1. Non-Face-to-Face Revenue Opportunities and Pitfalls
Moderator:
Steven Phillips, MD
Panelists:
Stephen Canon, MD
Gary Swartz, JD MPA

2. Faculty Disclosures
Canon – Phyzit, Inc – Co-Founder, Chief Medical Officer
Phillips – FEMR Group – Founding member
Swartz – no relevant disclosures

3. Objectives
Differentiate between the different non-face-to- face revenue opportunities.
Discuss the pitfalls related to the opportunities.

4. TRANSITIONAL CARE MANAGEMENT
Stephen Canon, MD
Program Director & Associate Professor UAMS Department of Urology
Chief, Division of Pediatric Urology
ACH Auxiliary-John F. Redman, M.D. Endowed Chair
Arkansas Children's Hospital
Chief Medical Officer, Phyzit®, Inc.

5. Outline
Review the impact of hospital readmission and the impact of Transitional Care Management (TCM)
Discuss the “5 Biggest Mistakes of Transitional Care Management”
Review the 2016 CMS TCM Fee Schedule Changes
Discuss the interface between TCM and Chronic Care Management

6. Hospital Readmissions
For every 5 Medicare patients admitted to the hospital, how many will be readmitted within 30 days after discharge?
Almost 1 of 5 patients are readmitted per month
In 2011, 1.8 million 30 day Medicare readmissions – cost $24 billion

7. What conditions have the highest readmission rates (2011)?
Congestive Heart Failure
Septicemia
Pneumonia
COPD
Cardiac dysrhythmias
134,500
92,900
88,880
77,900
69,400
June 10, 2013

8. Transitional Care Management
The Centers for Medicare and Medicaid Services (CMS) added transitional care management (CPT Code 99495/99496) to the list of services that are reimbursable in January, 2013.
CMS invested an estimated 1.34 Billion dollars per year through creation of TCM codes
Does TCM really lower readmissions?

9. Systematic review of 3 databases between 2004-2015 that report on readmissions in the US
Of 969 studies identified - 77 met inclusion criteria but only 3 included all elements for TCM

10. Readmission
reduction
8.87 %
1.8 %
19.9 %

11. Transitional Care Management Services Requirements
Initial Communication within 2 business days
Face-to-face visit in 7 (high complexity) or 14 (mod complexity) calendar days
Date of Service (DOS) on 30th calendar day with day 1 being the date of discharge (Jan – Dec 2015)

12. TCM Timeline

13. 5 Biggest Mistakes of TCM
Failure to make initial communication with patients fast enough
Failure to understand the metrics
Failure to correctly identify TCM candidates
Failure to schedule face to face in the right time frame
Billing the wrong date of service (before 1/1/16)

14. CMS 2016 TCM PFS Changes
The DOS will reflect the date of the face-to- face visit:
High Complexity – within 7 business days
Moderate Complexity – within 14 business days

15. CMS 2016 TCM PFS Changes
The service period has not changed with only one billable TCM per service period, AND
Only TCM or CCM are typically billed during the same calendar month.

16. Anticipated Effect of Mistake #5
Problems with billing occurring with:
Other Admissions/TCM periods
Chronic Care Management
Awareness of completion of the TCM period is imperative in both scenarios.

17. TCM/CCM Interface
Medicare and CPT specify that CCM and TCM cannot be billed during the same month.
Does this mean that if the 30-day TCM service period ends during a given calendar month and 20 minutes of qualifying CCM services are subsequently provided on the remaining days of that calendar month, CPT code cannot be billed that month to the PFS?

18. Future of TCM Improvement in awareness of hospital admission/discharge
Workflow integration with electronic medical records and chronic care management
Maintaining value for PCPs in the future for continuation of TCM

19. Care Management Services use for Practice Transformation and payment under Value Based Payment Models
Gary H. Swartz, JD, MPA
Associate Executive Director
American Academy of Home Care Medicine

20. Care Management Services Support DHHS Announced Goal of Transformation to Quality and Alternative Payment Models
Many of you saw this in presentation this morning with Dr. Smith with phases CMS going to 90% by 2018

21. Care Management Services - Why
Spring rulemaking and fall final to begin the program in 2019 lets look at top line where from this year to there is to be .05 increase to fee schedule

22. How much can payment be reduced unless excluded from Merit Based Incentive Payment (MIPs) System?
Year
Potential reduction
2019 based on 2018
minus 4 percent
2020 based on 2019
minus 5 percent
2021 based on 2030
minus 7 percent
2022 and after
minus 9 percent
can go down up to 9% off of MFS so this in important
Sliiding scale against threshold So consider what receiving less than Medicare Fee Schedule would mean budget neutrality except if all do poorly or all do exceptional well
The Government Accountability Office (GAO) is required to evaluate the MIPS and issue a report in and 2021, including an assessment of the professional types, practice sizes, practice geography, and patient mix that are receiving MIPS payment increases and reductions.

23. MIPS +/- 9% adjustment in 2019 forward applied to illustrative housecall codes
Description
2016 MD
-9%
+9%
2016 NP/PA
99327
Domicil/r-
home visit new pat $ $ $ $ $ $
99336
home visit est pat $ $ $ $ $ $
99344
Home visit
new patient $ $ $ $ $ $
99349
est patient $ $ $ $ $ $
G0181
Home health care supervision $ $ $ $ $ $
99490
Chron care mgmt srvc 20 minutes $ $ $ $ $ $
99497
Advncd care plan
30 minutes $ $ $ $ $ $
Why we are working to protect your services in light of the plus minus 9% and current value based payment modifier we know due to the interaction of laws that the MFS will be within a couple of percent of this yeaar even if in full.5 percent so using this year – this is to be budget neutral so for those below there will be those above and vice versus.
Standalone compliance on medical necessity – OIG is looking at the medical justifcation for home visits
So make sure that discussion in the CC/HPI is there in the record why you are seeing the patient in the home in liew of office vist

24. Care management services - current
Counseling and Care Coordination
Prolonged Services
Care Plan Oversight - CPO
Transitional Care Management - TCM
Chronic Care Management - CCM
Advanced Care Planning - ACP

25. Care management services under development
Chronic Care Management Revisions – additional codes with more precision for more extensive non face to face services per month
Acute Non Face to Face Care Management Services - 30 minutes or more per month of physician or other qualified health professional time, per episode of acute illness
Atypical complexity - Atypically complex communication factors or extensive
additional evaluation related to medical, behavioral, functional or social
factors or atypical care coordination on the date of the E/M
Assessment & Care Planning for Patients with Cognitive Impairment - Comprehensive assessment of and care planning for the patient with cognitive impairment
Behavorial Health Collaborative Care/Psychiatric Collaborative Care - care manager time (70, 60) with consultation by a psychiatric physician or other qualified health care professional, directed by the treating physician or other qualified professional

26. Care management services and practice transformation
Common elements of care management services
Transformed practice functions;
Proactively manage across sites of care
24/7 access to practice
Electronic health record
Maintain an electronic care plan
Ensure beneficiary access to care
Facilitate transitions of care and referrals; medication reconciliation each transition
Coordinate care with home and community-based clinical service providers
Obtain patient preferences and goals of care
Staffing/relationships for 24/7 access
Patient stratification and interventions
Open scheduling for acute issues that arise
Real time EHR relationship with inpatient facilities
Access Regional health information organizations
Proactive contact with patients, caregivers, ALFs;
use of internal staff or contractual
Chaperone patients through admissions
Liaison with hospitalists and discharge planning
Liaise with SNF staff/see patients in SNF
Substitute practice services for those of more costly providers/suppliers, e.g., home health
Communicate/respect patient preferences and goals of care
Required Elements for Success Across Each Setting 
 Patient management in the home
proactive leadership and culture
practice capacities: human, financial, and organizational capital; adaptability and practice flexibility (ie, freedom of decision making)
functional ability to deploy the above capacities (people, technology, roles) to ensure situational awareness and ability to intervene in a setting of care and across settings of care
professional/clinical and administrative skills: the right training, skill sets, confidence, and demeanor to succeed in relation to the home-limited, sick, frail or disabled patient population

27. Comprehensive Primary Care + (CPC+) Begins 2017
25 million patient, multi-payer 5 year demonstration
Opportunity for Academy members to receive per patient per month payment in addition to Part B payments to support care management and practice transformation
CMS designation as Advanced Alternative Payment Model
Multi-payer aspects provide opportunity to embed HBPC
Two tracks – Risk adjusted (HCC) care management
capitation paid to practices
New CMMI Demonstration
Not a proposed rule for comment

28. The CPC+ Care Management Functions
systematically risk stratify patient population,
identify high-risk patients likely to benefit from longitudinal care
identify event triggers - hospitalization, ED visit, new diagnosis for episodic care
Access and Continuity
ensure 24/7 access to care team with real-time access to EMR
empanel patients to a practitioner/care team to build a therapeutic relationship
Planned Care for Population Health
team-based care, proactive evidence-based management of chronic conditions
act on the quality of care at both the practice and panel level
Patient and Family Caregiver Engagement
engage patients and families in the design and improvement of care
engage patients in goal setting and shared decision-making
Comprehensiveness and Coordination
provide comprehensive primary care services.
understand where in the medical neighborhood patients receive care and organize the practice to facilitate coordination of that care
Many practices already have medical neighborhood relationships
And staff that are paid by CCM
Track 1 practices will build capabilities in behavioral health, self-management support, and medication management to better meet the needs of these patients.
Track 2 practices will provide more intensive care management for
their patients with complex needs and will build additional practice capabilities in assessment and management of patients with complex needs, such as those with cognitive impairment, frailty, or multiple chronic conditions.
Track 2 practices will be expected to explore alternative means of access to reduce barriers to timely care, such as e-visits, phone visits, group visits, home visits, and visits in alternate locations (e.g., senior centers and assisted living centers).
Track 2 practices may also more directly involve patients and families in quality improvement initiatives, and must provide self-management support as well as support for caregivers of persons with functional disabilities (e.g., dementia).

29. Medical Home Model is an APM that has the following features:
Primary care or multispecialty practices with primary care
Empanelment of each patient to a primary clinician; and
At least four of the following:
Planned coordination of chronic and preventive care.
Patient access and continuity of care.
Risk-stratified care management.
Coordination of care across the medical neighborhood.
Patient and caregiver engagement.
Shared decision-making.
Payment arrangements in addition to,
or substituting for, fee-for­-service payments.

30. Care management services for your home care medicine practice FFS payment and other benefits
MD/DO
NP/PA
Other benefits
Counseling and Coordination of Care
Code selection
Care management fees
Capitation
Shared saving
Foundation for alternative payment models
Measure satisfaction
Re24/7 access
EHR
Patient tracking and management across settings of care
Medication reconciliation
Reduced admissions
Reduced readmissions
Patient preferences
Patient/caregiver satisfaction
Prolonged Services $ $
Prolonged Services $ $
Home Health Care Plan Oversight – G0181 $ $
Hospice Care Plan Oversight – G0182 $ $
Transitional Care Management – 99495 $ $
Transitional Care Management – 99496 $ $
Chronic Care Management $ $
Advanced Care Planning – 99497 $ $
Advanced Care Planning – 99498 $ $
Note services under review and new faqs

31. Comprehensive Primary Care+ PBPM compared with IAH Year 1 Results and Private Market Examples
CPC+
Track 1
Average
Track 2
CPC+ Track 2
Complex
Tier
IAH
Year 1
Blended Shared Savings
(if PBPM)
Northwest US
Example
Texas
$15
$28
$100
$396 $ $
Plus Fee for Service
Plus
Shared
Savings
So the private market is reconizing the benefits of hbpc and the
Practices are doubling revenue based on care management payments
Important to sustain practice particularly community based
And to be able to recruit and retain medical professionals

32. Example of value of shared savings
Number of shared savings patients/
provider 25 50 75
IAH year one savings per beneficiary
$3,000
Total savings to practice – Approx. 50 percent after application of performance measures
$75,000
$150,000
$225,000
50-60 IAH patients is the modeOne million dollars to 4 person group shared savings story by Patrick Conway, MD, Medicare Deputy Director and Director of Innovation Center

33. CHRONIC CARE MANAGEMENT
Steven L. Phillips, MD
Medical Director
Sanford Center for Aging
Professor of Clinical Internal Medicine
University of Nevada School of Medicine

34. One of the greatest challenges facing elders is the increase in the number of chronic conditions as they age. Chronic conditions can stem from a range of causes and often impact an individual’s quality of life and experiences.

35. Chronic Conditions and Impact on Health Care
133 million Americans suffer from at least one chronic condition
70% of all deaths result from chronic diseases
85% of all healthcare dollars go to treating chronic disease
Two-thirds or more of Medicare dollars spent on patient with five or more chronic diseases

36. 63% of patients with six or more chronic conditions were hospitalized one or more times, compared to 4% of those with 0 or 1 chronic conditions
49% of patients with six or more chronic conditions received post-acute care, compared to less than 1% of beneficiaries with 0 or 1 chronic conditions
70% of patients with six or more chronic conditions had one or more Emergency Department (ED) visits, compared to 14% with 0 or 1 chronic conditions

37. Disproportionate Share of Hospital Readmissions
6 or more Chronic Conditions percent
4 to 5 Chronic Conditions percent
2 to 3 Chronic Conditions percent
0 to 1 Chronic Conditions percent

38. The Centers for Medicare and Medicaid Services (CMS) added chronic care management (CPT Code 99490) to the list of services that are reimbursable.

39. Chronic Care Management Services
20 minutes of non-face-to-face care per calendar month
Two or more chronic conditions expected to last at least 12 months.
Patient at significant risk of death, acute exacerbation or functional decline
Comprehensive care plan established, implemented, revised or monitored

40. Eligible Chronic Conditions
Acquired Hypothyroidism
Acute Myocardial Infarction
Alzheimer’s and other dementia
Asthma
Diabetes Mellitus
Anemia
Benign Prostatic Hyperplasia
Colorectal, Breast, Lung, Prostate Cancer
Cataracts

41. Eligible Chronic Conditions
Chronic Kidney Disease
Hypertension
Chronic Obstructive Pulmonary Disease
Heart Failure
Hip/Pelvic Fracture
Depression
Glaucoma
Hyperlipidemia

42. Requirements to Participate
Secure the eligible beneficiary’s written consent
Provide five specified capabilities
Provide 20+ minutes of non-face-to- face services per calendar month

43. Five Specified Capabilities
Use a certified Electronic Health Record
Maintain an electronic care plan
Ensure beneficiary access to care
Facilitate transitions of care and referrals as needed
Coordinate care with home and community- based clinical service providers

44. Practitioners Eligible to Bill Medicare for CCM
Physicians
Advanced Practitioner of Nursing
Physician Assistants
Clinical Nurse Specialist

45. Non-Face-to-Face Care Management Team
Physicians
Clinical Nurse Specialist
Advanced Practitioner of Nursing
Licensed Practical Nurse
Registered Nurse
Certified Medical Assistant
Certified Nursing Assistant
Licensed Clinical Social Worker
Physician Assistant

46. Chronic Care Management in the Post-Acute Long Term Care Continuum
Data Management Key to:
- Patient Identification
- Care Coordination
Risk Stratification:
- Analysis of patients’ health history
- Calculation of Hierarchical Condition
Category (HCC)

47. Care Coordination
Care Plan Development - Cloud-based technology - Integrates data from EMR - Automatically populates a care plan - Action plan based on chronic conditions

48. Care Plan Distribution
Electronic platform shares care plan
- Patient
- Family
- Caregiver
- Specialists
- Other involved providers

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