Will include ALL imaging modalities  ICD  Catheterization

35. 35 Medical Directors’ Institute 2007 Partnerships for Transformation: Systematic Assessment, Recognition, and Reporting -Identifying gaps in performance, assessment, recognition, and reporting and develop clear, collaborative recommendations for improvements that can be implemented in 2009. October 24-25, 2007 Phoenix, Arizona

36. 36 Blue Cross Blue Shield Settlement  How to get your share!  ACC Dues statement

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38. 38 ACC Payer Advocacy Kathy Flood Director kflood@acc.org Eileen Hagan, RN, APN Associate Director ehagan@acc.org P4P, Patient Centered Medical Home Mia Thomas, MBA Senior Specialist mrosenbe@acc.org Imaging, Coverage Henry McCantshmccants@acc.org Medicare Carrier, CAC, Coding, Coverage