PHYSICIAN SERVICES:
Where Are You Leaving
Money Behind?
Nelda Fields, WebsterRogers LLP
Gordon Wilhoit, MD, Value Health Partners
Julian “Bo” Bobbitt, Value Health Partners
2 0 2 0 H F M A S O U T H E A S T E R N S U M M I TF E B R U A RY 1 9 , 2 0 2 0
Today’s Discussions
❑ Improvements under Value Based Payment Systems▪ Quality performance and Outcomes
▪ EHR-Promoting Interoperability
▪ Improvement activities
▪ Patient engagement; Patient satisfaction
❑ Coding and documentation ▪ ICD-10 codes
▪ Risk Factor Adjustment and Hierarchical Condition Category (HCC)
▪ Contracting opportunities – Commercial, Medicare Advantage and Medicaid MCO
❑ Focus on Pay forward to Value Based Care▪ Value Based Coding
▪ Bonus opportunities
❑ Looking ahead and wrap up on key points
Reimbursement Systems and Patient-
Centered Delivery Care
Patient & Physician
Disease/ Episodic/
Population Management
Fee for Service
ACO and CIN
Medical Homes/ Primary
Care Models
MIPS and APM
Bundled Payments
Physicians clinically
focused and know
payments as FFS
“comfort zone”
Rapid changes in the
Reimbursement Systems –
Physicians must be aware
Collectively they
have the most control
over improving the
delivery and
management of care
and cost.
Success in transitioning
to value-based care
requires strong
leadership from
physicians and clinical
staff
Regulatory Push - Modernization Act of 2003, Affordable Care Act, MACRA,
Presidential Executive Orders
Source: CMS-MACRA-LAN.Path to Value.PPT
Those who participate in the most advanced APMs may be determined to be qualifying APM participants (“QPs”). As a result, QPs:1. Are not subject to MIPS2. Receive 5% lump sum bonus payments for years 2019-20243. Receive a higher fee schedule update for 2026 and onward
APM Participation and Qualifying Professionals (QPs)
Source: CMS NPRM-QPP-Fact-Sheet.pdf
5
Increasing challenges and Provider/Organizational Risk to maintain QP status
Growing Medicare Advantage as Percent of Total
Enrollment
6
21.95
23.7924.48
25.27
26.70
28.25
30.03
31.48
32.24
33.85
35.67
37.54
20.00
22.00
24.00
26.00
28.00
30.00
32.00
34.00
36.00
38.00
40.00
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Assigned Beneficiaries in Medicare ACOs
3,200,000
4,900,000
7,300,000 7,700,000
9,000,000
10,500,000 10,900,000
2,000,000
3,000,000
4,000,000
5,000,000
6,000,000
7,000,000
8,000,000
9,000,000
10,000,000
11,000,000
12,000,000
2013 2014 2015 2016 2017 2018 2019
Assigned Beneficiaries in Medicare ACOs
Over 500 ACOs with
almost 20% of Medicare
beneficiaries assigned
to one
CMS – New Model
Primary Care First is based on the underlying principles of the existing
CPC+ model design
Enhancing care for patients with complex chronic needs and high need
Focusing financial rewards on improved health outcomes
Population-based payment to provide more flexibility in the provision of patient care
along with a flat primary care visit fee
Performance based adjustment providing an upside of up to 50% of revenue as well as a
small downside (10% of revenue) incentive to reduce costs and improve quality
Assessed and paid quarterly
The Healthy Adult Opportunity (HAO) emphasizes the concept of value-based care.
New opportunity to support states with greater flexibility to improve the health of their
Medicaid populations and enhance Medicaid program through focus on accountability.
Required to report 25 quality and access measures drawn from the CMS Adult Core Set
Value Reimbursement -Commercial
Value-Based Reimbursements Hit 53% in 2017 in the commercial sector according to Health Payer Intelligence 12/19/19
“Not all payment reforms are equally effective and it’s time to put our energy towardpayment methods that don’t rely on fee for service but, instead, empower healthcare providers to manage our populations and assume financial risk for theirperformance,” said Robert S. Galvin, MD, chief executive officer of EquityHealthcare and chair of the Catalyst for Payment Reform board (CPR).
An overwhelming 91 percent of payers think that alternative payment model (APM) activity will increase in the future
LAN survey looked at responses from 62 health plans in addition to 7 fee-for-service (FFS) state Medicaid programs and the traditional Medicare program to evaluate APM utilization.
Source- https://healthpayerintelligence.com/news/value-based-reimbursements-hit-53-in-2017-reform-slows
Value Reimbursement by Source
Source- Oliver Wyman top 10 Prediction article
Do your Physicians understand key Drivers in
Value Reimbursement systems?
Medicare, Medicare Advantage, Medicaid, Commercials
- Quality measures
Understanding of all Specific quality measures captured and reported Example - MIPS measure - 110 and ACO-14 Preventive Care and Screening:
Influenza Immunization
Example – ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions
- EHR-Promoting Interoperability
Understanding of all Core PI measures and the workflow Example – ACO Certified EHR required
Example MIPS Core measures – Transition of Care and Closing the Referral Loop
Do your Physicians understand key Drivers in
Value Reimbursement systems?
- Improvement activities Example ACO-46 CAHPS: Care Coordination
Example MIPS IA 57- Care coordination plan
- Patient engagement/ Satisfaction (CAHPS) Example ACO-4 CAHPS: Access to Specialists
Example MIPS - IA_BE_12 Beneficiary Engagement Use Evidence-based decision aids to support shared decision-making.
- CostEvidence Based Medicine
Integrated system approach
What is needed to advance understanding and support? What data is needed? What compensation incentives are needed to share/ modify compensation?
Providers assume accountability for patients across the full continuum of services and associated reimbursement.
Drivers- Quality measures and Outcomes; EHR Interoperability and Data; Improvement Activities; Patient Engagement and Satisfaction
Source- Health Care Payment Learning & Action Network (HCPLAN, or LAN)
Physicians/
Providers
. Preventative Care
. Care Management
. Transition Care
Physician Engagement and Alignment
across System
Physician Engagement and Alignment
across System
RSM se – RSM Industry
RSM HC Industry updates 2020
However according to
Sullivan Cotter’s latest
report – a very small
fraction of physician comp
is tied to VBC
Patient-Centered - Payment Models
Aligned with Providers in the Delivery of Care
PHYSICIAN ALIGNED TEAMS
Source- chqpr.org website
Coding and Documentation
Focus In Value Based Payments
Nelda Fields
Stacey Mosay
Coding and Documentation Necessities
Capture Missed Revenue Opportunities
Reduce higher exposure for CMS Audits and other compliance issues
Code diagnoses to the highest level of specificity with required documentation
Codes impact Reimbursement in Value Payment Models (Risk Adjustment Factor)
Did the physician make a note about this diagnosis during this encounter, or is it just listed in the past medical history or in an ongoing problem list?
Capture diagnoses and assign codes according to MEAT criteria
Monitored, Evaluated, Assessed/Addressed, and Treated
Commonly missed diagnoses for lack of documentation
Alcohol/drug dependence, amputation status, diabetes and manifestations, renal dialysis status, secondary cancers, hemiplegia, transplant status, ostomy status, asymptomatic HIV, ventilator dependence
Risk Adjustments – Money to Payers and You
Risk adjustment is a reimbursement methodology where health insurers are compensated based on the underlying health status of their enrollees For MA, the RAF score is based on ICD-10-CM codes associated with the patient during the previous calendar year.
The RAF score determines the monthly payment to the MA organization (MAO).
A patient with multiple comorbidities will generate higher payments than a patient with fewer comorbidities, as well as be associated with more office visits, hospitalizations, tests, and prescriptions.
Providers are reimbursed for “value and cost” based on prior year expenditures for services provided through the contract.
Direct clinicians to focus on resource-intensive chronic conditions and preventive measures to drive down complications and costs
Align with Payers for Reimbursement results for your System
Reap enhanced incentive payments from payers
Seeks ways and Opportunities to Align with payers!
Hierarchical Condition Category (HCC)
Comprised of:
Diagnoses Only
Approximately 9,000 diagnoses map to 80 HCCs
No procedures- No E/M, CPT, or ICD-10-PCS
Categorize and compensate plans and providers for patients
who may need disease management interventions
Reimburse plans and providers who treat patients with higher-
than-average health care risks taking into consideration
complexity of care
Considered the ‘money codes’
Two Patients, Same Diagnosis, Different Care
Patient A is newly diagnosed
with influenza and pneumonia
Patient age is 35
Patient has no chronic
diseases
Patient B is newly diagnosed
with influenza and pneumonia
Patient age is 72
Patient comorbidities: Diabetes, type 2
Chronic bronchitis
Emphysema
Capturing the difference is called Risk Adjustment.
If the comorbidities are not documented and coded for Patient B, the true cost of
the encounter is not captured. Comorbidities bring extra risk, requiring extra
utilization of resources. The risk results in an adjustment of payment. Erroneously
reporting a more complex diagnosis can lead to overpayment.
Aged 75 female 1.062
Type 2 DM with CKD E11.22 0.318
CKD Stage 4 N18.4 0.237
HBP with controlled CHF I11.0 0.323
Long term insulin use Z79.4 0.104
BMI 42 Z68.41 0.273
Total 2.32 x $9,345 = $21,652
Benchmark in SC $ 9,345
Patient Encounter ICD-10 codes HCC Relative Factor
Aged 75 female 1.062
Type 2 DM w/o complications E11.9 0.104
Essential HBP none
Hyperlipidemia none
Total 1.166 x $9,345 = $10,896
What Does This Mean For Providers and Coders?
Improve the quality of documentation and coding of diagnoses. Successful in the Value
Based Payment Models
NEW E & M CODING – PROPOSED FOR 2021- Based on Medical Decision Making, Overall Time
Seek to Capture and Improve with External Coding and Documentation Audits and Provider
training
Records must be:
Specific
Accurate
Clinically valid
Unambiguous
According to guidelines
Accurate
To highest specificity
Complete
Supported by Documentation
Coding must be:
Value-Based Care Coding-
Paying the Way
Gordon Wilhoit MD
COMMERCIALBonus Quality
Fee Schedule Increase
Care Management Fee
MEDICARE
ADVANTAGEBonus
P4P
Risk
MEDICARE
MCO/HMOBonus
P4P
Risk
FFS
VBCAWVCCMTCMBHIPCMH
MIPS ACO
MSSPCPC+APMRisk
RPMTelehealthClinicalResearchTrials
STAR RATINGHCCRAF/SCORESBENCHMARKS
BUNDLEDPAYMENTS
Value Care Pathway
Depression $25 $25k
Alcohol $17 $17k
CVD $25 $25k
Tobacco $27 (8x annually) $27k -- $108k
Obesity $25 (14x – 22x annually) $350k
TOTAL $444k – $525k
LDCT $27 $27k
TOC $220 $220k
AWR $150 $150k
End of Life $84 $84k
CCM $40 $480k
TOTAL $1.2 -- $1.28 Million
BONUS
• PCMH3 Quality Metrics
• Medicare Advantage Quality Metrics,
Risk Adjustment Factor, and Timing of
AWR
• Medicaid Quality Metrics and
Preventive Care
New Opportunities
1) Assessment of Cognitive Impairment and Creation of
Care Plan
2) Additional CCM Codes Aligning Increased
Reimbursement with Complexity of Illness
3) Diabetes Self-Management Training
4) Obesity Management
5) Increased E&M Payment for Mobility Impaired
6) Diabetes Prevention Program
7) Collaborative Care Model – Integration of Behavioral
Health
8) Telehealth and remote patient monitoring, e consults
All of these
are DESIGNED
to increase
payments to
PCP’s by 37%
New codes for 2020 introduced by CMS
E-visits, patient initiated online through patient portal or secure
email, provider or licensed professional response online
Home BP monitoring, patient recorded data
PCP teamwork delivering health and behavioral assessment and
intervention
These codes are among those set up by CMS to emphasize use of
technology to monitor and interact with patients remotely.
E-consults, PCP initiated online or by phone, consult with
specialist about patient care, both providers may bill
Looking Ahead
Julian “Bo” Bobbitt
Is Major Change Really Coming?
Source: Congressional Budget Office
Total Spending for Health Care Under CBO’s
Extended-Baseline Scenario
Federal taxes and other
revenues consume about
19% of America’s gross
domestic product
% of GDP
What the Experts are Saying
“The places that get the best results are not the most expensive
places. Indeed, many are among the least expensive. This means
there is hope—for if the best results required the highest costs,
then rationing care would be the only choice. Instead, however,
we can look to the top performers—the positive deviants—to
understand how to provide what society most needs: better care
at lower cost. And the pattern seems to be that the places that
function most like a system are most successful.”
-Dr. Atul Gawande
Inpatient Days Per Decedent During The Last Six Months Of Life, By Gender And Level Of Care Intensity
(Level of Care Intensity: Overall; Gender: Overall; Year: 2007; Region Level: HRR)
Inpatient Days Last Six Months of Life
Percent Of Diabetic Medicare Enrollees Receiving Appropriate Management, by Race and Type of Screening
(Race: Overall; Type of Screening: Hemoglobin A1c Test; Year: 2003-2007; Region Level: HRR)
Percent of Diabetic Medicare Enrollees
Price-Adjusted Medicare Payments per Enrollee, by Adjustment Type and Program Component
(Program Component: Overall; Adjustment Type: Price, Age, Sex & Race; Year: 2008; Region Level:
HRR)
Price-Adjusted Medicare Payments
Trend continues- GDP Health Expenditure
This could be the dawning of the golden age of
health care — powered by technology advances
and innovation in patient-centered care.
BUT, it will be “Disruptive Innovation”
Source: Smith Anderson Law Horne
The 8 Essential Elements of a Successful ACO
These are the keys to recognizing whether to join or build an ACO
that is likely to succeed
| A B O U T O U R S P E A K E R S :
Nelda Fields Director, Healthcare Services Group
Over 30 years practice management, financial and operational
consulting, compliance, and other specialized services to healthcare
providers and organization
[email protected] | 843.577.5843
Stacey Mosay Consultant, Healthcare Services Group
29 years experience in health care and health information
management, compliance, coding, credentialing, data analysis,,
billing operations and consulting as well as auditing medical claims
[email protected] | 843.577.5843
Gordon Wilhoit, MD Clinical Innovation Director
Over 37 years’ clinical experience in primary care delivery
Alex Nunez Chief Operating Officer
• Over 20 years in health care, including 10 at leading hospital system Banner Health
• Seasoned CFO with experience in finance, operations, and value-based care
| A B O U T O U R S P E A K E R S :
[email protected] | 919.906.4054
[email protected] | 919.906.4054
Julian “Bo” Bobbitt President
Over 30 years’ experience in providing experienced strategic counsel
to assist healthcare providers and organizations
[email protected] | 919.906.4054
Founded in 1984, WebsterRogers LLP is a leading accounting and consulting firm
based in South Carolina. WebsterRogers has a core focus on the health care
industry. The Healthcare Service Group specializes in providing consulting,
outsourced management, value base reimbursement, compliance, accounting, tax,
employee benefits services to healthcare providers, including physicians; clinics;
hospitals and healthcare systems; ambulatory surgery centers; assisted living
centers, and others. Backed by RSM, WebsterRogers LLP enjoys unlimited
potential to provide high-level services to clients across a global marketplace.
www.WEBSTERROGERS.com
A B O U T W E B S T E R R O G E R S , L L P
Value Health Partners is your trusted partner in the transition
to value-based care delivery, offering focused strategic
counsel, development, and engagement services from industry
leaders with a demonstrated track record of success.
www.VALUEHEALTHPARTNERS.com
A B O U T VA L U E H E A LT H PA RT N E R S
