+ the future of healthcare: how to comply, survive, and ultimately thrive virginia chapter –...
TRANSCRIPT
+The Future of Healthcare: How to Comply, Survive, and Ultimately Thrive
Virginia Chapter – October 11, 2012
Justin Moore, PT, DPTVice President, Public Policy, Practice, and Professional AffairsAmerican Physical Therapy Association
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Source: Kaiser Family Foundation. Health Care Reform. 2012
+Public: Split 2 year after ACA
3
January 2010 January 2011 Jan 12 June 12 Sept 12
http://www.kff.org/kaiserpolls/8315.cfm
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+
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Health Care Reform: Ideas and Implementation(2010-2018)
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+Health Care Reform:Achieving the Three Part Aim
Better Care
(Individuals)
Better Health (Populations)
Lower Growth in Expendit
ures
+
The Patient Protection and Affordable Care Act (ACA) signed into law on March 23, 20101
Health Care Reform
Coverage & Insurance Market ReformMake insurance more accessible and affordable for all individuals
1
Delivery & Payment System Reform
Pay for quality instead of volume of care2
Financing Strategies for Health Reform
Find sustainable funding to pay for reform provisions3
1) The Affordable Care Act is the combination of the Patient Protection and Affordable Care Act (PPACA), P.L. 111-148, enacted on March 23, 2010, and the Health Care and Education Reconciliation Act of 2010
(HCERA), P.L. 111-152, enacted on March 30, 2010.
+Overall Reform Aims to Expand Coverage and Reduce Spending Over Time
Source: Congressional Budget Office, Score of ACA, March 20, 2010
+Estimated Effect of HCR in 2019
60.5
165.9
63.5
25.7
56.960.5
164.5
83.9
41.6
23.1
Medicare Employer Sponsored Medicaid / SCHIP Individual Coverage (Exchange
Uninsured
Pre HCR Post HCR
Source: Office of the Actuary – Centers for Medicare and Medicaid Services – April 22, 2009
+Implementation at a Glance
2010 Popular Insurance Reforms
2011 Primary Care Prevention Innovation
2012 ACOs SUPREME COURT Exchange / EHB Development
2013 Payment Reforms (Bundling)
2014 Mandates (Individuals / Employers) Exchanges / EHB Medicaid Expansion Consumer Protections
Beyond Taxes
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+ Issue What the Law Did Effective Date
Pre-existing Conditions
Insurance companies barred from denying coverage to Children. Temporary national high risk pool for individuals with pre-existing Conditions
Effective Now
Business Tax Credits
Small Business (< 25 FTEs) received tax credits (up to 35% of employers contribution if pay 50% of total.
Now, increases to 50% in 2014
Dependent Children
Mandates coverage for dependent children up to age 26 Effective Now
Prevention Health insurances companies required to cover preventative services (immunizations, cancer screenings)
Effective Now
Tanning Tax 10% tax on all indoor tanning services Effective Now
Insurance Coverage
Plans prohibited from lifetime limits on how much they pay out to individual policyholders or rescinding coverage except in fraud
Effective Now
Referral for Profit
Bans new or expanding specialty hospitals, provides for disclosure (advancing imaging services)
Effective Now, pending regs
Commissions Panels named for the Patient Center Outcomes Research Center and National Workforce Commission
Effective
2010
+ Issue What the Law Does Effective Date
Insurance Reform
Insurance Companies required to pay rebates to enrollees if they spend less than 80 to 85% the premium dollars on health care services
January 1, 2011
Primary Care Medicare will pay primary care doctors and general surgeons 10% bonus payment
January 1, 2011 (goes to 2015)
Prevention Medicare will pay for an annual wellness visit and a personalize prevention plan
January 1, 2011
Medicaid Start of Medicaid Expansion (Childless Adults < 133% FPL)
January 1, 2011
Payment Reform
.5 bonus payment for PQRI / Quality Report 2011-2014. Penalties – 2015
Innovation Center for Medicare and Medicaid Services Center for Innovation Started. One of the studies / pilots – Direct Access to PT
January 1, 2011
Tort Reform Five year demonstration grants to states to develop, implement, and evaluate alternatives to current tort litigations in health care.
January 1, 2011
Health Saving Accounts / FSA
Revised criteria, $2500 limit, and tax doubled to 20% on ineligible medical expenses
January 1, 2011 (Limit set Jan 1, 2013
Taxes Fees placed on drug makers and manufacturers January 1, 2011 (increases in 2013, 2017 and 2018)
2011
+Issue What the Law Does Effective
Date
Long Term Care
Establishment of a voluntary long-term care program (The CLASS act).
October 1, 2012
Accountable Care Organizations (ACOs)
Establishment of integrated models of care delivery.
Proposed rule making 2010Operational 2012
Taxes New Medicare tax on individuals earning more than $200,000 and couples earning more than $250,000
January 1, 2013
Administrative Simplification
Adoption of single set of eligibility verification and claims status, electronic fund transfers, referral certification and authorization, etc.
January 1, 2013
Out of Pocket Costs
Threshold for deducting health care expenses increase from 7.5% of adjusted gross income to 10%
January 1, 2013
Bundled Payments
Medicare will initiate a pilot program on bundled payments to providers and facilities
January 1, 2013
Co-ops Creation of Consumer Operated and Orientated Health Plans
January 1, 20132012-13
+ Issue What the Law Does Effective Date
Exchange American Health Benefits Exchange Created. Small Business Health Option Plans Established. Each Exchange will have at least 2 multistate plans operated by Office of Personnel and Management.
January 1, 2014
Essential Benefits Plan
Essential Benefits Program Established, including rehabilitation and habilitation as essential benefits
January 1, 2014
Individual Mandate
Required to have health insurance. $95 fine for individual / $ 285 for family or 1% of taxable income, whichever is greater.Subsidies for 133% to 400% FPL (ranges from 3 to 9.5% of adjusted gross income)
January 1, 2014
Employer Mandate
Employers over 50 FTEs. Must provide meaningful health coverage for face fine ($3000 per employee over first 30 employees)
January 1, 2014
Medicaid Expansion
Coverage expanded to all Americans under 133% Federal Poverty Level ($29, 347 for family of four)
January 1, 2014
Payment Reform
Establishment of Independent Payment Advisory Board January 1, 2014
Consumer Protections
Non-discrimination, Guarantee Issue, Renewal and Choice
January 1, 2014
Taxes New fees on health insurance companies January 1, 2014 (increases in 2015)
2014
+Issue What the Law Does Effective Date
Individual Mandate
Penalties increase to $325 individual, $975 family or 2% taxable income
January 1, 2015
Interstate Commerce in Health Care Insurance
Permits states to form compacts to sell policies in states within the compact
January 1, 2016
Individual Mandate
Penalties increase to $695 individual, $2085 family or 2.5% taxable income
January 1, 2016
Cadillac Tax
Imposes an excise tax of 40% on insurers of employer sponsored plans with an aggregated value that exceeds $10,200 for an individual, 27,500 for families
January 1, 2018
2015-18
+
Health Care Reform 2.0 - Moving Forward Following the Supreme Court
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+What’s Next: The Cliff of 2012
Supreme Cour
t Decision
Election 2012
PT Reform
Deficit
Reduction
/ Sequester
Medicare
Extenders
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Tight Race for President and US
Senate
Long Term: Entitlement Reform, Tax Reform, Revenue/Spending Trade-Offs
Doc FixRural Payments (GPCIs)Therapy Cap Extension
June 29, 20125-4 Decision to Uphold- Legislative Changes Required Medicare Physician Fee
ScheduleMedPAC
+Overview of Supreme Court Decision Four (4) Questions Considered: Anti-injunction, Individual
Mandate, Severability, and Medicaid Expansion
Individual Mandate: The Court held that the individual mandate is a constitutional exercise of Congress’s power to levy taxes
Medicaid Expansion: The Court held that forcing states to expand Medicaid is unconstitutional States must be give a choice about whether or not to move forward
on the ACA’s Medicaid expansion, federal government can not cut off existing funds to states that do not proceed with expansion
Medicaid expansion requirement is severable from the rest of the ACA, so remainder of law remains in effect
Court Majority Opinion: Chief John Roberts joined by Breyer, Ginsberg, Sotomayer, and Kagan
Court Minority Opinion: Scalia, Kennedy, Thomas, Alito
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+Legislative Action
Congress
•House has voted to Repeal or Defund all or part of the ACA 26 Times•Once every 10 days in Session•Once every 54 hours in Session•Senate Killed Almost Every Change to ACA•Limited Changes•1099 (Repeal Signed into Law)•CLASS Act (Administration Decision)•Class Act (House Vote)•IPAB•Prevention Fund•Physician Owned Specialty Hospitals•Center for Medicare and Medicare Innovations
+Election 2012: Health Care Impact President Obama Re-
electedRomney Elected
Democrats Keep Senate
Implementation of ACA Continues
Lack of Consensus – Deadlock and Delay
Republicans win Senate
Changes to ACA Projected
-Greater State Flexibility- Delayed Timelines
Republicans Push for Repeal and Replace
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Senate Elections 2012
30 8 3711 65 3
Solid Likely Lean Toss-Up Lean Likely Solid
+Therapy Reform: Here and Now
October 1 – Therapy Cap Exception Process Changes Manual Review and Hospital Outpatient Exceptions
November 1 – Medicare Physician Fee Schedule (Jan 1) Functional Measures - NPI
December / January – Medicare Payment Advisory Commission Short Term Reform Long Term Reform
Legislative / Regulatory Changes Therapy Cap Extension SGR / Payment Reform Quality Bundling
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+The Pending Fiscal Cliff Medicare Extenders Policy (December 31, 2012)
Doc Fix / Sustainable Growth Rate (SGR) 30% reduction in Part B Payments
Therapy Cap Extension Exceptions Process (2 Tiered / Expanded to Hospitals – Oct
2012)
Sequestration (1 Trillion – January 2, 2013) 11 Billion from Medicare (2% across the Board Cut) 52.4 Billion for non-Defense (NIH projects 7.8% cut – 2.39 B) Medicaid and SCHIP exempt
Entitlement Reform (Medicare and Medicare)
Tax Cut Expiration
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+ Lame Duck Session of Congress
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+Next 2 Months in Payment Reform
Short Term Reforms Elimination of V Codes Authorization (Prior/Pre) Extension of Current Policy Uniformity of Benefit Hot Spotting Self-Referral
Long Term Reforms Patient Assessment Episodic
Functional Measures Policy
New Cap Environment
Extension of Quality Move to Penalty Phase
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MedPACMedicare Physician Fee
Schedule Rule
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Health Care Reform 2.0 - Implications for Rehabilitation Professionals
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+The Next Decade in Health Care
Integrated Models of
Care Delivery
Realignment of Care
Payment Reform
Standardization of Practice
Enhanced Accountabi
lity
+ Next Decade In Health Care:
• Accountable Care Organizations• Medical Homes
Integrated Models of Care – Innovation in
Programs
• Prevention, Wellness & Community Incentives
• Chronic Care Management
Re-alignment of Care Models
• Bundled Payments• Expansion of Quality Initiatives
Refining / Changing Payment
Methodologies
• HIT to Patient Assessment Instrument to Registries
• Maintenance of Certification
Standardization of Practice
• Provider Enrollment, including funding• Expansion of Programs for Detention &
Recovery
Enhanced Accountability
(Program Integrity)
+ Physical Therapy and Rehabilitation at a Crossroads
• Direct access under the new Center for Innovation
• Consumer Protections in Bill (non-discrimination)
• Rehabilitation and Habilitation part of the essential benefits package
Green Light
• Role of PT in new models of care delivery (ACOs, PCMH)
• Impact of new payment methodologies across the continuum
• Prevention and Wellness Initiatives• Comparative Effectiveness Research
Yellow Light
•No payment reform (SGR, Caps, Rural Payments)•Market basket cuts to settings (home health, SNFs, etc.)•Regulatory Activism (MPPR, Provider Enrollment, RACs)
Red Light
+Value: A Need for Focus Need for Right Rehabilitation Professional (PT, OT,
Physician) for Right Patient at Right Time Focus on Differentiation
Need to Meet Society's Need Today Focus on Disability, Chronic Care, Populations as well as Patients
Need to Embrace Current Scope not New Scope Focus on Rehabilitation
Need To Invest in the Development of Data Focus on Research
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+Common Theme: Need to Prove Value Value-based health aims to improve quality, lower cost,
and drive toward value in healthcare delivery
The demand for value requires greater accountability on the part of all stakeholders within healthcare
Identification of best practices
Provider adherence to best practices
Measurement of provider performance
Benefit design
Cost-effectiveness
Value
+
EvidenceDefinition of value
Performance MeasuresAssessment of
provider performance to ensure quality
care
Payment Models
Incentives to deliver valuable
care
Transparency
Demonstration of value for
consumers and purchasers
Health Information Technology*
Value-Based Health Care
Realigning provider
payments to incentivize the
provision of high value care, where value is a function of both quality and cost
Facilitation of information collection and
exchange
ACA relies on HIT provisions authorized in ARRA to enhance infrastructure necessary to support efforts around care coordination and VBP
Defining Value in Health Care
+APTA In Action
Impact
Integration
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ImplementationInnovation
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APTA in Action: Influencing Reform
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+ Driving Forces of Change
Current System
Unsustainable
Health Care Reform
Changes
Growth and Movement
Beyond Service in PT
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Sustainable Growth Rate (SGR) of Medicare Physician Fee Schedule – Unsustainable into Future
Therapy Cap applied under Medicare Legislation (Balance Budget Act) Call for an “Alternative Payment System”
Current System Unsustainable
+Future of Fee Schedule Payment: MPFS
+
Current Medicare Physician Fee Schedule Rule Reporting on Claims Form of Functional Measures
MedPAC Charged to make recommendations for therapy
benefit reforms Must consider private sector innovations / policies Standardized patient assessment / classification Targeting aberrant providers / areas Episodic models
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Increasing Number of Insured Individuals
Premium on Right Provider in the Right Role for the Right Patient at the Right Time
Need to Show Value / Quality / Outcomes in Delivery System
Health Care Reform Changes
+
Volume - Utilization Growth Over Past Decade
Variation - Increasing Fraud and Abuse, Lack of Data on Care Patterns (Consistency)
Value – Demonstrating Role in System and to Patients / Payers (Clarity)
Growth and Movement
Beyond Service in PT
+ What is Wrong with Current Codes? Unclear distinctions in nomenclature
Primary reporting focus is on amount of time spent and units billed
Edits on procedures reported in combination preclude “correct coding” to reflect practice
Nomenclature does not facilitate describing practice or differentiate in context of patient care Guide to Physical Therapist Practice describes
intervention: Therapeutic Exercise
CPT Manual has 6 reporting options: 97110, 97112, 97113, 97530, 97545, 97546
+ What Should Payment Be Based On?
• Patient presentation and physical therapist clinical decision making– Professional skill and judgment– Mental and physical effort– Psychological stress of impact of interventions– Length of involvement to a limited extent
In other words, payment based on:
• The clinical decision making needed to address the severity and complexity involved
• How is that communicated in terms of the services provided to the patient (intensity)
+ Key Factors in Determining Payment
• Accurate and complete communication of the following:
– Completed Patient Assessment Tool– Evaluation: Clinical Presentation – Treatment: Management – Outcomes: Value
+ Key Characteristics of ModelPer session coding rather than specific
interventions or unit based
97000 series collapsed (with a selected codes being kept as separately reportable)
Focus on outpatient setting, but can be modified for IP
Focus on accurately communicating clinical reasoning and decision making by supporting choice of treatment level
+Alternative Payment Methodology: Level 1 Evaluation
Problem Focused-Limited Complexity Clinical presentation stable, minimal to no safety
concerns due to health and/or cognitive status Problem focused history and exam,
straightforward clinical decision making, no personal factors or co-morbidities impacting condition to be evaluated
Establishment or update of problem focused plan of care addressing one or more similar impairments, activity limitations and/or participation restrictions by a physical therapist
+ Alternative Payment Methodology:Level 2 Evaluation
Detailed – Moderate Complexity Evolving or changing characteristics related to patient condition, complaints, cognitive status and with moderate safety concerns, with potential for functional decline or delayed progress
A detailed history and examination and consideration of impact of other health conditions/impairments on functional recovery with commensurate complexity of clinical decision making due to 2 or less personal factors and/or co-morbidities
The establishment or update of a detailed plan of care by a physical therapist addressing more than one impairment, activity limitation and/or participation restrictions using functional assessment instrument
+Alternative Payment Methodology:Level 3 EvaluationComprehensive – Significant Complexity Unstable and unpredictable characteristics of patient condition, complaints, cognitive status with substantial risk for diminished safety
A detailed history/examination and complex consideration of clinical decision making due to multiple health conditions or impairments on function and 3 or more personal factors or co-morbidities that impact condition being evaluated
The establishment or update of a comprehensive plan of care by a physical therapist addressing more than one impairment, activity limitation and/or participation restrictions as identified by functional assessment instrument
Requires referral to, coordination/communication with other involved providers
+ Alternative Payment Methodology:InterventionsSeverity – Intensity Level 4
Limited Severity
Prognosis certain/stable, predictable minimal to no safety concerns, Co-morbidity no impact, minimal to no gap between prior and current level of functionLimited Intensity of InterventionsStraight-forward application of interventions, minimal to no risk of complications related to care, limited interventions (typically 30 minutes or less), Limited face to face or group interaction, care can be supervised
+ Alternative Payment Methodology:InterventionsSeverity-Intensity Level 8
Moderate Severity
Variable outcome/prognosis, age may be relevant, comorbidity could impact management, gap between prior and current function, moderate
Moderate Intensity of Interventions
Data acquired inform treatment changes/modifications, interventions (typically 31-45 minutes) a portion involve individualized interaction between patient and qualified health care professionals, low risk of injury, and clinical decision making informing the intervention choice based on changes in patient status with treatment
+ Alternative Payment Methodology:InterventionsSeverity-Intensity Levels (12)
Significant Severity
Age highly relevant to outcome, uncertain/unpredictable clinical presentation, requires constant monitoring, characteristics of condition unpredictable, constant assessment of patient response during session, large gap between current level of function and prior level of function
Significant Intensity of Interventions
Response to treatment highly variable and involves ongoing clinical decision making, complex selection of intervention significant interventions (typically more than 45 minutes of 1:1)
+“Moving Forward”
Profession’s FeedbackMember Survey early 2011Member Comment Spring 2012 – August
2012Development of APTA Coding proposal
Fall/winter 2012
Other Rehab Professions’ FeedbackAOTA developing their applications for this
modelASHA supportive but most likely maintain
current Model for reporting CPT
+“Moving Forward”
External StakeholdersAMA CPT Staff Discussions initiated early
2011 and ongoingCMS meetings initiated early 2011 and
ongoingPhysician groups introduced to concepts
(AAPMR) Likely result is a CPT Workgroup with
participation of external stakeholdersCPT Coding Proposal and acceptance of
new coding system
+“Moving Forward”
Once CPT proposal has been accepted AMA Relative Value Update Committee
(RUC) process Vetting through Medicare proposed and final
rules Publication in MPFS and other commercial
payer Fee schedules Collaborate in education initiatives
+
Contact Information
Justin Moore, PT, DPTAmerican Physical Therapy AssociationPublic Policy, Practice and Professional Affairs Unit
1111 North Fairfax StreetAlexandria VA 22314