Intentionally Well Collaborating physician

1. Planning for prevention with intention Terri Pinder, MSN, ANRP, FNP-BC Integrative Health Coach 772-215-9945 www.IntentionallyWell.com

2. Background Information • Lived in Martin County since 1977, moving from Long Island, New York • Attended Martin County High School, Graduated from John Carroll • Married for 30 years, 3 adult children, Same address since 1984. • Successful business owner, active community member, respected family • Nursing degrees from IRCC (1983) and FAU (1990, 1997) • Additional training in holistic and preventive medicine through Duke University Center for Integrative Medicine, the Health Sciences Institute, Functional Medicine University. • Nursing career that began at MMH, has included many settings and roles • Health promotion and chronic disease management have been a focus • Effective problem solver, consensus builder, change agent • Advocate for HC reform since 1992

3. Medicare AWV • Newly defined benefit un the PPACA of 2010, implementation 2011 • Supplements the ‘Welcome to Medicare’ assessment • Includes HRA, Biometrics, Personalized prevention plan that establishes both short & long term screening schedules • No Cost to beneficiary (No deductable/ No co pay). • Must be comprehensive covering assessment of risk for chronic disease, injury, urgent medical needs, psych/social factors, • Great deal of flexibility in how/where it is accomplished. • Multiple options for who can perform this service.

4. Services included in the Medicare AWV • Review and update medical and family history • Review and update a list of current providers • Measure height, weight, body mass index (BMI), blood pressure and other routine measurements • Assess for any possible cognitive impairment • Review potential risk factors for depression, including current or past experiences with depression or other mood disorders • Review functional ability and level of safety

5. Services included in the Medicare AWV • Establish or update a written screening schedule for the individual for the next 5-10 years, based on health status, screening history and age • Prepare a list of risk factors and conditions for which interventions are recommend or are underway for the individual, and a list of treatment options and their associated risks and benefits • Provide health advice and a referral, as appropriate, to health education or preventive counseling services or programs, designed to reduce risk factors, such as for weight loss, smoking cessation, fall prevention, and nutrition. • Review of the responses to the Health Risk Assessment

6. What Impact Can Prevention and Screenings Realistically have? Look at Hypertension: • An estimated 31.3% of the US adult population have HTN • 22.4% of those who have HTN are unaware that they have it • While 66.2% of those with HTN are screened in a doctors’ offices and 70% are on medication for their condition, less than half (46.2%) of those diagnosed have their condition in control. • Top 3 causes of death are: Heart Disease, Cancer and Stroke-all can be ameliorated with primary prevention.

7. AWV FACTS • Among persons over 65 years of age, only 33% of women and 40% of men are up-to-date on age specific screenings. • Very few beneficiaries know about this benefit, with only 7% having received this benefit. • It is complex and planning must be individualized. • While re-imbursement is decent, it requires a new practice flow, a different focus for visit that makes it difficult to integrate into a typical practice setting. • Re-imbursement is contingent on eligibility annually- this has been a big FAIL in many practices. With the right approach, the AWV can be an effective tool in improving health outcomes.

8. What is the right approach? • Tools that are efficient • Provider that is skilled • Setting that is conducive

9. Two Models for the Delivery of this Service • The Wellness Fair • Independent Contractor serving Independent Practitioners (IC2IP)

10. The Wellness Fair • Contract with various Organizations and Groups to provide the service • Requires billing directly under the mid-level NPI (85% reimbursement) • Generates referrals for IC2IP • Requires more overhead (Equipment, marketing materials) and sweat equity

11. Wellness Fair Process • Organization arranges location for fair. • Event is promoted by host organization and by Intentionally Well, LLC • On day of event, members complete the HRA, have blood drawn. • AWV appointment is arranged. Location may be community center or client’s home. Clinician provides supplies. • Billing submitted. • Reimbursement received. • Clinician and software license paid per visit. • Billing service and supervising physician is paid as a percent of collections. Wellness fairs have the potential of identifying those who have no PCP. For those established with a PCP, it provides the opportunity to reach out to that provider and demonstrate the value of this service.

12. The Independent Contractor serving the Independent Practice (IC2IP) • Contract with individual practices to offer this service in their office • Meets standards for “Incident to” billing under the PCP’s NPI (100% reimbursement) • Generates income for PCP via facilities fees

13. IC2IP Process • Contract is entered into between Intentionally Well, LLC and Independent Practice defining expectations/responsibilities. • Medicare patient list is provided to Intentionally Well, LLC for eligibility verification, appointment scheduled. • AWV appointment is accomplished at the IP practice location, Intentionally Well, LLC pays a facilities use fee per AWV to IP. • IC completes referrals, documentation and follow up in accordance with IP’s defined preferences. There are added benefits in terms of PQRS and MU measures. • Billing submitted by the IP’s staff, under his/her NPI as incident to the plan of care. • Reimbursement received by Practice, and forwarded to Intentionally Well, LLC. • Clinician and software license paid per visit. • Supervising physician is paid as a percent of collections.

14. So Much Being Left on the Table $868,170 in revenue

15. The Stakeholders • Principle, funder, administrator and provider • Community Based Groups • Independent Practices (PCP) • Medicare Beneficiaries • Software provider • Collaborating Physician (signed protocol with State of Florida)

16. If you are a Physician Who: • Believes it is our responsibility to participate in finding creative solutions to emerging challenges; • Honors the unique role of the Advanced Practice Nurse; • Respects the patient’s role in planning for his/her own well being; • Recognizes the value of prevention and screening to individuals and the larger system; • Is excited by the opportunity to participate in a business start-up, willing to invest in the form of “sweat equity”; • Holds integrity and ethical practice above quick profits; • Is willing to capitalize on his/her professional associations to gain insight into the struggles of colleagues in Independent Practice for the purpose of defining new solutions; Than this is a chance to be the change!

17. What I am Seeking • Physician willing to enter into a collaborative agreement of limited scope with myself and other mid-levels that will be added in the future. • Must be committed to finding opportunities in the current state of chaos resulting from reform. • Assists in identifying the particular needs of physicians as the model is improved to meet those needs. • Must be willing to enter into collaboration up to 3 months before any billing (and hence payment) can occur. • Must accept fair and reasonable reimbursement under the law. There will not be any stretching of the “Incident to” criteria in order to pay the supervising physician.

18. What I Can Offer • Percentage of collections; • Ideal approach to building a patient panel for your own individual practice; • Leadership role in a cutting edge health care business; • Expertise in details of regulatory-compliant health care management; • Full transparency with regard to earnings, opportunity to renegotiate contract terms as profits improve; • A collaboration wherein you can be confident that your integrity will not be compromised.

19. Terri Pinder, MSN, ARNP, FNP-BC 712-215-9946 www.IntentionallyWell.com Planning for Prevention with Intention…