Practice Management: Pay for Performance Trends

1. Practice Management: Pay for Performance Trends Jama Allers, Practice Consultant MedChi, The Maryland State Medical Society

2. Change… • Monitor

3. Change… • Assess

4. Impact of Change

5. “Controlling Cost of Care” • What criteria are insurance carriers using to calculate “cost of care?” • Claims Data • Disease • Utilization • Outcomes = COST$

6. Claims Data Collected… • Physicians, Ambulatory Surgery Centers, Hospitals, Pharmacies, Laboratories, Diagnostic Centers, DME Suppliers, Skilled Nursing Facilities • Insurance carriers have been collecting this information for the last THREE to FIVE years.

7. Take a closer look at claims • ICD-9 • Level of specificity • CPT • Level of encounter • POS • Level of care

8. ICD-9Highest Level of Specificity • Diabetes 250. ? ___ • 0 = without mention of complication • 1 = with ketoacidosis • 2 = with hypersmolarity • 3 = with other coma • 4 = with renal manifestations • 5 = with ophthalmic manifestations

9. Diabetes • Diabetes 250. __?_ ____ • 6 = with neurological manifestations • 7 = with peripheral circulatory disorders • 8 = other unspecified manifestations • 9 = with unspecified complications

10. Diabetes Diabetes 250.___ __?__ • 0 = type II or unspecified, not stated as uncontrolled • 1 = type I juvenile, not stated as uncontrolled • 2 = type II or unspecified, uncontrolled • 3 = type I juvenile, uncontrolled

11. Super Bills, Fee Tickets • New ICD-9 codes effective October 1 each year • Leave 4th/5th digit ___ ___ • Be familiar with your most used codes

12. Super Bills, Fee Tickets • Number your diagnoses • 1.) Reason for today’s encounter • 2.) Other disease processes that impact your medical decision making • Diagnoses should be numbered the same way they are listed in assessment

13. Documentation of Quality Measures • Document in the patient record • Physicians are doing the work of the quality measure • Create templates • Incorporate into EMR • May be documented by ancillary staff

14. Physicians and P4P • 1998 First seen in Maryland • 2005 AMA released guidelines for evaluating P4P programs • 2005 MGMA released guidelines for P4P programs

15. Insurance and P4P • May offer employers • Lower premiums • Influences patients by • Lower out of pocket expenses • Website designation

16. CareFirst • 1998 PCP and Specialty Recognition Program • 2005 Bridges to Excellence Pilot Program • Practices financially rewarded for completing modules

17. CareFirst • 2009 CareFirst “Quality Rewards” • NCQA Accreditation • Cost for materials and per physician • Primary Care • Heart/Stroke • Diabetes • Back Pain

18. Aetna • 2004 AEXCEL Designation • Tiered Networks • Targets high cost specialties • Invitation only

19. United Healthcare • 2008 Premium Designation Program • Tiered Networks • Specialty and Primary Care • Evaluates efficiency • Unit price • Utilization rates • Physician comparisons

20. Medicare • 2006 Physician Voluntary Reporting Program • 2007 Physician Quality Reporting Initiative • “Pay For REPORTING” • Based on 74 initiatives • Report directly on CMS 1500 form • Modifiers • 2008 Physician Quality Reporting Initiative

21. PQRI “pay” ? • 2008 Professionals that report successfully are eligible for a 1.5 percent bonus payment • 2009 Funds have been allocated for PQRI

22. Worksheet • Example in your handout

23. PQRI -modifiers • 1P- Performance Measure Exclusion Modifier due to Medical Reasons • 2P- Performance Measure Exclusion Modifier used due to Patient Reason • 3P- Performance Measure Exclusion Modifier used due to System Reason

24. PQRI • Website and Downloads • Measures and codes • Reporting • Educational resources • PQRI Tool Kit • www.cms.hhs.gov/pqri

25. Winds of change for 2009 • All insurance carriers watching PQRI • Specialty Societies working with CMS to create initiatives • Volunteer vs. Mandatory????