Opportunities in Today's Healthcare Delivery System

MGMA – TuscaloosaApril 24, 2013

William F. Cockrell, FACMPE

Personal32 years of medical management experienceFACMPEHealthcare organizations - Small primary

care, large multi-specialty, hospital network, large single specialty

Formed Cockrell and Associates, LLC in 2009Focus on

Practice managementNetwork development

Incentives Prior to 2010See more patientsDo more tests – appropriatelyHope fees did not get cut

What Happened in 2010The Accountable Care Act (ACA)Problems and Concerns but It’s Here to StayFinancially, the FFS Model Cannot be

SustainedHow Do You Argue with High Quality / Low

CostSo Let’s look for Opportunities

Today’s, and Tomorrow’s, OpportunitiesMedicareMedicaidBCBSElectronic Medical Records / Meaningful UseOperationsFuture

Or

The Three Levels of Incentives1. Just cause we like you2. We like you but we need you to prove you

like us3. We think we like you but you need to

prove that we should like you

What Base Do We UseCognitive encounters for Primary CareMajor surgery codes for general surgeonsSpecialty codesNew measurements

QualityCost

Primary Care Base for BonusesTypically, Primary care bonuses are based on

these: Office/outpatient visits, CPT 99201-99215; Nursing facility services, CPT 99304-99318; Domiciliary, rest home, or custodial care services,

CPT 99324-99340; and Home services, CPT 99341-99350.

In many cases, surgery and other non-diagnostic codes are included BCBS list is 20 pages long

Cause We Like You Category

MedicarePrimary Care Incentive Payment Program

Part of the ACARuns from2011 to 201510% bonus on to of the fee schedule payment

for select primary care services (earlier slide)60% of billings must fall in the primary care

services category

MedicareHPSA General

Shortage area10% bonusAll specialties plus chiropractors, optometrists,

podiatrists, medical tele-consults

MedicareHPSA - General Surgery

HPSA Surgical Incentive Payment (HSIP)1/1/2011 – 12/31/2015Covers major surgical procedures in a

geographic HPSAAdditional 10% on top of the regular HPSA

bonus

We Like You but We Need You to Prove You Like Us

Category

MedicareTransitional Care Management

Effective 1/1/2013CPT Codes 99495 and 99496Used to report physician or qualifying non-

physician care management services following a discharge for a hospital, SNF or CMHC stay

30 day transition period

MedicareTransitional Care ManagementRequires

Direct, telephone or electronic contact with the patient or care giver within two days of discharge

Medical decision making of moderate (CPT 99495) or high (CPT 99496) complexity

Face to face patient visit within 14 days (CPT 99495) or seven days (CPT 99496) of discharge

99495 about $150.00 99496 about $200.00

BCBS2012 Primary Care Value-Based Payment

ProgramThree Elements

Efficiency (5% bonus)Quantitative (5% bonus)Qualitative (5% bonus)

BCBSQualifiers

PMD doctor for at least one year in good standingMust practice Geriatrics, Family Practice, Internal

Medicine, General Medicine or Pediatric MedicineMust utilize ETFMust file claims electronicallyMust have 24 hour on call coverageMust be Board CertifiedMust participate in all applicable BCBS of

Alabama Networks

EfficiencyOverall Score of 70 is required

Generic drug utilization performance >90% = 75 points 88 – 89% = 60 points 86 – 87% = 45 points

Preferred drug utilization performance >90% = 25 points 88 – 89% = 20 points 86 – 87% = 15 points

QuantitativeOverall score of 70 is requiredPhysician Quality Indicators

> 2.5 = 75 points2.25 – 2.49 = 60 points2.0 – 2.24 = 45 points

Satisfaction3 Stars = 25 Points2 Stars = 20 points

QualitativeOverall score of 70 is required

Patient Centered Medical Home (PCMH) NCQA Level 3 = 75 points NCQA Level 2 = 60 points NCQA Level 1 = 45 points

NCQA Diabetes = 45 pointsActive E-Prescriber = 25 points

We think we like you but you need to prove that we should like you

Electronic Medical Records / Meaningful UseMedicare incentivesMedicaid incentivesPenaltiesMeaningful Use

OperationsPQRS

Should already be on boardA basis for future programs

CodingDocument

CredentialingDon’t be lateBe complete

Where Is All This Headed

OtherMedicare Value Based ModifierACO and other Shared SavingsOther

Medicare Value Based ModifierSupports the transformation of Medicare

from a passive payer to an active purchaser of higher quality, more efficient healthcare

Specific to Fee-For-Service (FFS) MedicareIt’s base is PQRSTwo primary components

Physician Quality and Resource Use Reports (QRURs)

A Value Based ModifierMandated to start in 2015 based on 2013

data

Medicare Value Based Modifier2013 – Focused on groups with 25 or more

eligible providers filing under a single tax identification number (TIN) who will receive QRURs

2015 – Groups with 100 or more eleigible providers filing under the same TIN will be subject to the modifier based on their performance in 2013

2017 - Expands to all physicians who participate if FFS Medicare

ACO’s and Shared SavingsShared savings are starting on the hospital

levelAccountable Care Organizations (ACO’s)

(excluded from the Value Based Modifier Program)Not any real traction in Alabama, yetPrimary care driven but control could be

through a hospital or large specialty network

So, why are these last two considered a positive?Information is powerIt’s time to get our information together now

andWhere it’s good – let everyone knowWhere it’s not good – fix it

PCMH?Meaningful Use?Next up – NCQA is looking at Specialty

Centered Medical Homes (SCMH)

Information is Here - Now

OperationsPQRS

Should already be on boardA basis for future programs

CodingDiagnosesDocument

CredentialingDon’t be lateBe complete

William F. (Bill) CockrellCockrell and Associates, LLC

www.caahms.combcockrell@caahms.com