1. AMDA Update October 2007 Charles Crecelius MD PhD FACP CMD

2. Trends in LTC Younger physicians in LTC Younger physicians in LTC Worsening shortage of geriatricians Worsening shortage of geriatricians Increase in Medicare beneficiaries Increase in Medicare beneficiaries Increasingly ill residents in NH Increasingly ill residents in NH Bowel & bladder incontinence Bowel & bladder incontinence Mechanically altered diet Mechanically altered diet Assistance with > 5 ADLs Assistance with > 5 ADLs Mental/Cognitive & Physical Impairments Mental/Cognitive & Physical Impairments Recent admits > 1 major dx Recent admits > 1 major dx ALOS declining, less beds per 1000 > 65 ALOS declining, less beds per 1000 > 65 2006 AMDA Survey Data 2007 Kaiser Foundation Report www.kff.org/medicaid/upload/7663.pdf. 2007 Managed Care Digest Series, Senior Care Digest, www.managedcaredigest.com AAMC Recent Studies and Reports on Physician Shortages in the US April 2006 www.MedPac.gov/documents/Jun07_Entirereport.pdf

3. Trends in LTC Increase in persons with multiple chronic diseases, but decline in disabled person Increase in persons with multiple chronic diseases, but decline in disabled person Increased education / sophistication beneficiaries Increased education / sophistication beneficiaries Healthcare costs outpace personal income, with increase in income disparity Healthcare costs outpace personal income, with increase in income disparity Increase in AL beds Increase in AL beds Nursing shortage Nursing shortage Increased use of physician expenders Increased use of physician expenders Quality measure / performance evaluation Quality measure / performance evaluation Increase interest in care coordination and comparative effectiveness analysis Increase interest in care coordination and comparative effectiveness analysis

4. AMDA Strategic Planning Four Areas of Concentration Organizational strength & stability Organizational strength & stability AMDA’s Roles AMDA’s Roles Membership & State Chapters Membership & State Chapters Improving Practice & Performance Improving Practice & Performance

5. Organizational Strength & Stability Leadership Development Leadership Development Accountability & Oversight Accountability & Oversight Continuity Continuity Board & Staff relations Board & Staff relations Financial Viability Financial Viability

6. Organizational Strength & Stability Examples Board of Directors & staff responsibilities clearly written & delineated in writing, with yearly evaluations Board of Directors & staff responsibilities clearly written & delineated in writing, with yearly evaluations President, president-elect & vice-president work together to ensure year to year continuity and project development President, president-elect & vice-president work together to ensure year to year continuity and project development Reserves being set aside for emergencies, appropriately invested Reserves being set aside for emergencies, appropriately invested Five year Executive director contract Five year Executive director contract

7. AMDA’s Roles Functioning in the Current Environment Functioning in the Current Environment AMDA’s current constituency AMDA’s current constituency Other Settings in the Continuum Other Settings in the Continuum Improving LTC Quality and Practice Improving LTC Quality and Practice Other organizations and associations Other organizations and associations

8. AMDA’s Roles - Examples NPP Role in LTC continuum NPP Role in LTC continuum Recent legislation (AHCA) Recent legislation (AHCA) Regulatory re-evaluation Regulatory re-evaluation Ideal practices (NP Ideal practices (NP Medical Home Model (ACP) Medical Home Model (ACP) Physician Quality Reporting Initiative (AGS) Physician Quality Reporting Initiative (AGS) Physician Consortium for Performance Improvement (AMA) Physician Consortium for Performance Improvement (AMA) Home care LCD (AAHCP) Home care LCD (AAHCP) F tags -Pain, EOL, Abuse & Neglect (CMS) F tags -Pain, EOL, Abuse & Neglect (CMS)

9. Membership & State Chapters Core membership Core membership State Chapters State Chapters Liability & Risk Issues Liability & Risk Issues Reimbursement Reimbursement

10. Membership & State Chapters Examples Interactive State Network News Interactive State Network News State Chapter Open Mike Call State Chapter Open Mike Call Mentoring Program Mentoring Program Toolkit, other members only website benefits Toolkit, other members only website benefits Weekly emails, Health Policy Advisor Weekly emails, Health Policy Advisor Professional Liability Insurance Professional Liability Insurance LTC Direct LTC Direct Improved Reimbursement Improved Reimbursement

11. Reimbursement & the RUC Relative Value Update Committee (RUC) Relative Value Update Committee (RUC) Determines how 78 billion dollars of physician payment are distributed to physicians and paraprofessionals via RVS process Determines how 78 billion dollars of physician payment are distributed to physicians and paraprofessionals via RVS process 26 RUC voting members, 114 advisory committee members (Dennis Stone MD MBA CMD AMDA Advisor; Dr Crecelius alternate representative) 26 RUC voting members, 114 advisory committee members (Dennis Stone MD MBA CMD AMDA Advisor; Dr Crecelius alternate representative) Resource Based Relative Value System (RVS) Resource Based Relative Value System (RVS) Determines the relative value of one CPT code to another based on survey data of resources used Determines the relative value of one CPT code to another based on survey data of resources used 3 components of RVS – Work, Practice expense, malpractice 3 components of RVS – Work, Practice expense, malpractice Nursing Home Codes re-evaluated for 2008 Nursing Home Codes re-evaluated for 2008

12. Work RVU & Sites of Service 2008 (2007) Comprehensive NF NFOffice RCF, House Call 1.61 (1.20) (99304) 1.34 (99203) 2.27 (99326, 99343) 2.3 (1.61) (99305 2.30 (99204) 3.04 (99327, 99344) 3.0 (2.01) (99306) 3.0 (2.01) (99306) 3.00 (99205) 3.79 (99328, 99345) RUC Data Annual 1.71 (1.20) (99318)

13. Work RVU & Sites of Service 2008 Subsequent Visits NF NFOffice RCF, Home Visit 0.76 (0.60) (99307) 0.45 (99212) 0.76 (99334, 99347) 1.16 (1.00) (99308) 0.92 (99213) 1.26 (99335, 99348) 1.55 (1.42 ) (99309) 1.42 (99214) 2.02 (99336, 99349) 2.35 (1.77) (99310) 2.0 (99215) 3.03 (99337, 99350) RUC Data

14. Improving Practice & Performance Medical Director and Attending Physician Education Medical Director and Attending Physician Education Other disciplines Other disciplines

15. Improving Practice & Performance Examples Improved website links to best practices, toolkit, & other educational sources Improved website links to best practices, toolkit, & other educational sources Exploring collaborative educational efforts with other organizations Exploring collaborative educational efforts with other organizations Considering certification in LTC medicine Considering certification in LTC medicine Promoting educational material / offerings of AMA Promoting educational material / offerings of AMA Healthcare information technology Healthcare information technology

16. AMDA Needs You !! We are a grass roots organization We are a grass roots organization Comments and concerns always welcome Comments and concerns always welcome Look at our website regularly for updates Look at our website regularly for updates