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

2 Contact Information - Phone

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4 The 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

5 Filling Vacuums and Making Solutions- The PCMH A complete patient centered medical home program combines- 1. a quality service delivery model 2. A reimbursement model that recognizes the care improvements

6 The Agenda-Creating Value in Your Practice The Agenda-Creating Value in Your Practice 1.The Triple Aim- Improving quality of care, the cost of care, and the general health of the population 2.Creating Value – Value = Quality / Cost 3. Payment will follow Value

7 Practice Transformation Requirements The Medical Home Makeover is transformation - an evolution to an improved model of delivering health care, and creating value for patients, payers, and your practice Physician LeadershipPhysician Leadership Subject Matter KnowledgeSubject Matter Knowledge ResourcesResources

8 Creating Value- What Families Want A personal physician A place other than the emergency room to receive care (access) Convenience (access) A Navigator (Care Coordination) Lower costs of insurance and drugs

9 Creating Value- What Employers Want A healthy workforce Easy employee access to care Controlled Cost of health insurance- stable premiums

10 Creating Value- What Payers Want A Network of Providers who can partner to- Improve Quality- measured (HEDIS) Lower Cost – inpatient, emergency, and pharmacy services Use Evidenced Based Medicine Create and maintain Access for their members Receive and Use data to improve care

11 Accountable Care-Here We Go……

12 A Key Concept-Accountable Care 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.

13 Medical Home Program- Core Attributes with Value 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

14 National Payment Models – Multimodal and Evolving to Risk Model National Payment Models – Multimodal and Evolving to Risk Model 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 Reimbursement Ongoing- Fee Schedule for Visits/Procedures ) Retrospective Pay for Value Quality, Utilization, Patient Experience Prospective- Care Coordination /Infrastructure

15 Improving the Fee Schedule for Key Medical Home Services Improving the Fee Schedule for Key Medical Home Services Non-Face-To-Face Services Care Plan Oversight Special Services –Afterhours Care Team Services

16 Care Plan Oversight- Why a Key Service 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

17 Care 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,

18 Care Plan Oversight 99339Individual physician supervision of a patient (patient not present) in HOME, domiciliary or rest home (eg, assisted living facility) minutes- Calendar Month minutes or more

19 The Key Services for the Medical Home Expanded Access: After Hours Codes

20 After Hours Codes “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

21 The Key Services for the Medical Home Team Care Non-Physician Services

22 USEFUL Non Physician SERVICES USEFUL Non Physician SERVICES –NURSE VISITS – ($19.71 for one visit)* –HEALTH BEHAVIOR ASSESSMENT INTERVENTION CODES ($21.07 per 15 min)* –MEDICAL NUTRITION SERVICES ($31.94 per 15 min)* –PATIENT EDUCATION (new in 2006) ($26.16 per 30 min)* *CMS 2011 Fee Schedule for Medicare

23 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

24 The “NEW” Pay For Performance- PAY FOR VALUE

25 Review 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 )

26 Review 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

27 Review 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.

28 Review of P4P Programs- Physician Perspective 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?

29 Evolution of P4P Programs- Payment 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 plus Meeting threshold targets for Efficiency measures creates a cost savings pool (the “gain”) that can be shared

30 Evolution of P4P Programs- the Present and near future Example- 500 patients under one payer- Quality Scores 1. Adolescent well care- 100% of target 2. Asthma care –controller medication- 90% 3. ADHD Medication follow up- 65% Composite score= 85%

31 Evolution of P4P Programs- the Present 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

32 Evolution of P4P Programs- the Present and near future Your Gain Share payment for value is …. Quality score X Savings 85% x $50,000 = $42,500 Your group divides up the money by its own rules, or if part of an ACO, by ACO rules

33 Payer Engagement-The First Meeting Payer Engagement-The First 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

34 Resources- The First Meeting 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

35 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

36 Change…Is Constant in Health Care It is not necessary to change… Survival is not mandatory Edward Deming Speaking to a group of Detroit automaker executives 1970s-

37 PCMH Resources 1. AAP National Center for Medical Home Implementation Mentors, Toolkit 2. Center for Medical Home Improvement Medical Home Index, Role of Family 3. NCQA- Patient-Centered Medical Home (PCMH) 2011 Recognition Program

38 PCMH Resources 4.PCPCC- Patient Centered Medical Home Collaborative Subject Matter- How and Why It works Payment Rate Brief –a survey of pcmh reimbursement models Outcomes Report a summary of quality and cost improvement made by exiting PCMH programs 5. Commonwealth Fund The national perspective on PCMH,ACO, and Health Care

39 AAP Coding Resources AAP Coding Hotline is a resource for practitioners to submit coding questions and receive a response from AAP coding

40 AAP Core Coding Resources AAP Pediatric Coding Newsletter™AAP Pediatric Coding Newsletter™—proven coding solutions you can’t afford to miss! Month after month, AAP Pediatric Coding Newsletter™ helps you maximize payment, save time, and implement best business practices to support quality patient care. Included in this annual subscription product is print and online access to broad coverage of coding for pediatric primary care and subspecialty services. Coding for PediatricsCoding for Pediatrics 2012—new 17th edition of the number 1 pediatric coding and billing resource! For beginners and advanced coders alike, this is the first place to look for pediatric-specific, AAP-endorsed, peer- reviewed coding solutions…all new and updated Current Procedural Terminology (CPT ® ) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) pediatric codes…practical recommendations, tips, and techniques…and much more Pediatric ICD-9-CM Coding Pocket Guide2012 Pediatric ICD-9-CM Coding Pocket Guide— convenient go-anywhere format! Streamline pediatric diagnosis coding with this newly revised reference. Here are the basic guidelines for selecting appropriate codes for commonly encountered pediatric diagnoses and diseases.

41 Practice Management Online Practice Management Online (PMO) ( supports pediatricians in running a practice that is fiscally sound and efficient and provides quality health care to children and families.

42 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 for additional information or to register!