Value Based Care Education is Key! Rural Health Association Lisa McFann MSN/ED, RN Kimberly Kicklighter BSN, RN
Value Based Care requires a NEWway of thinking! “It’s not the strongest of the species that survives, nor the most intelligent that survives. It is the one that is most adaptable to change.” Charles Darwin
Changes in Healthcare Triple Aim- Better Care, Lower Cost and Improved Patient Experience The Affordable Care Act (2010) was the driving force behind: • Health insurance reform (beneficiary / patient): • Providing access to affordable and adequate health insurance • Higher Premiums • Higher Deductibles • Promoting Wellness Visits • Healthcare payment and delivery system reform (provider and facility): • Improving quality and reducing costs in Medicare and Medicaid programs • Quality Measure • Resource Use • Risk Adjustment
CMS stated the goal is to move 90% of payments from feefor service to alternative payment models by2018 In January 2015, the Department of Health and Human Servicesannounced new goals for value-based payments and APMs inMedicare Volume to value: Target % for Medicare reimbursementshift Medicare Fee For Service payment tied to volume Payments linked to quality or value through alternative payment models link ACOs or bundled payment arrangement Payments linked to quality or value through programs like Hospital Value Purchasing & Hospital Readmissions Reductions 2011 2014 2016 2018 Internal goals HHS- so we need to be ready! SOURCE: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-LAN-PPT.pdf
MACRA what is it ? Background Fears MACRA permanently eliminated the SGR (and annual rate cuts) - 2015 Medicare projects 70% of rural practices with 2-9 doctors will be penalized via MIPS Consolidated Medicare PQRS, MU, VBM reporting programs 50 percent of non-pediatric physicians have NEVER heard of MACRA Established a path to predominant Value-Based payment methodologies MIPS program is budget neutral; penalized providers will pay the rewards for other providers Passed with bipartisan support in the Senate (92-8) and the House (392-37) It is widely reported MACRA will force further consolidation
MACRA and the Quality Payment Program (QPP) MACRA is bipartisan legislation that significantly changes how physicians are reimbursed for providing healthcare to Medicare beneficiaries Replaces the Sustainable Growth Rate (SGR) $ Extends the Children’s Health Insurance Program (CHIP) Transitions from fee-for-service to pay-for-value Physicians must choose one of two paths: 1 2 Advanced Alternative Payment Models (APMs) Merit-based Incentive Payment System (MIPS) 5% Lump Sum Payment Performance-based payment adjustment Clinicians are evaluated based on their Composite Performance Score (CPS) Comprehensive End-Stage Renal Disease Care Model Large Dialysis Organization (LDO) arrangement Quality 60% Non-LDO two-sided risk arrangement $ Resource Use 0% Comprehensive Primary Care (CPC+) Model Medicare Shared Savings Program (MSSP) Track 2 Advancing Care Information 15% Medicare Shared Savings Program (MSSP) Track 3 Clinical Practice Improvement Activities 25% Next Generation Accountable Care Organization Model MACRA will engender widespread payment reform for physicians, regardless of their specialty Oncology Care Model, two-sided risk arrangement only *CPS domain weights (%) are for the 2017 performance year
Legislation – Affordable Care Act (ACA) Incentive Payments and Authorization Under the ACA, the Secretary of Health and Human Services established many new rules and new programs with the goal of transforming the way we deliver healthcare. The most impactful are: 1 2 Value Based Care models ACO, PCMH, MSSP – just to name a few ! Risk Adjustment- Used to calculate the spending budget and utilization of a patient for the following year.
The core goals and strategies for healthcare payment reform 1 Control overall healthcare spending 2 Improve population health through preventative services 3 Compare clinical quality through quality measures and analytics 4 Assess patient satisfaction through CAHPS and HOS surveys
Rural Healthcare Challenges High costs and Fewer Resources Fragmentation and variation Physician Burnout Provider shortage Health care disparities Aging and sicker population ICD-9 to ICD-10
Rural Healthcare Advantages Dominant provider in the area: Strong community loyalty, can help rural hospitals with negotiations with providers in larger market areas interested in securing rural hospitals as a source of referrals Advantages for rural healthcare providers transitioning to value-based care Ability to offer non-traditional medical services: Rural hospitals can help fill some gaps in the continuum of care (mental health, dental), which is helpful as they consider opportunities to improve the health and needs of the community Strong local governance As smaller facilities, rural hospitals benefit from strong local governance that allowing them to be more nimble in responding to community needs in a dynamic payment environment Defined service area: A rural hospital’s defined service area lends itself to tailored approaches to population health management and patient engagement Source: Healthcare Financial Management Association
Historically Providers: • Document the history of a patient when the patient is new- They do not document on an annual basis • Submit CPT & ICD diagnosis codes on claims to validate reimbursement for services already rendered. To get Paid! • Look at outcomes from a financial perspective. • Treat chronic conditions as maintenance visits • Preventive care was treated as an option to patients because traditionally is was not a covered service • Does not utilize care teams to assist in the care and management of patients.
Successful Value Based Programs require providers and staff to be educated in the following : 1 2 • Quality Program • Process to capture quality measures • Quality Measure Cheat Sheet • Annual Wellness Visit (AWV) • Day to day office visits • Patient Engagement • Chronic Care Coaching • Shared Decision making • Motivational Interviewing 3 4 • Coding • Coding accuracy • Highest level of specificity • Risk Adjustment • RADV Audit Compliance • Wellness & Prevention • Annual Wellness Visit • Chronic Care Management • Transitional Care Management • Advanced Care Planning • Patient Health Coaching
Understanding Risk Adjustment Risk adjustment: a predictive analytics tool utilizing actuarial data from claims submitted by health care providers, used to determine payments based on the relative health of at-risk populations. How Risk Adjustment Works: Submitted I-10 codes that risk adjust will be used by a payer to calculate each of your patients’ Risk Adjustment Score The RAS will determine the projected ‘spending budget’ and prospective payments during the coming calendar year Profitability or losses will depend on the net difference between Risk Adjusted payments and actual utilization costs for care rendered.
Risk Adjustment Education for Rural Health Systems is Critical Accurate for Fee for Service Reimbursement Accurate calculation of patient acuity Accurate risk adjustment for cost and quality measures Physician Compare website publishes data Level the paying and playing field with payers Payers will continue to move towards risk adjusted contracts
Risk adjustments impact for Value-Based Reimbursement Value Based Purchasing- Pay-for-Performance Medicare Advantage – Capitated Payment Medicare ACO Shared Savings Program – ACO Shared Savings/Risk MACRA- MIPS vs APMs- Quality Payment Programs Hospital Quality Performance- Clinical Care- (Mortality), Safety- (Infection/HAC Rates), Efficiency- (Spend per patient) Quality and Resource Use Report- report provides an overview of quality, cost and utilization for providers Source: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/Riskadjustment
Name: John Doe Gender: Male DOB: 07/01/1950 Height: 64 inches Weight: 240 pounds BMI: 42 Let’s look at an example! Chief Complaint & HPI: No symptoms, presents for AWV with known T2DM on Insulin x 7 yrs. Polyneuropathy, COPD & Major Depression Past Medical History: T2DM, Polyneuropathy, COPD, Major Depression, Traumatic tow amputation (1996) ROS: Per HPI, all other symptoms negative Exam: Unremarkable except for obesity, decreased breath sounds and expiratory wheezes, great right toe amputation and positive monofilament Assessment/Plan: (1) Preventative visit and findings discussed (2) DM, Type 2 – stable, continue current treatment plan (3) COPD – stable, continue Advair (4) Neuropathy – stable, optimize BS control (5) Major depression – stable, continue Lexapro (6) Morbid obesity – IBT to lose weight John Doe has an Annual Wellness Visit (AWV) with his primary care doctor. His AWV notes are in the report above.
Risk Adjustment Pays! As you can see, when John Doe’s PCP codes more accurately the annual payment for providing care is significantly higher – over $16,000!
The 4 Keys to Improving Rural Healthcare Quality and Financial Outcomes: 1 Mastering Risk Adjustment Factor (RAF) recognition, documentation, and coding! 2 Mastering compliance with quality measure reporting 3 Eliminating inefficient spending and resource consumption 4 Delivering exceptional customer service to achieve outstanding patient experience
Key Takeaways Healthcare as we know it has changed Education is the key to population management! Educate on Risk Adjustment Every person in the office needs to understand the data, goals, and processes. Audits should be performed routinely. Redesign your care teams. Use staff already in place. Maximize analytics. Data is powerful. If it’s not documented it wasn’t done. Healthcare 101… Preventative care was treated as an option to patients because traditionally is was not a covered service. Make it a PRIORITY!