Transition Sleep Practice to Respond to ACO Challenges DUANE JOHNSON PHD KATHRYN HANSEN, BS, CPC REEGT SLEEP CENTER MANAGEMENT INSTITUTE

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1 Transition Sleep Practice to Respond to ACO Challenges DUANE JOHNSON PHD KATHRYN HANSEN, BS, CPC REEGT SLEEP CENTER MANAGEMENT INSTITUTE

2 ACCOUNTABLE CARE ORGANIZATION (ACO) CARE INTEGRATION AND QUALITY MONITORING Group of providers and suppliers of services (e.g., hospitals, physicians, and others involved in patient care) Designed to work together for coordinated care for Medicare fee-for service patients Goal - deliver seamless, high-quality care for Medicare beneficiaries, fragmented care often results from a fee-for-service payment system Focus: patient-centered organization where the patient and providers are partners in care decisions. 2

3 STRUCTURE Incentives for health care providers to work together across care settings doctor s offices, hospitals, and long-term care facilities. Medicare Shared Savings Program (Shared Savings Program) Reward ACOs who lower their growth in health care costs Meet performance standards on quality of care Puts patients first Provider participation was voluntary 3

4 HOW DO PROVIDERS PARTICIPATE? Providers develop Medicare Accountable Care Organization (ACO) and apply to CMS Meet eligibility and program requirements serve at least 5,000 Medicare fee-for-service patients and agree to participate in the program for at least three years Shared Savings Program will continue to receive payment under Medicare fee-for-service rules. 4

5 HOW DO PROVIDERS PARTICIPATE? Members of Shared Savings Program will receive payment under Medicare fee-for-service rules Establish a governing body representing 5

6 RESPONSIBILITIES Develop processes to promote evidence-based medicine, promote patient engagement, internally report on quality and cost, coordinate care, and maintain a patient-centered focus 6

7 SLEEP MEDICINE: PRQS MEASURES AASM contract to record the value-based modifiers, called the Physician Quality Reporting System (PQRS) Many approved electronic medical records have approved indicators in database for direct reporting to CMS 7

8 SLEEP MEDICINE: PRQS MEASURES OF CLINICAL EFFECTIVENESS FOR SLEEP APNEA Assessment of Sleep Symptoms: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea that includes documentation of an assessment of symptoms, including presence or absence of snoring and daytime sleepiness 8

9 Severity Assessment at Initial Diagnosis: Percentage of patients aged 18 years and older with a diagnosis of obstructive sleep apnea who had an apnea hypopnea index (AHI) or a respiratory disturbance index (RDI) measured at the time of initial diagnosis 9

10 Positive Airway Pressure Therapy Prescribed: Percentage of patients aged 18 years and older with a diagnosis of moderate or severe obstructive sleep apnea who were prescribed positive airway pressure therapy 10

11 Assessment of Adherence to Positive Airway Pressure Therapy: Percentage of visits for patients aged 18 years and older with a diagnosis of obstructive sleep apnea who were prescribed positive airway pressure therapy who had documentation that adherence to positive airway pressure therapy was objectively measured 11

12 FINANCIAL INCENTIVES 0.5% financial incentive payment on ALL total estimated charges for Medicare Physician Fee Schedule covered services furnished during the 2013 reporting period Providers not SUCCESSFULLY reporting PQRS measures in % negative adjustment with the 2015 Medicare reimbursements. Negative adjustment will increase to 2% for each year thereafter Provider must elect to report at least one measure group, or at least three individual measures listed in one group to obtain the incentive. 12

13 OPPORTUNITIES Collaboration with third party payers, the patient, your referral network, and the community will boost reimbursement for services 13

14 IMPACT ON SLEEP MEDICINE Independent sleep specialist will practice as part of a team of patients Patient centric Bundled payments Accountable for effective outcomes

15 IMPACT ON SLEEP MEDICINE Increased measurement of standardized outcomes Team conferences to improve care Focus on chronic diseases Diabetes Hypertension Heart disease Obesity Prevention sleep apnea

16 IMPACT ON SLEEP MEDICINE Everyone Insured or covered ACA prohibits insurers from denying insurance for pre-existing medical conditions No lifetime limits or caps Insurer takes new insurance risks Increased costs for the insurers New costs needs to be passed on..who?

17 IMPACT ON SLEEP MEDICINE Healthcare patients will cover more of the costs Affordable care means affordable coverage This may result in higher premiums or deductibles

18 FINANCIAL IMPACT Higher deductibles mean: Most covered doctor visits will be paid by the patient deductible Less money from the insurance companies More money due from patients

19 PATIENT REACTIONS Insured means Don t Expect to pay Don t Want to pay May Not pay Solutions Payment up front or at time of service Review payment schedules for allowed amount Determine if deductible has been met prior to service

20 SOLUTIONS Payment for services Cash Credit card CareCredit Payment terms

21 SOLUTIONS Education for patients Address expectations How insurance pays What insurance pays/does not cover Communicate up front with patients Calculate payments in advance Provide patients detailed list of services and costs to arrange payment terms

22 OPPORTUNITIES Niche focus In addition to chronic disease management Workplace safety Workplace productivity Women s health Nutrition and Exercise Transportation

23 SUMMARY Define the purpose of ACOs Describe impact of ACOs on reimbursements and payments Explain Physician Quality Reporting System (PQRS) Provide ideas to incorporate for a successful transition 23

24 QUESTIONS Sleep Center Management Institute T Website:

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