Opportunities in today's healthcare delivery system final
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Transcript of Opportunities in today's healthcare delivery system final
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