Disclaimer 1/12/2015 HEALTHCARE REFORM. Compliance, Medicare Advantage and Accountable Care Organizations

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1 HEALTHCARE REFORM Compliance, Medicare Advantage and Accountable Care Organizations Jon Weeding President CS EYE Disclaimer This material is designed to offer basic information for creating a compliant atmosphere in the small private practice. The information presented here is based on the experience, training, and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omissions, misuse, or misinterpretation. This presentation is intended as an educational guide and should not be considered a legal/consulting opinion. CPT is a registered trademark of the American Medical Association. All rights reserved. Introduction: Compliance, Medicare Advantage and Accountable Care Organizations Provide understanding of Healthcare Reform driven compliance Provide insight into what minimum requirements must be met to ensure full participation within healthcare reform and newly forming organizations Define new organizations and Review changes impacting optometry Medicare Advantage Plans Managed Care Organizations Accountable Care Organizations 1

2 Healthcare reform driven compliance: Funding for enforcement Minimum requirements for on-going participation with plans Standard of care Attestation Reporting Auditing Healthcare reform driven compliance: Funding for enforcement Patient Protection and Affordable Care Act put teeth into the laws already in place Funded Medicare Program Integrity Partners for enforcement Audit are big business $23 for $1 Healthcare reform driven compliance: Minimum requirements for on-going participation Meet compliance standards for written and followed policies and procedures, a risk assessment in place and proper medical record documentation Provide best practices standard of care To have an electronic medical record system To have universal formatting of certain components of the record To communicate with other providers through electronic pathways 2

3 Written Policies and Procedures Policy - Compliance Officer; Privacy Officer; Public Information Officer and Security Officer Policy - Business Associates Defined; BAA Template Policy - Practice Standards Policy - Procedures and Adherence to Health Care Laws and Regulations Policy - Record Retention, Privacy and Security Policy - Auditing, Benchmarking and Monitoring of Charts and Claims Policy - Training and Education Policy - Communication and Compliance Reporting Policy - Enforcement, Employment and Employee Discipline Policy - Inspection Risk Assessment Identify all potential risks Create a document of findings of all risks Identify HIPAA regulation each risk potentially violates Identify each risk as High, Moderate or Low Identify mitigation plan for each risk Create a time table for mitigation of risks identified Healthcare reform driven compliance: Standard of Care Fee for service plus models drive healthcare reform Outcome based to drive cost down Coordinated care within organizations Include chronic coding on claims form 3

4 Healthcare reform driven compliance: Attestation with Certified EHR for Meaningful Use Why? Inviting Audits? Not worth it? Stimulus funds to drive reform with ultimate goal of reducing healthcare costs through coordinated care Tracking who is opting in and fully participating in healthcare Risks of not attesting: Not part of panels in the future Lost patients Healthcare reform driven compliance: Minimum requirements for on-going participation Age of Big Data tracking: Claims data to review panel members Attestation for meaningful use Coding, HCCs (fee for service plus) PQRS/E-Prescribe Standard of Care Reporting Outcomes (registries) Secure communication with patients and providers HEALTHCARE REFORM MCOs, MAs and ACOs MCO = Managed Care Organizations MA = Medicare Advantage Plans ACO = Accountable Care Organizations Review impact from each of these 4

5 MCOs, MAs, and ACOs Changing the way healthcare is delivered and paid for (fee-for for-service +) Driven by primary care provider and outcome based (huge incentives for saving $$) Managed Care Organizations (MCOs), Medicare Advantage Plans (MAs) and Accountable Care Organizations (ACOs) and impact on Optometry Managed Care Organizations Continuum of Organizations that provide managed care. Common network-based managed care programs: Managed Care in a Public Setting (MCPS) Health Maintenance Organization (HMO) Independent Practice Association (IPA) Preferred Provider Organization (PPO) Point of Service (POS) Private Fee-For-Service (PFFS) Managed Care Organizations Impact: Overall impact is widely debated Proponents: Increased efficiency Improved overall standards Led to a better understanding of relationship between costs and quality State there is not consistent, direct correlation between the cost of care and its quality 2002 study estimated that the "cost of poor quality" caused by overuse, misuse, and waste amounts to 30 percent of all direct health care spending. The emerging practice of evidence based medicine is being used to determine when lower-cost medicine may in fact be more effective. 5

6 Managed Care Organizations Impact: Overall impact is widely debated Opponents: For profit managed care has been an unsuccessful health policy Higher costs (25-33% higher overhead at large HMOs) Increased number of uninsured Health care providers driven away Downward pressure on quality National Committee for Quality Assurance showed worse scores on 14 of 14 quality indicators Impact to Optometry Capitation plans Managed Care Organizations Place ODs in role of micro-health insurers Assuming responsibility for managing the unknown future health costs for their patients Transfers risk of providing services at capitated rates Replacing tradition Medicaid with Vision Care Plans providing routine vision care Reduction in reimbursement Managed Vision Care Plans Vertically integrated player EyeMed/Luxottica aggressively pricing plans in order move consumers to retail stores VSP starting to add Luxottica locations Improved online sites and consumer comfort in online purchases Another discussion another time 6

7 Medicare Advantage Plan A type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefit An alternative to Traditional Medicare plans Many seniors are transitioning to Medicare Advantage Similar coverage to Traditional Medicare Higher premiums with better coverage May include prescription drug coverage May include routine eye care coverage May include dental coverage Medicare pays these privately run plans a set "premium" per enrollee for hospital and physician services (averaging $10,123 in 2012) based on a prediction of how costly the enrollee's care will be. UnitedHealth and Humana make up one third of all MA plans. Risk adjustment was implemented to pay Medicare Advantage Plans more accurately for the predicted health cost expenditures of members by adjusting payments based on demographics (age and gender) as well as health status. "Medicare overpayments to private plans, : Shifting seniors to private plans has already cost Medicare US$282.6 billion." Ida Hellander, M.D., Steffie Woolhandler, M.D., M.P.H., David U. Himmelstein, M.D. International Journal of Health Services, May 10, 2013 (online first), Vol. 43, No. 2. DOI: /HS.43.2.g Medical Record Documentation Important for Risk Adjustment Accurate risk adjusted payment relies on complete medical record documentation and diagnosis coding. CMS conducts risk adjustment data validation by medical record review. Specificity of the ICD-CM diagnosis coding is substantiated by the medical record. 7

8 Risk Adjustment Audits CMS audits about 30 Medicare Advantage Plans (MA) contracts each year. Passed down to providers (physicians) MA payments based on number of members Increased payments if claims show increased percentage of sick people during a reporting period. Risk adjustment audits of facilities ($13 million to provider over one reporting period) MA plans have huge incentive to work with facilities and providers to make sure they are following standard of care and reporting chronic illnesses on claim form (not just in chart) Risk Adjustment audits of physicians pulling charts to review chronic care patients. New claim forms can hold up to 16 diagnosis. Recommend reporting chronic conditions on all claim forms. May require provider to resubmit. Not usually a recoupment type audit. Stars Ratings affected and can reduce payments Stars Ratings for Medicare Advantage Plans (MA) 1-5 stars covering health services Measuring the overall score for quality of those services and covers 36 different topics in 5 categories Staying Healthy: screenings, tests, and vaccines; Includes how often members got various screening tests, vaccines, and other check-ups that help them stay healthy Managing chronic (long-term) conditions: includes how often members with different conditions got certain tests and treatments that help them manage their condition Ratings of health plan responsiveness and care: includes ratings of member satisfaction with the plan Health plan member complaints and appeals: includes how often members filed a complaint against the plan Health plan telephone customer service: includes how well the plan handles calls from members PA Medicare Advantage plan stated ODs were main culprit behind drop from 5 stars to 4 stars (standard of care, chronic disease, and communication). If plan falls to 4 stars and doesn t come back up to 5, the plans funded is cut drastically, typically leading to failure/closure of that MA plan. Big $$ in play!! Standard of care!!! Websites showing fees, reviews and claims data based on standard of care UnitedHealth reduced panel of optometrists in PA by 10%. No data showing how decision made, but 8

9 Accountable Care Organizations An accountable care organization (ACO) is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients. The ACO is designed to address a key problem: The fragmented, disconnected nature of fee-for-service health care delivery in most parts of the U.S. and the ways in which it rewards volume instead of results. Approaches vary, but in practice, an ACO should allow hospitals, clinics, administrators and clinicians to work together usually across systems to address challenges in planned, measurable ways. It should be able to manage a continuum of care as an integrated system either an actual integrated system or a virtual one. It should be large enough to support meaningful and comprehensive performance measures. And lastly, it should be able to distribute payments of shared savings (as well as allow the sharing of risk) internally among participants The state of Accountable Care Organizations 500+ as of 9/1/ CMS funded and approximately 250 private-sector 3 Models (Pioneer, Shared Savings, Advance Payment Model) Pioneer ACO Model support organizations with experience operating ACOs or similar arrangements to provide more coordinated care to beneficiaries at a lower cost to Medicare. 32 ACOs participated in this demonstration project. Allina, Fairview, Park Nicollet in MN 9

10 Shared Savings Program rewards ACOs that reduce their growth in health care costs while putting patients first and meeting performance standards on their quality of care. The organization shares in the costs savings with CMS (85%). 220 ACOs participated in this program. Advance Payment ACO Model is designed for physician based and rural providers who are already interested in the Shared Savings Program and are coordinating high-quality care to Medicare patients. This model allows selected participants to receive upfront and monthly payments, which they can use to make important investments in their care coordination infrastructure, such as purchasing electronic health records and hiring nurse diabetes educators. 35 ACOs participated in this demonstration project. Health care leaders are focusing on finding ways to achieve Triple Aim outcomes the simultaneous improvement of the health of a defined population, the experience of each individual within it, and the affordability of care. Enter the ACO. The Affordable Care Act, for example, set aside $10 billion for the creation of a Medicare Center for Innovation to evaluate new approaches to health care, such as ACO reforms and payment models, through MN Organizations that are already performing in a manner similar to an ACO and implementing alternative accountable care models/contracts: Allina Hospitals & Clinics (ACO) Fairview Health Services (ACO) Health Partners Park Nicollet Health Services (ACO) Mayo Clinic St. Mary s/duluth Clinic Health System Avera Health Sanford Health Optum Health 10

11 o Key Issues and Challenges for ACOs Engaging physicians to change practice patterns and practice more in teams: Following professional medical guidelines Implement EHRs Treating patients with chronic illness as an interdisciplinary team and implement teambased care Standardized reporting metrics across multiple payers Hiring Health Information Technology support staff to maintain functionality of EHRs Compliance will be key to participate o Performance measurement and evaluation Physicians receive monthly feedback on his/her performance measured against the performance of other physicians/practices. Registry outcome based Impact on Optometry o Goal for a reduction in health care expenditures from feefor-service from 78% to 50% o Participation risks outside looking in Group practice in OH drove 500 patients per month to their facilities by proactively promoting the benefits of their group joining ACO (raised HEDIS scores) 11

12 HEDIS (healthcare Effectiveness Data and Information Set) performance measures in managed care. Developed and maintained by the National Committee for Quality Assurance NCQA. Required for Medicare Advantage plans 75 HEDIS measures are divided into eight domains of care o Effectiveness of Care o Access/Availability of Care o Experience of Care o Health Plan Stability o Utilization and Relative Resource Use o Informed healthcare choices (availability of new member orientation, education and language translation services, etc.) o Health Plan Descriptive Information o Requirements for participation Be present at the table Compliance minimums EHRs and communications with other specialties Standard of care must be followed Outcome based Registry Risks To Optometry Patient base attrition due to exclusionary contracts Decreased efficiency due to increased documentation and reporting Benefits to Optometry Increased patient based due to increased contracts Increased payments with fee-for-service plus (new healthcare dollars introduced into the system) Increased care based on outcome analysis Hope it works medicine Specific, outcome based, patient specific care 38 year old, diabetic with retinopathy care plan 65 year old, diabetic with retinopathy care plan 12

13 5 stages of Healthcare Reform Grieving DENIAL Refusal to accept facts THEY ARE TOO BUSY TO WORRY ABOUT ME IT S NOT LIKE THEY CAN CHECK EVERYONE I BOUGHT A MANUAL 10 YEARS AGO, A LOT OF GOOD THAT DID ME AND NOBODY EVER ASKED TO SEE THAT IT WILL NEVER HAPPEN TO ME Anger Upset with self/ upset with others THANKS A LOT OBAMA CARE THEY WON T BE HAPPY UNTIL THEY CLOSE EVERY O.D. HOW DO THEY EXPECT ME TO SEE PATIENTS I M JUST GOING TO SELL MY PRACTICE I WISH I HAD JUST WENT TO LAW SCHOOL YOU GUYS ARE JUST MAKING MONEY BY FEAR MONGERING 13

14 BARGAINING Make a deal with yourself/others IF ANYONE COMES IN HERE, THEY WILL SEE THAT I AM A GOOD DOCTOR I SPOKE TO 3 OTHER DOCS AND NONE OF THEM HAVE DONE ANYTHING EITHER WHAT IF I JUST GET THE FREE DOWNLOAD MANUAL, THEN I M GOOD RIGHT I WILL LEAVE THIS MEETING AND START THIS TOMORROW DEPRESSION Regret, fear, anxiety, uncertainty HOW AM I SUPPOSED TO MEET EVERYTHING THEY WANT ME TO DO I WISH I HAD STARTED THIS EARLIER I KNOW I AM GOING TO GET AUDITED IF I GET AUDITED MY PATIENTS WILL THINK I AM A CROOK WHY DID I EVEN START M.U. I CAN NEVER GET THIS DONE ACCEPTANCE Completing a difficult task and knowing you have done what was necessary for your survival. THAT IS IT, I THOUGHT IT WOULD TAKE ME LONGER TO HAVE THIS SET UP WOW, I HAD NO IDEA THAT WAS AN AREA OF POTENTIAL BREECH I GAVE YOUR COMPANIES NAME TO MY FRIEND, HE REALLY NEEDS THIS TOO CAN YOU COME PRESENT TO OUR GROUP 14

15 HEALTHCARE REFORM Compliance, Medicare Advantage and Accountable Care Organizations Jon Weeding President CS EYE 15