Where capital P meets little p: Translating policy to ... Library/SGIM/Communities... · 1....
Transcript of Where capital P meets little p: Translating policy to ... Library/SGIM/Communities... · 1....
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Where capital P meets little p:Translating Policy to practice
Scott V. Joy, MD, MBA, FACPChief Medical Officer
HCA Physician Services Group, Continental DivisionDenver, Colorado
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Learning Objectives
• Understand the building blocks and forces in play to change health care reimbursement from volume to value based
• List two challenges a general internist may face by being in an Accountable Care Organization (be prepared to share with the group)
• Create an advocacy statement to use at your organization in support or in opposition of being part of an Accountable Care Organization (be prepared to share with the group)
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“The way physicians are organized and reimbursed in the United States is undergoing a once-in-a-generationtransformation from a fee-for-service system to alternative payment models.”
N Engl J Med 375;2: 104-105
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Health Policy Progress toward Value over Volume• The shifting definition of ideal medical practice is a fundamental
challenge in health policies that are always at risk of promoting standards that are outdated.”*
• Health Maintenance Organization Act 1973• American Recovery and Reinvestment Act (ARRA, HITECH), 2009
*J Gen Intern Med 30(6): 848-52
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https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2014/09/deciphering-the-reform-alphabet. Accessed December 7, 2017
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March 23, 2010
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“The shifting definition of ideal medical practice is a fundamental challenge in health policies that are always at risk of promoting standards that are outdated.” J Gen Intern Med 30(6): 848-52
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Accountable Care Organizations
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CMS Definition of ACO
• ACOs are groups of doctors, hospitals and other healthcare providers, who come together voluntarily to give coordinated, high-quality care to the Medicare patients they serve. Coordinated care helps ensure that patients get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds in both delivering high-quality care and spending healthcare dollars more wisely, it will share in the savings it achieves for the Medicare program.”
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https://www.advisory.com/research/care-transformation-center/care-transformation-center-blog/2014/09/deciphering-the-reform-alphabet. Accessed December 7, 2017
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https://www.cms.gov/Medicare/Fraud-and-Abuse/PhysicianSelfReferral/index.html?redirect=/PhysicianSelfReferral/95_advisory_opinions.asp. Accessed December 11, 2017
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https://www.hhs.gov/about/leadership/secretary/speeches/2018-speeches/remarks-on-primary-care-and-value-based-transformation.html
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Medicare Shared Savings Program
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/about.html. Accessed December 11, 2017
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• Focus on Transitions of Care• Focus on Preventive Services (Meet Quality Measures through
Preventive Visits)• Document Patient Complexity (HCC, ICD-10)
Building Blocks For Success in an ACO
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https://theincidentaleconomist.com/wordpress/aco-calculations-explained/Administrative Lingo: “Open Gates”
ACO Calculations Explained
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Four Ingredients for Engaging Physicians in a Network Setting
• Culture• Trust• Decision-Making• Local Infrastructure
https://catalyst.nejm.org/four-ingredients-independent-physician-network/. Accessed December 7, 2017
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Risk Adjustment
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Risk Stratification: Key Terms• Risk Adjusted Factor (RAF)• Hierarchical Condition Category (HCC)
a payment model mandated by the Centers for Medicare and Medicaid Services (CMS) in 1997.The HCC/RAF (Risk Adjustment Factor) point system is a "shadow" calculation that affects every physician's reimbursement, no matter what goes on the bill. The HCC/RAF regulation assigns a point value to a relatively small number of ICD diagnosis codes that indicate serious disease
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Each HCC-RAF must be:
1. Documented, coded and submitted on a payment claim form during each ‘calendar year’.
2. Addressed on a ‘face-to-face’ encounter with a provider.
3. Supported by ‘medical decision-making,’ especially when certain conditions are linked based on ‘cause & effect’ and generally carry a higher RAF weight when linked, e.g., Diabetes Mellitus w/ manifestation/complication.
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HCC 17: Diabetes with Acute/Chronic Complications
HCC 22: Morbid Obesity
HCC 58: Major Depressive, Bipolar, Paranoid Disorders
HCC 111: Chronic Obstructive Pulmonary Disease
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• 66 year old male presents for routine follow-up appointment for Type 2 Diabetes, Depression and Obstructive Sleep Apnea.
• Medication List• Insulin glargine• Oxygen 2L at night • Exam: BMI 41.0 kg/m2• PHQ9 score of 9(Mild depression)• Loss of monofilament sensation
bilaterally• Absent right great toe due to DM foot
ulcer in past
Condition ICD-10 Poor coding Appropriatecoding
66 y old male n/a 0.288 0.288
BMI 41.0 kg/m2 (morbid obesity)
E66.01 Not recorded 0.273
T2DM uncomplicated
E11.9 0.118 ----
T2DM with neuropathy
E11.40 ----- 0.368
Chronic Insulin Use
Z79.4 Not recorded 0.118
Depression, unspecified
F32.9 0.000 -----
Major Depression, single, mild
F32.0 ----- 0.330
Great toe amputation
Z89.419 Not recorded 0.779
Chronic respiratory failure, hypoxia
J96.1 Not recorded 0.329
RAF Score 0.406 2.485
PMPM Payment $325 $1,98826
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Colorado Care Partners Market
Actual $$ $102.00 PMPM $100.00 PMPM
We are more costly in total dollars
Risk Score 1.05 1.00
Normalized $102/1.05 = $97.14 $100/1.00 = $100
Now we beat the market; cost gate opens
Risk Adjustment Financial Adjustment
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Shared Savings Models Create Economic Winners and Losers• Whose revenue is lost to create savings• Who receives reduced expenses or proceeds• Who controls the flow of funds in these models
N Engl J Med 375;2: 104-105. July 14, 2016
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Questions:
• Are you practicing in an ACO or Clinically Integrated Network?• What will be your advocacy talking points at the local level in regards
to Alternative Payment Models?
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http://files.kff.org/attachment/Fact-Sheet-Medicare-Advantage
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https://www.medicare.gov/find-a-plan/results/planresults/plan-list.aspx#Errors
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https://www.healthcaredive.com/news/provider-groups-ask-medicare-advantage-be-counted-as-apm-under-macra-in-201/444194/
Administrative Lingo: “On Ramp”
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http://www.ncqa.org/portals/0/Public%20Policy/VBID_Fact_Sheet.pdf. Accessed December 9, 2017
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https://innovation.cms.gov/initiatives/vbid/index.html. Accessed December 7, 2017.
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https://innovation.cms.gov/initiatives/vbid/index.html. Accessed December 11, 2017
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https://www.civhc.org/shop-for-care/
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Principles of Advocacy
• Find Your Message• Stay on Message• Take the High Road• Visibility Wins
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Advocacy is relationship building
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Compelling Narrative
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Your Thoughts and Thank You!