kane - payment reform with acg...

Sunanda V. Kane, MD, MSPH, FACG

Payment Reform: Positioning YourPayment Reform: Positioning Your Practice for 2014 and Beyond

Sunanda Kane MD MSPH FACG

Professor of Medicine

Mayo Clinic Rochester MN

Disclaimers

• I am a clinician, not a practice manager, li k liti ipolicy maker or politician

• I didn’t change or make the rules

• I will probably put most of you to sleep, but maybe you might learn at least one new term todayterm today

ACG Women in Gastroenterology Forum - Chicago, IL Copyright 2014 American College of Gastroenterology

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Topics for Discussion(Alphabet Soup)

• Lowering costs to increase valueCMS I iti ti• CMS Initiatives– ACOs– Meaningful Use– PQRS– CMS Billing Reporting– VBPM (Value Based Payment Modifier)

• HIPAA violations• PEW (Physician Evaluation Websites)

Why are We Facing These Sweeping Changes?

H l h di i h US• Health care expenditures in the US went from 5.1% of GNP in 1960 to 17% in 2009

• This is unsustainable growth and the focus of health care reform has shifted to “optimizing value”optimizing value

Fineberg HV. NEJM 2012; 366:1020-27.


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Value Equation

Value = Quality

Cost

Lowering Cost

• Improve efficiency– Minimize overuse of endoscopy

– Weak inventory management

– Inefficient use of space/equipment/staff

• How?Develop efficiency metrics– Develop efficiency metrics

– Identify benchmarks

– Share data through registries


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Lowering Cost

• Process measures for efficiency– On-time starts

– Room turnover time

– Prep time

– Sedation time

– Procedure time (time to extent withdrawal)Procedure time (time to extent, withdrawal)

– Recovery time

Lowering Cost

• Outcome measures for efficiency– Patient wait times

– Flow time through unit

– Throughput (per unit or individual room)

– Resource utilization

– Overtime costsOvertime costs


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Bundling

• Concept is offering one price for a l t icomplete service

• Surgeons already do this, DRG for inpatient reimbursement

• Some practices already offer a bundled cost for colonoscopy-includes procedurecost for colonoscopy-includes procedure, meds, pathology, complications

CPT Coding

• CPT code most widely accepted medical l t t d ib di l i lnomenclature to describe medical, surgical

and diagnostic services

• Practices must report codes that match the description in the most current CPT book or risk losing revenue or being citedbook or risk losing revenue or being cited for fraudulent billing


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ICD 10

• Does not affect CPT (Current Procedural T i l ) dTerminology) code

• Start Date Oct 1 2014

• Codes reflect advances in medicine

• Diagnoses given greater detail

• 530.11 Reflux esophagitis now: – K21.0 GERD with esophagitis

– K21.9 GERD without esophagitis

Accountable Care Organizations

• Groups of doctors, hospitals, and other health care providers coming together voluntarily to p g g ygive coordinated high quality care to Medicare patients

• Goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errorspreventing medical errors

• Through the Advance Payment ACO Model, selected organizations will receive an advance on the shared savings they are expected to earn


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Accountable Care Organizations

• Participating ACOs will receive three types of payments:– An upfront, fixed paymentp , p y– An upfront, variable payment: Each ACO will receive a payment

based on the number of its historically-assigned beneficiaries – A monthly payment of varying amount depending on the size of

the ACO: Each ACO will receive a monthly payment based on the number of its historically-assigned beneficiaries

• The Shared Savings Program will reward ACOs that lower their growth in health care costs while meeting performance standards on quality of care and putting patients first

Meaningful Use

• Providers can qualify for federal incentive t h th d t tifi d HERpayments when they adopt certified HER

technology, up to $44,000 through Medicare Incentives and $63,750 in Medicaid

• If you do not adopt by 2015 MedicaidIf you do not adopt by 2015 Medicaid reimbursement will be cut 1% per year


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Physician Quality Reporting System (PQRS)

• A voluntary reporting program that provides anA voluntary reporting program that provides an incentive payment and prevents penalties for providers who report data on quality measures for Medicare patients

• For 2013 reporting period, 0.5% incentive payment based on total estimated allowed p ycharges for Medicare Part B fee for service

• Those who do not report measures for 2013 will receive a 1.5% pay cut in 2015

Physician Quality Reporting System (PQRS)

Ad i i t d b CMS ll t d t 144 i di id l• Administered by CMS, collects data on 144 individual quality measures

• CMS has started adopting patient satisfaction scores from its popular HCAHPS initiative, and hospitals with low scores are penalized

• Must report 3 individual measures or at least one 2013 measures group (HCV or IBD)

• Participation in a CMS-certified registry will satisfy this requirement (GiQuIC)

Scalise D. Hospitals and Health Networks. 2001;75(12):36-40


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Value Based Payment Modifier

• After reporting via PQRS, CMS will assign ti t lit d t ti b dpractices to quality and cost tiers based on

performance scores

• Scores will affect reimbursement rates

• In 2015, VBPM will apply if your practice has 100 or more eligible professionalshas 100 or more eligible professionals

• By 2016, groups 10-99 will be included

CMS Reporting of Billing• ACA mandates providing transparency to public in

regards to physician practice g p y p• Information on services and procedures provided to

Medicare beneficiaries by physicians and other healthcare professionals

• Contains information on utilization, payment (allowed amount and Medicare payment), and submitted charges organized by National Provider Identifier (NPI), Healthcare Common Procedure Coding SystemHealthcare Common Procedure Coding System (HCPCS) code, and place of service

• Based on information from CMS’s National Claims History Standard Analytic Files calendar year 2012


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CMS Reporting of Billing

• May not be representative of a physician’s entire practice as it only includesentire practice as it only includes information on Medicare fee-for-service beneficiaries

• Data are not intended to indicate the quality of care provided N t i k dj t d t t f• Not risk-adjusted to account for differences in underlying severity of disease of patient populations

HIPAA Violations

• Failure to adhere to authorization expiration date • Failure to promptly release information to patients p p y p• Improper disposal of patient records - Shredding is

necessary before disposing of patient’s record • Insider snooping - Avoided with password protection,

tracking systems and clearance levels• Missing patient signature • Releasing information to an undesignated party • Releasing unauthorized health information• Releasing unauthorized health information • Releasing wrong patient's information • Right to revoke clause – without one form is invalid • Unprotected storage of private health information


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HIPPA Violations

• Most recent June 23 2014P k i H lth S t i NE• Parkview Health System in NE Indiana/NW Ohio

• Left 71 boxes of patient records in the driveway of a physician of the practice when she was not home

• Settlement $800,000 to government• http://www.hhs.gov/news/press/2014pres/

06/20140623a.html

Physician Evaluation Websites

• Questions can be broken down into 5 categories– Overall rating g– Communication skills (explanation of medical care/treatment,

follow-up, attentiveness, listening skills, and bedside manner) – Access (availability of appointments, ease of scheduling,

punctuality) – Facilities (office cleanliness, lab services, waiting room

accommodations) – Staff (courtesy, friendliness, professionalism)

• Most important factors cited by patients: physician expertise, wait time for outpatient appointment, and wait time for surgery

De Groot A. Med Decis Making 2012;32(6):764-778.


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Physician Evaluation Websites• The Good• Most physicians are rated positively

O li ti t l fl t ti t ti f ti• Online ratings may accurately reflect patient satisfaction • High rankings (for hospitals) associated with better medical care• The Bad• Very few patient experiences determine composite score of an

individual physician • PEWs do not verify authenticity of a patient’s review • Information may be outdated and inaccurate • Patient complaints may not be within a physician’s influence • Physicians might avoid care of patients likely to have bad outcomes • The Ugly• Anonymity of online reviews and their potential for abuse may lead

to lawsuits

Merrell J. Am J Gastroenterol 2013;108:1676-85.

Take Home Points

• The practice of Medicine is changing

• What happens at government level trickles down to commercial payors

• Take care of your patients prudently and safely, document and bill appropriately and you will be fineand you will be fine

• There are resources to help navigate you and your practice through the maze


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