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2014 Reimbursement Update Impact on education and clinical practice for communication Sciences and Disorders- Part two Robert C. Fifer, Ph.D. Mailman Center.

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Presentation on theme: "2014 Reimbursement Update Impact on education and clinical practice for communication Sciences and Disorders- Part two Robert C. Fifer, Ph.D. Mailman Center."— Presentation transcript:

1 2014 Reimbursement Update Impact on education and clinical practice for communication Sciences and Disorders- Part two Robert C. Fifer, Ph.D. Mailman Center for Child Development, University of Miami

2 Disclosures Program evaluator for Duke University Medical School and University of Texas Medical Branch Program evaluator for Duke University Medical School and University of Texas Medical Branch Presenter at New Mexico Speech and Hearing Association, North Carolina Academy of Hearing Rehabilitation Presenter at New Mexico Speech and Hearing Association, North Carolina Academy of Hearing Rehabilitation Member Genetics and Newborn Screening Advisory Council, Florida Department of Health Member Genetics and Newborn Screening Advisory Council, Florida Department of Health Consultant to Children’s Medical Services Audiology Review Committee Consultant to Children’s Medical Services Audiology Review Committee Member ASHA’s Health Care Economics Committee Member ASHA’s Health Care Economics Committee

3 Documentation Requirements 1997 Documentation Guide for E/M Coding History (Soap): History (Soap): – Medical necessity for why the patient is there “Referred by” is not medical necessity “Referred by” is not medical necessity Requires a history covering the following areas as appropriate Requires a history covering the following areas as appropriate – Chief Complaint – Duration of symptoms – Family history – Social / occupational history – Prior medical history – Relevant diagnoses – This section justifies all that is done

4 Documentation Requirements Actions and results (sOap) Actions and results (sOap) Describing what was done Describing what was done The test forms cannot stand on their own The test forms cannot stand on their own Most professionals don’t know what it is or what the raw results mean Most professionals don’t know what it is or what the raw results mean Description of procedures and observations Description of procedures and observations Procedure description can be “canned” Procedure description can be “canned” Description of what was found (results) Description of what was found (results)

5 Documentation Requirements – Clinical Assessment (soAp) Must have a clear statement of practical and clinical significance Must have a clear statement of practical and clinical significance Must flow logically from the history and the findings Must flow logically from the history and the findings – Recommendations (soaP) Logical conclusion to the matter. Logical conclusion to the matter. Based on these outcomes, the following recommendations are offered:………… Based on these outcomes, the following recommendations are offered:………… Each recommendation must be supported by history, findings, and interpretation Each recommendation must be supported by history, findings, and interpretation Do not list unsupported recommendation Do not list unsupported recommendation

6 Additional Notes on Recommendations Medical Necessity Medical Necessity All recommendations must be supported by the concept of “medical necessity” All recommendations must be supported by the concept of “medical necessity” Recommendation should not be offered that is for the convenience of health care provider or patient Recommendation should not be offered that is for the convenience of health care provider or patient Transfer to plan of care Transfer to plan of care Use of report Use of report Separate document (Recommended) Separate document (Recommended)

7 Other Requirements Signature Signature – If a paper report, must be an original signature – Facsimile or stamped signature is not appropriate – If electronic medical record (EMR), your login constitutes your signature Date Date – Date of service must be specified and prominent in report – Other dates may include date of review, date of “signing”, date of dictation. These must be distinguished from date of service.

8 Impact of ICD-10 on Documentation ICD-10 allows greater specificity in diagnosis coding and will be even more so if functional scales are added ICD-10 allows greater specificity in diagnosis coding and will be even more so if functional scales are added Description of patient status in report will need to be more detailed in order to complement and justify the specific ICD-10 code selected Description of patient status in report will need to be more detailed in order to complement and justify the specific ICD-10 code selected Will affect descriptions of what was found and clinical assessment statement. Will affect descriptions of what was found and clinical assessment statement. BE CLEAR IN WHAT YOU WRITE! BE CLEAR IN WHAT YOU WRITE!

9 Say What You Mean – Clearly! I saw your patient today, who is still under our car for physical therapy The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week." Patient has chest pain if she lies on her left side for over a year. Discharge status: Alive but without permission. Patient needs disposition; therefore we will get Dr. Blank to dispose of him 9

10 Say What You Mean – Clearly! The patient was to have a bowel resection. However, he took a job as stockbroker instead. The patient was to have a bowel resection. However, he took a job as stockbroker instead. The patient is tearful and crying constantly. She also appears to be depressed. The patient is tearful and crying constantly. She also appears to be depressed. The patient refused an autopsy. The patient refused an autopsy. The respiration tube was disconnected and the patient quickly expired. The respiration tube was disconnected and the patient quickly expired. 10

11 Personal Observations Consists of audiogram with some notes Consists of audiogram with some notes Ex: Referred by Dr. Razzelfratz for hearing test. Ex: Referred by Dr. Razzelfratz for hearing test. Recommend hearing aids Recommend hearing aids Fails to meet federal guidelines for minimum documentation standards for covered services Fails to meet federal guidelines for minimum documentation standards for covered services Therapy notes incomplete or has sign-in sheets only Therapy notes incomplete or has sign-in sheets only

12 Diagnosis Coding October 1, 2014 October 1, 2014 To International Classification of Diseases, 9th Revision, Clinical Modification ICD-10-CM To International Classification of Diseases, 9th Revision, Clinical Modification ICD-10-CM ICD-9-CM: Approximately 18,000 codes ICD-9-CM: Approximately 18,000 codes ICD-10-CM: Approximately 64,000 codes ICD-10-CM: Approximately 64,000 codes Provides more flexibility for adding new codes Provides more flexibility for adding new codes 12

13 Clinical Billing Coding “Normal” Diagnosis Medicare guidelines on code selection Medicare guidelines on code selection Not allowed to be “normal” within the ICD-9 or ICD-10 coding system Not allowed to be “normal” within the ICD-9 or ICD-10 coding system Code signs / symptoms that caused you to do the test Code signs / symptoms that caused you to do the test Some recommend use of a V code for test encounter following (for example “Examination following a failed screening” Some recommend use of a V code for test encounter following (for example “Examination following a failed screening”

14 ICD-10-CM H90 Conductive and Sensorineural Hearing Loss H90 Conductive and Sensorineural Hearing Loss Includes: Includes: Congenital deafness Congenital deafness Excludes: Excludes: Deaf mutism NEC (H91.3) Deaf mutism NEC (H91.3)H91.3 Deafness NOS (H91.9) Deafness NOS (H91.9)H91.9 Hearing loss NOS (H91.9) Hearing loss NOS (H91.9)H91.9 Noise-induced (H83.3) Noise-induced (H83.3)H83.3 Ototoxic (H91.0) Ototoxic (H91.0)H91.0 Sudden (idiopathic) (H91.2) Sudden (idiopathic) (H91.2)H

15 ICD-10-CM H90.0 Conductive hearing loss, bilateral H90.0 Conductive hearing loss, bilateral H90.1 Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side H90.1 Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side H90.2 Conductive hearing loss, unspecified H90.2 Conductive hearing loss, unspecified Conductive deafness NOS Conductive deafness NOS H90.3 Sensorineural hearing loss, bilateral H90.3 Sensorineural hearing loss, bilateral H90.4 Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side H90.4 Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side 15

16 ICD-10-CM H90.5 Sensorineural hearing loss, unspecified H90.5 Sensorineural hearing loss, unspecified Congenital deafness NOS Congenital deafness NOS Hearing loss: Hearing loss: central } NOS central } NOS neural } NOS neural } NOS perceptive } NOS perceptive } NOS sensory } NOS sensory } NOS Sensorineural deafness NOS Sensorineural deafness NOS 16

17 Emphasis on Outcomes Congress is eager to do away with the therapy caps and the exceptions process and go to a simpler system. Congress is eager to do away with the therapy caps and the exceptions process and go to a simpler system. Now requires CMS to collect functional status and outcomes measurements Now requires CMS to collect functional status and outcomes measurements Seven-level functional outcome system to be phased in this year for therapy services Seven-level functional outcome system to be phased in this year for therapy services Similar to NOMS in structure Similar to NOMS in structure 17

18 Changing Landscape International Classification of Functioning, Disability and Health (ICF) International Classification of Functioning, Disability and Health (ICF) Describes body functions, body structures, activities, and participation Describes body functions, body structures, activities, and participation Useful for understanding and measuring outcomes Useful for understanding and measuring outcomes ASHA has information available online ASHA has information available online 18

19 ICF Levels 19 0 No impairment means the person has no problem 1 Mild impairment means a problem is present less than 25% of the time, with an intensity a person can tolerate, and happened rarely over the last 30 days. 2 Moderate impairment means a problem is present less than 50% of the time, with an intensity that is interfering in the person’s day-to-day life, and happened occasionally over the last 30 days. 3 Severe impairment means a problem is present more than 50% of the time, with an intensity that is partially disrupting the person’s day-to-day life, and happened frequently over the last 30 days.

20 4 Complete impairment means a problem is present more than 95% of the time, with an intensity that is totally disrupting the person’s day-to-day life, and happened every day over the last 30 days. 8 Not specified means there is insufficient information to specify the severity of the impairment. ICF Levels 20

21 Documentation and Audits Greatest problem in audits Greatest problem in audits Often inadequate and over-simplified Often inadequate and over-simplified Often not clear Often not clear Mismatch between CPT and diagnosis codes unsupported by documentation Mismatch between CPT and diagnosis codes unsupported by documentation 21

22 Audits To protect the Medicare Trust Fund To protect the Medicare Trust Fund Medicare QIO (Quality Improvement Organization) Medicare QIO (Quality Improvement Organization) CERT (Comprehensive Error Rate Test) CERT (Comprehensive Error Rate Test) RAC (Recovery Audit Contractor) RAC (Recovery Audit Contractor) ZPIC (Zone Program Integrity Contractor) ZPIC (Zone Program Integrity Contractor) MAC (Medicare Administrative Contractor) MAC (Medicare Administrative Contractor) PSC (Program Safeguard Contractor) PSC (Program Safeguard Contractor) OIG (Office of Inspector General Audits) OIG (Office of Inspector General Audits)

23 Audits To protect Medicaid funds To protect Medicaid funds MIP (Medicaid Integrity Program) MIP (Medicaid Integrity Program) MFCU (Medicaid Fraud Control Unit) MFCU (Medicaid Fraud Control Unit) RAC (Recover Audit Contractor) RAC (Recover Audit Contractor) IMRO (Independent Medical Review Organization IMRO (Independent Medical Review Organization

24 “In Your Presence” Audits QIO: Improve effectiveness, efficiency, economy, and quality of services provided to Medicare patients QIO: Improve effectiveness, efficiency, economy, and quality of services provided to Medicare patients MAC Audits: Sampling of patient records to ensure quality of service delivery and completeness MAC Audits: Sampling of patient records to ensure quality of service delivery and completeness MIC reviews: Looking for overpayments and billing errors MIC reviews: Looking for overpayments and billing errors MIC Audits: Looking for fraud often with local law enforcement (can also be behind the scenes) MIC Audits: Looking for fraud often with local law enforcement (can also be behind the scenes)

25 “Behind the Scenes” Audits ZPIC oversees the RACs and approves their CPT code selection for data-mined audits ZPIC oversees the RACs and approves their CPT code selection for data-mined audits RAC searches the Medicare and Medicaid data bases for inappropriate billing patterns that violate principles of code reporting RAC searches the Medicare and Medicaid data bases for inappropriate billing patterns that violate principles of code reporting PSC obtains information from RACs regarding possible fraud and abuse PSC obtains information from RACs regarding possible fraud and abuse

26 Recovery Achievements RAC Pilot Project RAC Pilot Project 3 year demonstration 3 year demonstration 6 states 6 states $1.3 billion recovered in overpayments $1.3 billion recovered in overpayments Overpayments Overpayments Medicare: $49.9 billion in 2013 Medicare: $49.9 billion in 2013 Medicaid: $14.4 billion in 2013 Medicaid: $14.4 billion in 2013 Point of comparison Point of comparison Deficit reduction bill by Rep. Ryan cut $20 from budget Deficit reduction bill by Rep. Ryan cut $20 from budget

27 Attributes of Overpayments Administrative and documentation errors Administrative and documentation errors Medically unnecessary services Medically unnecessary services Diagnosis coding errors Diagnosis coding errors Inappropriate procedure code reporting Inappropriate procedure code reporting

28 Prevention of Bad Outcomes KNOW THE RULES!!!!! KNOW THE RULES!!!!! Correct coding Correct coding Types of codes Types of codes Don’t go “code fishing” Don’t go “code fishing” Be truthful in code selection Be truthful in code selection Documentation Documentation “If it wasn’t documented, it never happened” “If it wasn’t documented, it never happened” The audiogram cannot stand alone, not even with notes The audiogram cannot stand alone, not even with notes Six elements of documentation – EVERY TIME Six elements of documentation – EVERY TIME Medical necessity – justify ALL procedures Medical necessity – justify ALL procedures

29 Clinical Billing Code Selection With rare exception, do not go outside of our family of codes for SLP and Aud services With rare exception, do not go outside of our family of codes for SLP and Aud services Do not code shop for what sounds good without understanding the procedure represented by that code Do not code shop for what sounds good without understanding the procedure represented by that code If a procedure does not have a code, use the unspecified/unlisted code If a procedure does not have a code, use the unspecified/unlisted code Know the difference between a unit code, contact code, and timed code Know the difference between a unit code, contact code, and timed code

30 Clinical Billing Code Type Contact code Contact code Untimed code reported once per date of service Untimed code reported once per date of service Will have no unit or timed designation in the descriptor Will have no unit or timed designation in the descriptor Unit code Unit code Report the code up to a maximum number of times per date of service Report the code up to a maximum number of times per date of service Designated by maximum number of units in descriptor Designated by maximum number of units in descriptor Timed code Timed code Designated in descriptor by “1 st hour” or “each successive 15 minutes” Designated in descriptor by “1 st hour” or “each successive 15 minutes”

31 Clinical Billing Timed Codes Usually the report preparation is included in the intra-service time. It will be designated “with report” if that is true Usually the report preparation is included in the intra-service time. It will be designated “with report” if that is true Be conservative when reporting the portion of time devoted to report writing Be conservative when reporting the portion of time devoted to report writing Document in progress notes the start time and stop time for the face to face contact Document in progress notes the start time and stop time for the face to face contact

32 Clinical Billing Supervision Medicare requires 100%, in the room supervision Medicare requires 100%, in the room supervision Medicare pays for the licensed professional’s time and not the student’s effort Medicare pays for the licensed professional’s time and not the student’s effort Decision-making must be by the professional Decision-making must be by the professional Cannot be involved with care of a second patient Cannot be involved with care of a second patient Medicaid Medicaid Supervision may vary from state to state Supervision may vary from state to state Typically professional contact with family and student to ensure appropriate procedures, outcomes, and decision-making Typically professional contact with family and student to ensure appropriate procedures, outcomes, and decision-making Depending on the student, may not require 100% supervision Depending on the student, may not require 100% supervision

33 The Question of Whether to See Medicare Patients Depends on supervision level and medical necessity Depends on supervision level and medical necessity Practice patients / clients Practice patients / clients If supervision CAN be met and the decision is to see Medicare patients, then must use an ABN if medical necessity is not met (more on ABNs momentarily) If supervision CAN be met and the decision is to see Medicare patients, then must use an ABN if medical necessity is not met (more on ABNs momentarily) If decision is to NOT see Medicare patients, then a sign must be posted informing all patients / clients that Medicare is not accepted because level of student supervision cannot be done in accordance with Medicare regulations If decision is to NOT see Medicare patients, then a sign must be posted informing all patients / clients that Medicare is not accepted because level of student supervision cannot be done in accordance with Medicare regulations

34 Per Capita Spending for Health Care; Source: Kaiser Family Foundation years of per capita spending by country

35 Health Care Costs for American Families Source: Milliman Medical Index 35

36 Health Care Costs for American Families Source: Milliman Medical Index

37 Miami most expensive at $24, Miami most expensive at $24, Phoenix least expensive at $18, Phoenix least expensive at $18, Primary utilization factors influencing out of pocket and overall expenses: Primary utilization factors influencing out of pocket and overall expenses: Inpatient facility care Inpatient facility care Outpatient facility care Outpatient facility care Professional services Professional services Pharmacy Pharmacy Other Other

38 Health Care Economics Cost inflation Cost inflation Risen 78% since 2000 vs. 20% for salaries Risen 78% since 2000 vs. 20% for salaries Average 9% per year with range of 7%-13% Average 9% per year with range of 7%-13% Defensive medicine (malpractice) Defensive medicine (malpractice) Unnecessary procedure/treatment (fee for service) Unnecessary procedure/treatment (fee for service) Ineffective treatment Ineffective treatment Inefficient service delivery models Inefficient service delivery models Pharmaceuticals Pharmaceuticals End of life care End of life care

39

40 Factors Affecting Reimbursement Sustainable Growth Rate (SGR) Sustainable Growth Rate (SGR) PQRS PQRS New models of reimbursement New models of reimbursement Procedure reviews Procedure reviews New Challenges New Challenges

41 Sustainable Growth Rate Part of the 1997 Balanced Budget Amendment to keep Medicare budget neutral Part of the 1997 Balanced Budget Amendment to keep Medicare budget neutral Includes several factors to calculate the reimbursement of Medicare services Includes several factors to calculate the reimbursement of Medicare services Independent from RVU assignments from AMA Independent from RVU assignments from AMA Annual budget allocation from Congress Annual budget allocation from Congress

42 Sustainable Growth Rate Intended to control the growth of Medicare costs Intended to control the growth of Medicare costs Payments for services not withheld if SGR targets are exceeded Payments for services not withheld if SGR targets are exceeded If target expenditures exceed budget, the next year’s update is reduced If target expenditures exceed budget, the next year’s update is reduced If target expenditures are below budget, the next year’s update is increased If target expenditures are below budget, the next year’s update is increased

43 Sustainable Growth Rate: How does it work? The estimated percentage change in fees for physicians’ services. The estimated percentage change in the average number of Medicare fee-for-service beneficiaries. The estimated 10-year average annual percentage change in real gross domestic product (GDP) per capita. (from 2008 forward) The estimated percentage change in expenditures due to changes in law or regulations.

44 Year% decrease Year% decrease Year% decrease SGR Adjustments:

45 The “Doc Fix”: Introduced February 2014 Immediate repeal of SGR Immediate repeal of SGR Transition period with 0.5% increase annually for 5 years Transition period with 0.5% increase annually for 5 years Merit Based Incentive Program Merit Based Incentive Program PQRS PQRS Value Based Modifier Value Based Modifier Meaningful Use for Electronic Medical Records Meaningful Use for Electronic Medical Records 5% added incentive payment to physician payment under new Alternative Payment Models 5% added incentive payment to physician payment under new Alternative Payment Models Increased funding for technical assistance to small physician practices (<15 physicians) Increased funding for technical assistance to small physician practices (<15 physicians) Creation of a technical advisory panel to review and recommend Alternative Payment Models Creation of a technical advisory panel to review and recommend Alternative Payment Models

46 Noteworthy Features of “The Fix” Consolidates quality programs (e.g., PQRS, Value Based Modifier, Meaningful Use) into one. Consolidates quality programs (e.g., PQRS, Value Based Modifier, Meaningful Use) into one. Payments based on achieving performance thresholds Payments based on achieving performance thresholds Introduces the concept of alternative payment models Introduces the concept of alternative payment models Incentivizes care coordination and shared responsibility of patient care Incentivizes care coordination and shared responsibility of patient care Requires ongoing development of quality measures to evaluate performance Requires ongoing development of quality measures to evaluate performance

47 Other Noteworthy Features of “The Fix” Increases transparency of metrics and quality Increases transparency of metrics and quality Physician Compare website Physician Compare website Posts quality and utilization data for patients to make informed decisions about their care Posts quality and utilization data for patients to make informed decisions about their care Allows qualified clinical data registries to purchase claims data for purposes of quality improvement and patient safety

48 Latest News on Doc Fix 3/31/14 Congress passed a bill to delay to freeze the current situation for one year. Congress passed a bill to delay to freeze the current situation for one year. Suspend 24% reduction in payments Suspend 24% reduction in payments Extend the therapy caps exceptions until March 2015 Extend the therapy caps exceptions until March 2015 Delay implementation of ICD-10 for one year Delay implementation of ICD-10 for one year

49 Other Factors Affecting Reimbursement CMS Screens of billed codes looking for CMS Screens of billed codes looking for Codes frequently reported together Codes frequently reported together Codes that have never been surveyed by the RUC or HCPAC Codes that have never been surveyed by the RUC or HCPAC Codes believed to be overvalued based on utilization increases Codes believed to be overvalued based on utilization increases AMA Responses to CMS AMA Responses to CMS Overseeing survey process Overseeing survey process Facilitating potential methods of payment revision Facilitating potential methods of payment revision

50 Physician Quality Reporting Initiative (PQRS) One of three performance based reimbursement factors affecting physicians – the primary performance based factor for audiologists at present One of three performance based reimbursement factors affecting physicians – the primary performance based factor for audiologists at present Began as an enticement to physicians to abide quality of care standards Began as an enticement to physicians to abide quality of care standards Participation is now a requirement to maintain full Medicare reimbursement Participation is now a requirement to maintain full Medicare reimbursement Each health care discipline / specialty will develop performance standards Each health care discipline / specialty will develop performance standards

51 PQRS Quality measures as evaluated by National Quality Alliance, Physician Consortium for Performance Improvement, and CMS Quality measures as evaluated by National Quality Alliance, Physician Consortium for Performance Improvement, and CMS Has moved to mandatory participation Has moved to mandatory participation Penalty Adjustment: -1.5% in 2015; -2% in 2016 and beyond Penalty Adjustment: -1.5% in 2015; -2% in 2016 and beyond Most recent rule for 2014 requires reporting on 9 measures. Audiology and speech-language pathology exempted from that for now. Most recent rule for 2014 requires reporting on 9 measures. Audiology and speech-language pathology exempted from that for now. 51

52 PQRS Measures Audiology Document or confirm the patient's current medications for 50% of the eligible patient visits for evaluation AND Document or confirm the patient's current medications for 50% of the eligible patient visits for evaluation AND Indicate a referral to a physician for 50% of the patients who report or are diagnosed with dizziness Indicate a referral to a physician for 50% of the patients who report or are diagnosed with dizziness

53 PQRS Measures Speech-language Pathology Document or confirm the patient's current medications for 50% of the eligible patient visits for therapy Document or confirm the patient's current medications for 50% of the eligible patient visits for therapy

54 PQRS Measures PQRS applies to audiologists and SLPs in private practice, group practice, or university clinics. PQRS applies to audiologists and SLPs in private practice, group practice, or university clinics. At this time, PQRS does not apply to providers in facilities such as hospitals or skilled nursing facilities. At this time, PQRS does not apply to providers in facilities such as hospitals or skilled nursing facilities. Separate enrollment is not required. Separate enrollment is not required.

55 Additional PQRS Item: Under SGR repeal, each “society” will develop discipline-specific measures Under SGR repeal, each “society” will develop discipline-specific measures Audiology is represented in this effort by the Audiology Quality Consortium (AQC) Audiology is represented in this effort by the Audiology Quality Consortium (AQC) AQC is comprised of representatives of 10 audiology organizations (list on ASHA, AAA, and ADA websites) AQC is comprised of representatives of 10 audiology organizations (list on ASHA, AAA, and ADA websites) At this moment, there are 5 proposed measures in development At this moment, there are 5 proposed measures in development 55

56 Health Care economics: Do I turn right or left to get to the future? 56

57 Current Recommendation MedPAC: Move Away From Fee-for-Service MedPAC: Move Away From Fee-for-Service Encourages increased utilization Encourages increased utilization More services => more payment More services => more payment Questions of true medical necessity Questions of true medical necessity IOM and CMS: Move Away From Fee-for-Service IOM and CMS: Move Away From Fee-for-Service 57

58 Medicare/CMS Actions Value-Based Purchasing Value-Based Purchasing Based on Medicare vision of “the right care for every person, every time” Based on Medicare vision of “the right care for every person, every time” Aligns payment to efficiency and quality of care delivery Aligns payment to efficiency and quality of care delivery Rewards providers for measured performance (read: outcomes) Rewards providers for measured performance (read: outcomes) 58

59 Value-Based Purchasing Promote evidence-based medicine Promote evidence-based medicine Require clinical and financial accountability across all settings Require clinical and financial accountability across all settings Focus on episodes of care Focus on episodes of care Better coordination of care Better coordination of care Payment based on outcomes, not number of sessions (performance-based payment) Payment based on outcomes, not number of sessions (performance-based payment) Focus on effectiveness of treatment Focus on effectiveness of treatment 59

60 Levels of Evidence 60 LevelType of evidence (based on AHCPR 1992) IaEvidence obtained from meta-analysis of randomized controlled trial IbEvidence obtained from at least one randomized controlled trial IIaEvidence obtained from at least one well-designed controlled study without randomization IIbEvidence obtained from at least one other type of well-designed quasi-experimental study IIIEvidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case control studies IVEvidence obtained from case reports or case series VEvidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

61 Bundled Payments Bundled payment models de-emphasize services that increase utilization and cost Bundled payment models de-emphasize services that increase utilization and cost Initiative by Center for Medicare and Medicaid Innovation called Bundled Payments for Care Improvement Initiative by Center for Medicare and Medicaid Innovation called Bundled Payments for Care Improvement Working to identify procedure groups to bundle, based on diagnosis rather than procedure(s) Working to identify procedure groups to bundle, based on diagnosis rather than procedure(s) 61

62 Current CMS Actions to Reduce Payments Medicare screens for procedures reported together => new, combined procedure CPT codes (92540, 92550, 92570) Medicare screens for procedures reported together => new, combined procedure CPT codes (92540, 92550, 92570) Re-survey and re-validation of procedure value (92587) Re-survey and re-validation of procedure value (92587) Bundled payments under Medicaid reform (more on this later) Bundled payments under Medicaid reform (more on this later) 62

63 Medical Home Model Primary care physician becomes medical manager Primary care physician becomes medical manager All referrals will go through PCP All referrals will go through PCP Different from “gate-keeper” concept of HMOs Different from “gate-keeper” concept of HMOs PCP paid to coordinate and manage all care of that patient PCP paid to coordinate and manage all care of that patient With rare exception, no physician/health care provider will have “direct access” under medical home model With rare exception, no physician/health care provider will have “direct access” under medical home model 63

64 Physician Private Practice Diminishing Physicians are facing same pressures as hospitals Physicians are facing same pressures as hospitals Leaving private practice to become salaried employees of hospitals and other large medical organizations Leaving private practice to become salaried employees of hospitals and other large medical organizations Lower costs Lower costs Meet government mandates on electronic medical records Meet government mandates on electronic medical records Percentage of physicians who own their own practices Percentage of physicians who own their own practices 2000 – 57% 2000 – 57% 2009 – 43% 2009 – 43% 2013 – 33% (projected) 2013 – 33% (projected)

65 Physicians and Private Practice Giving up fee for service or a salary… Giving up fee for service or a salary… Physicians lose autonomy Physicians lose autonomy Gain more regular hours Gain more regular hours Gain more predictable income level Gain more predictable income level Hospitals gain a guaranteed supply of patients from the physicians practices Hospitals gain a guaranteed supply of patients from the physicians practices Intent of health care changes under Obama Intent of health care changes under Obama More coordinated care (shared patient management) More coordinated care (shared patient management) Leading to cost reductions and better patient outcomes Leading to cost reductions and better patient outcomes Eliminate “silo” style of operation for patient care Eliminate “silo” style of operation for patient care

66 Emphasis on Outcomes Patient Satisfaction and Wellness Patient Satisfaction and Wellness Patient Centered (What do you want me to do?) Patient Centered (What do you want me to do?) FQHC payment per encounter FQHC payment per encounter Average payment Average payment Diagnosis based Diagnosis based Influence by Medical Home Influence by Medical Home Shared responsibility for care (Again, emphasis on Care Coordination and elimination of silos) Shared responsibility for care (Again, emphasis on Care Coordination and elimination of silos) 66

67 Emphasis on Patient Centered Care Remove traditional prescriptive perspective from SLPs and Auds Remove traditional prescriptive perspective from SLPs and Auds Patient / family actively participate in decision- making Patient / family actively participate in decision- making Patient / family establish goals to be achieved Patient / family establish goals to be achieved SLP / Aud role to educate, evaluate, guide, empower SLP / Aud role to educate, evaluate, guide, empower

68 Standard Versus Custom Protocols Every procedure must be supported by history or other test findings Every procedure must be supported by history or other test findings Every protocol must be customized for each patient based on the clinical question to be answered Every protocol must be customized for each patient based on the clinical question to be answered What we currently know of reimbursement directions indicate that it will be necessary to do what is necessary and stop there What we currently know of reimbursement directions indicate that it will be necessary to do what is necessary and stop there Bottom line: the individualized clinical question will be the driving force for what is done diagnostically Bottom line: the individualized clinical question will be the driving force for what is done diagnostically

69 Effects on Audiology We are not physicians, but sometimes the system treats us like physicians for payment and policy We are not physicians, but sometimes the system treats us like physicians for payment and policy We don’t know what our reimbursement will look like, but we have some hints based on physician- center proposals and movements away from fee-for- service We don’t know what our reimbursement will look like, but we have some hints based on physician- center proposals and movements away from fee-for- service Pay attention to the diminishing physician private practice and move toward joining large health care organizations Pay attention to the diminishing physician private practice and move toward joining large health care organizations

70 Effects on Audiology Changes in health care will require that you determine cost of service delivery Changes in health care will require that you determine cost of service delivery Carefully evaluate each procedure being performed (e.g., develop a clinical question and determine what tools are necessary; stay away from graduate school protocol … Carefully evaluate each procedure being performed (e.g., develop a clinical question and determine what tools are necessary; stay away from graduate school protocol … Time is money and each additional procedure is time Time is money and each additional procedure is time Justify what you do based on case history and outcome of previous test Justify what you do based on case history and outcome of previous test 70

71 Effects on Audiology Anticipation that payment may be based on diagnosis or “per patient” rather than procedure Anticipation that payment may be based on diagnosis or “per patient” rather than procedure Replace fee-for-service with bundled code crosswalked to diagnosis Replace fee-for-service with bundled code crosswalked to diagnosis Bundled fee based on data-mining median costs of procedures “typically done” to derive diagnosis Bundled fee based on data-mining median costs of procedures “typically done” to derive diagnosis May combine severity with diagnosis via ICF or similar scale May combine severity with diagnosis via ICF or similar scale Focus on participation in life activities (NOT ADLs—life activities) Focus on participation in life activities (NOT ADLs—life activities) 71

72 Effects on Speech- Language Pathology Anticipate episodic / periodic payments Anticipate episodic / periodic payments Single payment Single payment Covers all services Covers all services Covers specified period of time Covers specified period of time Already appearing in Medicaid “reform” Already appearing in Medicaid “reform” Single payment for date of service Single payment for date of service Based on diagnosis and level of severity Based on diagnosis and level of severity Focus on FUNCTIONAL outcomes Focus on FUNCTIONAL outcomes Realistic achievement of goals Realistic achievement of goals Activities of life Activities of life

73 Reimbursement Summit Factors Pressuring Change Unsustainable increasing cost of medical care Unsustainable increasing cost of medical care Patient Protection and Accountable Care Act Patient Protection and Accountable Care Act Increasing demands for quality, efficiency, and accountability by Increasing demands for quality, efficiency, and accountability by Regulators Regulators Health Care Rating Organizations Health Care Rating Organizations Accrediting bodies Accrediting bodies Employers Employers Commercial payers Commercial payers The Public The Public

74 Triple Aim Focus of Change Institute for Health Care Improvement Improving the patient experience of care (including quality and satisfaction) Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Improving the health of populations Reducing the per capita cost of health care Reducing the per capita cost of health care

75 Impact on Graduate School Training Teach clinical judgment rather than strictly procedures and protocol Teach clinical judgment rather than strictly procedures and protocol Mechanics of test administration are important, but know when to stop (emphasis: Aud) Mechanics of test administration are important, but know when to stop (emphasis: Aud) Mechanics of test administration and therapy techniques are important, but know how to set realistic goals (emphasis: SLP) Mechanics of test administration and therapy techniques are important, but know how to set realistic goals (emphasis: SLP) Develop a true sense of medical necessity, clinical questions, patient-centered recommendations and plan of care Develop a true sense of medical necessity, clinical questions, patient-centered recommendations and plan of care

76 Value of Health Care

77 “We practice according to how we are paid” Peter Hollmann, MD Chair, AMA CPT Editorial Panel October 2011

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