Download - Learning the New Language of Healthcare
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Page 0February 7, 2014
The Georgia Society of CPAs
Learning the NewLanguage of Healthcare
February 7, 2014
9:35am – 10:25am
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Page 1February 7, 2014
The Georgia Society of CPAs
What am I Trying to Say?
Everyone knows these… But what about these?
EBP Evidence-BasedProtocol
CQM Clinical QualityMeasures
CIN Clinically IntegratedNetwork
GPRO Group PracticeReporting Option
LOL Laughing out loud
SMH Shaking my head
BRB Be right back
JK Just kidding
BFF Best friends forever
BTW By the way
FYI For your information
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Page 2February 7, 2014
The Georgia Society of CPAs
ACO
CIN
PHOVBP
PQRS
Are We Speaking theSame Language?
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Page 3February 7, 2014
The Georgia Society of CPAs
The Curve
PE
RF
OR
MA
NC
E
TIME
First CurveFee-for-ServiceQuality Not RewardedPay for VolumeFragmented CareAcute Hospital FocusStand Alone Providers Thrive
Second CurveValue Payment
Continuity of Care RequiredSystems of Care
Providers at Risk for PaymentIT Centric
Physician Alignment
Straddle
Revenue DropsMinimal Reward for Quality
Volume Decreases
No Decisive Payment ChangePay for Volume Continues
High Cost IT InfrastructurePhysicians in Disarray
The Curve
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Page 4February 7, 2014
The Georgia Society of CPAs
• Sickness System
• Health: No Disease
• Acute Disease
• Fee for Service
• Hospital Beds Full
• Hospital Centric
• Doctor Centric
• Doctor Decides
• Quality Decided by Doc
• Wellness System
• Health: Wellness
• Chronic Disease
• Value Based Payment
• Hospital Beds Empty
• Community Centric
• Patient Centric
• Shared Decision Making
• Measurable Metrics
Old Healthcare New Healthcare
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Page 5February 7, 2014
The Georgia Society of CPAs
Old Healthcare New Healthcare
• Cost not considered
• Independent doctors
• Independent hospital
• Medical record secret
• Opaque
• Artificial harmony
• Analogue
• Hypothesis driven clinicaltrials
• Decreased cost
• Integrated doctors
• Integrated delivery sys.
• Open access record
• Transparent
• Cognitive conflict
• Digital
• Predictive analyticsactionable correlations
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Page 6February 7, 2014
The Georgia Society of CPAs
BundledPayments
PartialCapitation
GlobalPayment
Fee-for-Service
SharedSavings
Visitor
Symptomatic
Acute Needs
Services & Supplies
Unit Based
No Financial Risk
Visitor
Symptomatic
Acute Needs
Services & Supplies
Unit Based
No Financial Risk
Patient
Episode
Most CommonConditions
Packaged Treatments
Efficiency Based
Partial Financial Risk
Patient
Episode
Most CommonConditions
Packaged Treatments
Efficiency Based
Partial Financial Risk
Person
Overall Health
Community HealthCharacteristics
Manage Well Being
Outcome Based
Full Financial Risk
Person
Overall Health
Community HealthCharacteristics
Manage Well Being
Outcome Based
Full Financial Risk
Evolution of Reimbursement
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Page 7February 7, 2014
The Georgia Society of CPAs
The Healthcare System of the Past
PatientsPhysicians/Providers Payers
Hospitals & OtherProviders
Inefficiency
Lack ofCoordinatedInformation
UnsupportableEconomics
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Page 8February 7, 2014
The Georgia Society of CPAs
Hypothetical:Martha is a 67 year old women who needs a hip replacement
Six months later –Well Check
Hip Replacement Nine months later
• ED• Admitted for pneumonia
(payment)• Treated by hospitalist -
(payment)• Consulted by cardiologist -
(payment)
• Gaping hole in information• Information from previous
two episodes of care maynever reach primary careprovider-Drug interactions-Duplicative testing
Episodes of Care
• Orthopedic Surgeon (payment)• Surgery-Anesthesia (payment)-Pathology (payment)
• Acute Care (payment)• Rehabilitation-PT(payment)
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Patient-CenteredMedical Home
Primary CarePhysician
Specialist
Physician
Physician
IPA
BundledPayment
+ Coordinated Care
+ $ for Coord. Care
PHO
Payer
NarrowNetwork
ACO
SharedSavings
Capitation
The Road to Clinical IntegrationO
LDN
EW
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Page 10February 7, 2014
The Georgia Society of CPAs
What Does “Value” Look Like?
VALUE=
QUALITY COST EFFICIENCY+ +
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Page 11February 7, 2014
The Georgia Society of CPAs
What is a “Value-BasedPayment” Model?
Value-Based Payment:
A payment model which rewards healthcare providersfor meeting certain predetermined performancemeasures related to quality and efficiency
Efficiency: The state or quality of achievingmaximum productivity with minimum
wasted effort or expenseQuality: The standard of something asmeasured against other things of a similar
kind; the degree of excellence ofsomething “quality of life” also the general
excellence of standard or levelValue: The regard that something is held to
deserve; the importance or preciousnessof something: “Your support is of great
value”
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Page 12February 7, 2014
The Georgia Society of CPAs
Hospital Value-Based Purchasing(“HVBP”)
• Rewards and penalties based on qualitymeasures and patient satisfaction scores
• Penalties for high readmission rates
– FY12-14 for AMI, heart failure, and pneumonia;expand list in FY15
– Reduce overall inpatient payment by 1%-3%
• Penalties for Hospital Acquired Conditions (HACs)/NeverEvents
– In FY15, top 25% in HACs will have payments reduced by 1%
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Page 13February 7, 2014
The Georgia Society of CPAs
Value: PVBP
PVBP: Physician Value-Based Purchasing
• Physician feedback program
– Individual reports on resource use and quality of careas compared to peer group
• Physician value-based payment modifier
– Phased in between 2015 and 2017
– 2014 performance determines 2016 modifier
– Budget neutral
– wRVU x conversion factor x VBPM
• Positive number = paid more
• Negative number = paid less
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Page 14February 7, 2014
The Georgia Society of CPAs
PVBP vs. SGR
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Page 15February 7, 2014
The Georgia Society of CPAs
Sustainable Growth Rate(“SGR”) Fix
• On October 30, 2013 the Senate Finance Committee and the HouseWays and Means Committee released a discussion draft of a SGR fix,offering a comprehensive approach to MPFS payment reform.
• Key provisions include:
– Payment freeze
– Termination of payment penalty programs (PQRS, MU)
– New value-based performance (VBP) program
– Alternative payment model (“APM”) participation
– Complex chronic care management
– Appropriate use criteria
– Valuation of services
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Page 16February 7, 2014
The Georgia Society of CPAs
Physician Quality Reporting System(PQRS)
• 2014: 201 quality measure available forreporting
• Paid for reporting (pay-for-reporting or P4R),not attaining certain scores (pay-for-performance or P4P)
• Carrots followed by sticks
– 0.5% bonus for 2012-2014
– 1.5% penalty for 2015
– 2.0% penalty for 2016 and thereafter
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Page 17February 7, 2014
The Georgia Society of CPAs
PQRS: How Patients are Identified
Patients whose care you directed: you billed 35% or moreof all their outpatient E&M visits
Patients whose care you influenced: you billed less than35% of outpatient E&M visits but 20% or more of theircosts
Patients whose care you contributed are those you billedless than 35% of visits and less than 20% of their total cost
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Page 18February 7, 2014
The Georgia Society of CPAs
Tiered Value-Based Payment ModifierAssessment Low Cost Average Cost High Cost
High Quality 2.0%* 1.0%* 0.0%
AverageQuality
1.0%* 0.0% -0.5%
Low Quality 0.0% -0.5% -1.0%
* Physicians who score in these categories who treat high-risk beneficiaries could receive an additional one percentage point in bonus money.
Source: Proposed 2013 physician fee schedule, Centers for Medicare & Medicaid Services, Federal Register, July 30.
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Page 19February 7, 2014
The Georgia Society of CPAs
Other Forms of PQI
Meaningful Use Incentives/Penalties
- Stage One objectives and clinical quality measures
- Stage 2 delayed – if attested Stage 1 in 2011 attestStage 2 in 2014 (instead of 2013)
- 1% penalty in 2015 if not MU in 2014; 2% in 2016; 3% in2017; 4% in 2018 or 2019
Electronic Prescription Incentive Program
- 2.0% penalty in 2014 unless used eRx 10x by 06/30/13(only receive 98% of Medicare Part B PFS amount forcovered professional service in 2014)
MU
eRx
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Page 20February 7, 2014
The Georgia Society of CPAs
Fundamentals DrivingClinical Integration
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Page 21February 7, 2014
The Georgia Society of CPAs
Defining Clinical Integration
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Page 22February 7, 2014
The Georgia Society of CPAs
Plotting Your Course on the way toManaging Population Health
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Page 23February 7, 2014
The Georgia Society of CPAs
PCMHPCMH: Patient-Centered Medical Home
• Improves primary care through patient-centered care, cooperation among physicians,and coordination and tracking care over time
• Facilitates partnerships among patients, theirphysicians and the patient’s family members
• Care is facilitated by registries, healthinformation technology (HIT), healthinformation exchange (HIE), etc. to ensurethat patients receive the appropriate care atthe appropriate time in the appropriate manner
Patient-Centered MedicalHome
Primary CarePhysician
+ Coordinated Care
+ $ for Coordinated Care
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Page 24February 7, 2014
The Georgia Society of CPAs
IPA: Independent Practice association
• Association of medical doctors(primary care physicians andspecialists) and other healthcareprofessionals that have contractedwith most PPO, POS, and HMOinsurance plans
IPA
Specialist
Physician
Physician
Primary CarePhysician
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Page 25February 7, 2014
The Georgia Society of CPAs
PHO
PrimaryCare
PhysicianSpecialist
Physician
PHO: Physician Hospital Organization
• Joint venture between hospital(s)and physician group(s)
• Acts as a single agent for managedcare contracting
• Aligns interests of hospitals andphysicians but allows each to retainautonomy
• Opportunity to act as a vehicle toadvance clinical integration networkinitiatives
Physician
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Page 26February 7, 2014
The Georgia Society of CPAs
CIN
What is a CIN?
A network of physicians working in collaboration with a hospital, usinga performance management infrastructure to develop and implementinitiatives to improve the quality and efficiency of healthcare services
Network negotiates and contracts with payers for improvedreimbursement based on quality and efficiency
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Page 27February 7, 2014
The Georgia Society of CPAs
Understanding BasicCIN Economics
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Page 28February 7, 2014
The Georgia Society of CPAs
What Does a CIN Do?
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Page 29February 7, 2014
The Georgia Society of CPAs
ACO: Accountable Care Organization
• “Under the program, primary care physicians areencouraged to join together with other providers to takeresponsibility for the full continuum of their primary carepatients’ care.”
• “[Physicians] must commit to reporting comprehensivemeasures of the quality and -- eventually -- outcomes ofcare. If they are able to improve quality and therebyreduce costs, they will receive a share of the savingsachieved.”
• “The term “accountable” is intended to mean just that;ACOs should only receive additional payments to theextent that they are demonstrably improving care for theirpatients.”
ACO
– The Dartmouth Atlas of Health Care –
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Page 30February 7, 2014
The Georgia Society of CPAs
MSSP ACOMSSP ACO: Medicare Shared Savings Program ACO
• Clinically integrated networks that have contracted withCMS to share in whatever money the community saves
– To be eligible for shared savings, must meetminimum performance standards for 33 ACO qualitymeasures.
– How do we know if they have “saved”?
– CMS reviews the historic costs of the patients in thenetwork and uses that as the baseline to determinesavings.
– As of January 1, 2014, 343 MSSP ACOs approvedby CMS.
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Page 31February 7, 2014
The Georgia Society of CPAs
MSSP ACO FunctionsWhat Really Matters
Establish and maintainquality assurance andimprovement program
Promote evidence-basedmedicine, patientengagement, care
coordination, patient-centeredness
Compile and reportparticipants’ quality
measure scores
Distribute shared savingsand assess shared losses
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Page 32February 7, 2014
The Georgia Society of CPAs
Each ACO participant continues to bill fee-for-service independently
Eligibility for and level of shared savings based on performance score
Calculate actual annual Medicare spent for assigned beneficiariesagainst pre-determined benchmark
Apply formula to determine share of savings (losses)
Calculating Shared Savings/Losses
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Page 33February 7, 2014
The Georgia Society of CPAs
Episode 1: Hip Replacement
• Orthopedic Surgeon• Surgery
o Anesthesiao Pathology
• Acute Care• Rehabilitation Facility
o PT
BPPBPP: Bundled PaymentProgram
• A single “bundled”payment covers the entirerange of servicesdelivered by two or morehealthcare providers thatare rendered during asingle episode of care orover a specified timeperiod
Single payment
- payment
- payment
- payment
- payment
- payment
- payment
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Page 34February 7, 2014
The Georgia Society of CPAs
Success in Bundling forEpisodes of Care
SuccessfulBundling forepisode of
care
Decrease Costs• Financial/Gain-
sharing Model
CreateEfficiencies
• Re-design CareModel
Improve Care• Quality Focus
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Page 35February 7, 2014
The Georgia Society of CPAs
What is Next?
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Page 36February 7, 2014
The Georgia Society of CPAs
Other InterestingDevelopments/Disruptions
• Gamification
• Big Data
• Quantified Self Movement
• Nanomedicine
• Digital Medicine
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Page 37February 7, 2014
The Georgia Society of CPAs
Questions?
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Page 38February 7, 2014
The Georgia Society of CPAs
Terms
ACO Accountable Care Organization
BPP Bundled Payment Program
CIN Clinical Integrated Network
eRx Electronic Prescription
FFS Fee-for-Service
HACs Hospital Acquired Conditions
HIE Health Information Exchange
HIT Health Information Technology
HVBP Hospital Value-Based Purchasing
IPA Independent Practice Association
IQR Inpatient Quality Reporting
MSSP Medicare Shared Savings Program
MU Meaningful Use
P4P Pay-for-Performance
P4R Pay-for-Reporting
PCMH Patient Centered Medical Home
PHO Physician Hospital Organization
PQI Physician Quality Incentives
PQRS Patient Quality Reporting System
PQRS Physician Quality Reporting System
PVBP Physician Value-Based Purchasing
VBP Value-Based Purchasing
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Page 39February 7, 2014
The Georgia Society of CPAs
Thank you!
David McMillan
Principal
PYA
865-673-0844