Health Care Economics and Audiology: Why are WE Feeling the Pain? Disclosures. Disclosure 1/6/2016

Transcription

1 Health Care Economics and Audiology: Why are WE Feeling the Pain? Robert Fifer, Ph.D. University of Miami Miller School of Medicine Mailman Center for Child Development Disclosures Employed by the University of Miami Former member of ASHA Health Care Economic Committee (reimbursement for ASHA travel) Member ASHA Board of Directors (Vice President for Audiology Practice) Disclosure Opinions and information presented in this conference represent the personal perspectives and opinions of Robert Fifer and do not necessarily represent those of the American Speech-Language-Hearing Association. 1

2 4 Expenditure Amount (Millions) Total National Expenditures $3,031,292 Out of pocket $329,819 Health Insurance $2,216,888 Private Health Insurance $990,988 Medicare $618,706 Medicaid (Title XIX) $495,766 Federal $305,134 State and Local $190,632 2

3 Expenditure Amount (Millions) CHIP (Title XIX and Title XXI) $13,183 Federal $9,191 State and Local $3,992 Department of Defense $41,082 Department of Veterans Affairs $57,163 Other Third Party Payers and Programs $251,730 Worksite Health Care $5,680 Other Private Revenues $132,655 Source: Martin et al. (2014)National Health Spending in Health Affairs. December Impact of Low Out of Pocket Costs Lack of transparency of costs / prices Consumer price insensitivity Health care as a right Greater demand for more services 3

4 Additional Factors for Rise in Health Care Costs Hospital consolidation Fewer physician private practices Fee for service incentives to do more in order to be paid more Use of ER for primary care Access disparities due to race/ethnicity/gender Quality of care disparities due to race/ethnicity/gender Reduction in reimbursement (Medicare/Medicaid/Insurance/HMO) Topics of Reimbursement Doc Fix Caloric codes ICD-10 PQRS Anticipated future trends for quality reporting Repeal of the SGR SGR: Sustainable Growth Rate Method of maintaining budget neutrality for Medicare fund Cumulative reduction in reimbursement by 21% Replaced by fixed formula: 0.5% payment update through % payment update from 2020 through 2025 Additional changes due to alternative payments systems 4

5 Caloric Vestibular Testing Picked up through Potentially Misvalued Screen Caloric vestibular test with recording, bilateral, bithermal (i.e., one warm and one cool irrigation in each ear for a total of four irrigations) Caloric vestibular test with recording, bilateral, monothermal (i.e., one irrigation in each ear for a total of two irrigations) Caloric Vestibular Testing CPT Recommended Work RVU CMS Final Work RVU CY 2016 National Rate $ $20.78 More work to be done with all stakeholders to convince CMS that their value is too low for the work involved and the risk to the patient. ICD-10 Coding System ICD-10 PCS (hospital procedure coding since 1998) ICD-10 CM (outpatient diagnosis and encounter codes since 10/1/2015) 5

6 ICD-10 CM Currently 69,823 diagnosis codes (up from 14,025 in ICD-9 CM) (Source: CDC) 3 7 characters Character 1 is alpha Character 2 is numeric Characters 3 7 alpha or numeric Capacity for approximately 160,000 diagnosis codes ICD-10 CM H90 Conductive and sensorineural hearing loss Excludes1:deaf nonspeaking NEC (H91.3) deafness NOS (H91.9-) hearing loss NOS (H91.9-) noise-induced hearing loss (H83.3-) ototoxic hearing loss (H91.0-) sudden (idiopathic) hearing loss (H91.2-) H90.0 Conductive hearing loss, bilateral H90.1 Conductive hearing loss, unilateral with unrestricted hearing on the contralateral side H90.11 Conductive hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.12 Conductive hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side H90.2 Conductive hearing loss, unspecified Conductive deafness NOS H90.3 Sensorineural hearing loss, bilateral ICD-10 CM H90.4 Sensorineural hearing loss, unilateral with unrestricted hearing on the contralateral side H90.41 Sensorineural hearing loss, unilateral, right ear, with unrestricted hearing on the contralateral side H90.42 Sensorineural hearing loss, unilateral, left ear, with unrestricted hearing on the contralateral side H90.5 Unspecified sensorineural hearing loss Central hearing loss NOS Congenital deafness NOS Neural hearing loss NOS Perceptive hearing loss NOS Sensorineural deafness NOS Sensory hearing loss NOS Excludes1:abnormal auditory perception (H93.2-) psychogenic deafness (F44.6) 6

7 PQRS: Current Audiology Measures Measure #261 One referral to a physician per calendar year for a minimum of 50% of the eligible Medicare patient visits for BBPV or dizziness, AND Measure #130 Medication must be documented for a minimum of 50% of every eligible Medicare patient visit, OR Measure #134 Screen and follow-up plan must be documented one time per calendar year for a minimum of 50% of the eligible Medicare patients. This measure applies to CPT code AQC website: PQRS: Incentives Audiologists should start immediately in order to avoid the 2% penalty to be retained on all 2017 claims for failure to report on 2015 eligible measures. Life limited to 2019: to be replaced by MIPS (Merit-based Incentive Payment System) MIPS Consolidates and strengthens: Meaningful Use penalties PQRS penalties Value-based modifier incentives and penalties MU (HER): 25% PQRS/VBM 30% VBM cost 30% Clinical Practice Improvement 15% 7

8 MIPS Payment Adjustment Threshold for 0% adjustment is a MIPS score of 50. Below threshold => -5% (2019), -7% (2020), - 9% ( ) Scoring above threshold => unspecified positive adjustment Orientation of Value Programs PQRS: Individual practitioner Value based modifier: group practice EHR: Physician, LLP Ensuring accurate payment 1% fee schedule reduction in RVUs in Additional Important Factors Chronic care coordination Interprofessional service Medical home ACOs Performance improvement initiatives Performance and data sharing (e.g., Physician Compare) 8

9 Value Based Modifier Method of calculating value of both cost and quality Proposed to Auds and SLPs in 2015/2017 but ASHA and others were able to delay for 2016 Based on PQRS benchmark reporting and other measures of cost and efficiency applied to physicians that do not exist for other healthcare providers Payment Factors Process measures (PQRS) Private practice Group practice University clinics (not affiliated with hospitals) Some critical access hospitals Transition to outcome measures Ex.: patient satisfaction Ex.: patient function re: activities of life Ex.: quality of life improvement We Practice by How We Are Paid Current: fee for service incentive to do more Not dependent on outcomes, only ability to submit clean claim PQRS first step in modifying payment Establish data registry for audiology outcomes => quality outcomes 9

10 Be Prepared For Additional misvalued screens Coincident billing screens (e.g., to combine codes into one procedure) Alternative payment models: Bundled payments Pay by the head Outcome Measure Considerations Quality of life / patient status outcomes Patient satisfaction with quality of service Patient access to service Meeting patient expectations Engagement in activities of life Inquiry of patient desires, needs and goals Use of functional outcome measures Evaluation of cost associated with patient visit Summary and Conclusions It appears that reimbursement is continually decreasing, and it is. Downward pressure will continue for the foreseeable future. These changes are impacting how we will practice and how we will demonstrate our value as part of the health care world. How we think and hold ourselves accountable must also change in order to allow the profession to grow and thrive. The Chinese proverb is true: We do live in exciting times. 10