ACG 2014 Annual Postgraduate Course Copyright 2014 American College of Gastroenterology 1

Transcription

1 Healthcare Reform and the Gastroenterologist: The Future of our Profession Harry Sarles Jr., MD, FACG PREPARATION TAKE YOUR FAVORITE PPI MIX WITH YOUR FAVORITE H2 BLOCKER AND ANTACID SWALLOW REPEAT PRN TUCKS PADS AND PREPARATION H MAY BE HELPFUL AS WELL AFTER 2013 ADD PROZAC Copyright 2014 American College of Gastroenterology 1

2 Healthcare Statistics: Aging Population 10,000 Americans turn 65 every day Number of Americans 65 and older greater than the present population of Canada Percent of Americans 65 and older expected to increase from 13% to 20% by 2050 Better job at treating chronic illnesses/delaying death USA life expectancy highest ever: 78.2 years Healthcare Statistics: Expenditures Since 2001 health insurance premiums up 59% 52 million Americans were uninsured 60% of USA bankruptcies related to medical expenses USA only wealthy, industrialized nation that did not offer universal healthcare coverage. Healthcare cost: 17.9% GDP ($2.64 trillion) Medicare fund predicted to be bankrupt by 2030 Copyright 2014 American College of Gastroenterology 2

3 WE ARE LABOR HARRY S FACTS SINCE 1984 WE HAVE BEEN ON A STEADY BUT RELENTLESS REIMBURSMENT RETREAT FROM MEDICARE PATIENT PROTECTION AND AFFORDABLE CARE ACT IS PHASE ONE OF UNIVERSAL HEALTHCARE FOR THE UNITED STATES OF AMERICA FEE FOE SERVICE IS NEAR DEAD? LEARNING OBJECTIVES Affordable Care Act (universal health coverage) Accountable Care Organizations RUC analysis of all GI Procedure Codes (Misvalued codes) The Quality Movement Physician unions? ICD-10 (Now postponed to Oct. 2015) Copyright 2014 American College of Gastroenterology 3

5 ACA COST ACCESS QUALITY VALUE HERE VALUE IS QUALITY DIVIDED BY COST WHAT THE ACA DOES NOT DO No provision for reform of Medicare reimbursement and the SGRf formula This was the behind the scenes deal the AMA made with President Obama that was not honored No real tort reform at a national level Copyright 2014 American College of Gastroenterology 5

6 ACA PROVISIONS Many new regulations for insurance companies Massive expansion of Medicaid recommended by the Government to the states (with federal funding for 3 years) Insurance exchanges to be established by 2014 for those individuals who are uninsured and do not qualify for Medicaid ACA AND THE SUPREME COURT FEDERAL GOVERNMENT CANNOT REQUIRE STATES TO EXPAND MEDICAID. Copyright 2014 American College of Gastroenterology 6

7 ACA PROVISIONS EVERYTHING IS PHASED IN PROHIBITING DISCRIMINATION DUE TO PRE-EXISTING EXISTING CONDITIONS OR GENDER INCREASING ACCESS TO MEDICAID* PROMOTING INDIVIDUAL RESPONSIBILITY (requirement to carry Ins.) PAYING PHYSICIANS BASED ON VALUE NOT VOLUME Copyright 2014 American College of Gastroenterology 7

10 Texas Medical Association Biennial Physician Survey Research Findings on Medicare Source: Texas Medical Association 2012 Physician Biennial Survey Copyright 2014 American College of Gastroenterology 10

11 Source: Texas Medical Association 2012 Physician Biennial Survey Note: A physician is designated as young if age 46 and under, established if 47 to 50, and senior if 59 and older. Indirect access physicians (i.e., Radiologists, Anesthesiologists, Hospitalists, Pathologists, Emergency Medicine specialists) are grouped together regardless of age. Source: Texas Medical Association 2012 Physician Biennial Survey Copyright 2014 American College of Gastroenterology 11

13 Source: Texas Medical Association 2012 Physician Biennial Survey 100% Access to Primary Care Physicians in Rockwall County, Texas 80% 60% 40% 20% Percentage of physicians accepting new patients by payer type 0% Copyright 2014 American College of Gastroenterology 13

14 Medicaid Practice Management Accounts receivables (AR) > 90 days for Mdi Medicare is 35% 3-5 AR > 90 days traditional Insurance 1-3% AR > 90 days Medicare replacement 3-5% AR > 90 days Medicaid 30-35% 35% Copyright 2014 American College of Gastroenterology 14

15 ACA Cost Access QUALITY Value QUALITY MEASUREMENT/VALUE PQRS MEANINGFUL USE VALUE BASED PATIENT MODIFER 2015 ROLL OUT OUTCOMES/PROCESS MEASUREMENTS (GIQUIC) PATIENT SATISFACTION SURVEYS Copyright 2014 American College of Gastroenterology 15

16 PQRS QUALITY MEASUREMENT PQRS GI RELATED MEASURES measures to choose from/19 GI # 83 Confirmation of Hepatitis C viremia with RNA test # 84 Quant. RNA 6 months before starting treatment #85G Genotype prior to treatment t t # 86 % of pts offered treatment with Peg and Ribavirin # 87 RNA test at 12 weeks of therapy Copyright 2014 American College of Gastroenterology 16

17 PQRS GI CONT. # 89 Hep C counseling about risks of alcohol # 90 Hep C counseling men and women about use of contraception prior to antiviral therapy # 130 documentation current meds in medical record includes otc s, supplements, herbs etc. # 183 Hep A vaccine in pts with Hep C # 184 Hep B vaccine in pts with Hep C # 185 Pt with history of adenomatous polyps, colonoscopy done 3 or more years later PQRS CONT. # 269 IBD pts type, anatomic location, and activity ii all lld documented d # 270 IBD pts on 10 mg/day steroids for 60 days or longer started on steroid sparing therapy # 271 IBD pts on 10 mg/day steroids for 60 or more days have bone loss assessed. #272 IBD pts offered flu vaccine # 273 IBD pts offered pneumococcal vaccine Copyright 2014 American College of Gastroenterology 17

18 PQRS CONT. # 274 IBD pts TB test before Anti-TNF therapy # 275 IBD pts Hep B status checked before Anti-TNF therapy # 320 pts 50 yr or older with a normal colonoscopy have a 10 yr follow-up recommended in the report PQRS CONT. #113 % of patient age who received CRC screening # 265 % of patient whose biopsy results have been reviewed and communicated to referring MD and the patient by the performing MD #249 % of esophageal biopsy reports that document Barrett s and have a statement about dysplasia (pathologist measure) GI practice with path labs may report this measure Copyright 2014 American College of Gastroenterology 18

19 Physician Quality Reporting System (PQRS) Must successfully participate in PQRS in 2013 or receive only 98.5%of his/her allowed Medicare Part B payments in 2015 Option 1: report 1 PQRS measure to avoid 2015 penalty Option 2: report at least 3 PQRS measures in 2013 to avoid penalty and receive 0.5% incentive bonus in 2014 A measure is considered successful if > 50% is achieved in calendar year PQRS Incentive Payments 2011: +1% : +.5% 2015: -1.5% 2016+: -2% Copyright 2014 American College of Gastroenterology 19

20 PQRS 2014 MEASURES WILL BE GROUPED INTO DOMAINS AND WILL REQUIRE REPORTING FROM THE VARIOUS DOMAINS 6 NATIONAL QUALITY STRATEGY DOMAINS PQRS DOMAINS Person and caregiver-centered Experience and Outcomes Patient Safety Communication and Care Coordination Community/Population Health Efficiency and Cost Reduction Effective Clinical Care Copyright 2014 American College of Gastroenterology 20

21 PQRS GI MEASURE 2014 SCREENING COLONOSCOPY ADENOMA DETECTION RATE MEASURE (new 2014) (EFFECTIVE CLINICAL CARE NQS DOMAIN) 2014 TO EARN.5% INCENTIVE YOU MUST REPORT 9 MEASURES COVERING 3 DOMAINS 2014 TO AVOID PAYMENT CUT 2% YOU MUST REPORT 3 MEASURES COVERING 1 DOMAIN MEANINGFUL USE QUALITY MEASUREMENT Copyright 2014 American College of Gastroenterology 21

23 MEANINGFUL USE Stage focus on data collection and sharing Stage focus on advanced clinical practice (17 EHR processes required) Stage focus on improved outcomes Additional stages to be proposed in the future All providers must adopt EHR and demonstrate meaningful use by 2015 or their reimbursement will be cut 1% each year VALUE BASED PATIENT MODIFER QUALITY MEASUREMENT Copyright 2014 American College of Gastroenterology 23

24 VBPM Using outcomes reports submitted via the PQRS system, CMS will assign practices to Quality and Cost tiers which will affect reimbursement access In 2015 the VBPM will apply to practices with 100 or more providers In 2016 the VBPM will apply to practices with providers. PATIENT SURVEYS QUALITY MEASUREMENT ARE THEY REALLY COMING? HOSPITAL SIDE OF THINGS THEY MAKE UP 45% OF THE VALUE BASED PURCHASING EQUATION 55% IS BASED ON CLINICAL OUTCOMES NO OUTCOME NO INCOME AND PATIENTS HAVE TO LIKE YOU 100% OF THE TIME Copyright 2014 American College of Gastroenterology 24

25 OUTCOMES AND PROCESSES MEASUREMENT GIQUIC NOW A CMS CERTIFIED DHQR SUBMITTED MEASURES WILL COUNT TOWARDS PQRS PATICIPATION Incentives Become Penalties 2015 Based On 2013 Work TMA/MGMA data for an average annual income in a multispecialty i l practice with 19% Medicare volume PROGRAM PENALTY AMOUNT PQRS 1.5% $2,544 E-PRESCRIBING 20% 2.0% $3, MEANINGFUL 1.0% $1,696 USE EHR S VALUE-BASED 1.0% $1,696 MODIFER TOTAL 5.5% $9,328 Copyright 2014 American College of Gastroenterology 25

26 ACA ADDITIONAL PROVISIONS Independent Payment Advisory Board (IPAB) Reducing the per-capita growth in Medicare spending Recommendations must result in net reduction in spending without effecting premiums, cost sharing, health care access or payment rates It is not clear what actions might or could meet the criteria i Implementation date: 2015 Unprecedented power to affect Medicare policy Republicans refuse to nominate any members and insist that it be repealed Copyright 2014 American College of Gastroenterology 26

27 MISVALUED CODES ACA directs CMS to identify misvalued services CMS has directed the AMA RUC (relative value update committee) to provide recommendations on 33 codes 4 of which are GI codes: EGD, EGD with Bx, Colonoscopy with Bx, Colonoscopy with polypectomy. Physician Compare Website Requires the HHS Sec. to develop a PCW by 2011 and publish data on providers based on achievement and compliance with PQRS quality measures by 2013 Uncertainties: Will other voluntary quality improvements qualify: fellowship, meaningful use, medical societies, GIQuIC Insure a process to allow adequate provider review and vetting process before changes to the profile are updated Possible silver lining : Positive marketing tool for best practices Copyright 2014 American College of Gastroenterology 27

28 ACA COST Access Quality Value Accountable Care Organizations (ACO) Section 3032 of the Patient Protection and Affordable Care Act (PPACA) directs HHS to establish a Medicare Shared Savings Program by January The Secretary shall determine an appropriate method to assign Medicare fee-for-service beneficiaries to an ACO based on their utilization of primary care services provided by ACO professionals (PPACA 3022(c)) Copyright 2014 American College of Gastroenterology 28

29 Goal of the ACO Transition US healthcare system from volume based payment to value based payments. Federal Government proposes a shared savings approach where spending is estimated with a set savings target. If goal is met the ACO and federal Government share in the savings. ACO History ACO framework was tested in the Medicare Physician i Group Practice Demonstration enacted in 2000 and ran with 10 physician groups participating There was modest success The Gov. formally embraced the approach in the Patient Protection and Affordable Care Act there are 428 ACO s in 49 states and growing fast Copyright 2014 American College of Gastroenterology 29

30 Who can form ACO S? Professionals in group practice arrangements Networks of individual practices of ACO professionals Partnerships or joint venture arrangements between hospitals and ACO professionals. Hospitals employing ACO professionals. ACO continued Federal Government does not require a hospital to participate ii in an ACO Physician groups can form an ACO independently Hospitals can not establish an ACO in the shared savings program without physician participation Copyright 2014 American College of Gastroenterology 30

31 The Law prohibits Administrative or Judicial Appeal You disagree with Gov. decision on eligibility of your ACO to participate i in shared savings plan or the amount of shared savings your ACO is paid You disagree with Gov. assignment of Medicare patients to your ACO You disagree with the Gov. measurement of your quality of care Law Prohibits Appeal continued: You disagree with Gov. assessment of the quality of care you are delivering i in your ACO If the Gov. terminates the ACO from participating in the shared savings program Copyright 2014 American College of Gastroenterology 31

32 Accountable Care Organizations (ACO) ACA specifies an ACO must: 1. Be accountable for the quality, cost, and overall care of Medicare fee-for for-service beneficiaries assigned to it 2. Agree to participate for not less than 3 years 3. Establish a formal legal structure to receive and distribute shared savings to ACO participants 4. Have at least 5,000 fee-for for-service Medicare beneficiaries assigned to it 5. Establish a leadership and management structure that includes clinical and administrative systems 6. Develop process that promotes evidence-based medicine, patient engagement, reporting method on quality and cost measures, and coordinated care Copyright 2014 American College of Gastroenterology 32

33 *MEDICAID EXPANSION ACA/SUPREME COURT: Ruled that Federal Government cannot require Medicaid id expansion States have option to expand Medicaid eligibility up to 138% of federal poverty level. Includes any adult. ($15,400/I,$31,800/family of 4) Federal Government to cover 100% of cost , 2016, then 90% in 2020 and beyond. There will be a gradual decline Ready for ICD-10? October 1, 2015 data foundation will undergo a major transformation. 14,000 codes to 70,000 codes TMA estimates cost of transition $83,000 per doctor for a 3 person group. $28,500 per doctor for a 10 physician practice. Integrate this change into your business plan ACG will soon have a tool for members to use Copyright 2014 American College of Gastroenterology 33

35 HOT TOPICS CMS PUBLISHED IN JANURARY 2014 REIMBURSMENTS FOR GI CODES ERCP MINUS 20-21% 21% BASED ON RUC/CMS EGD MINUS 8-12% BASED ON RUC/CMS COLONOSCOPY MINUS 4-5% PE/ME MANIPULATION WITHOUT RUC ASC PROCEDURE RATES PLUS 5-8% SEQUESTRATION 2%/YR SGR FORMULA COST OF A 10-YR SGR FREEZE CURRENTLY IS $139 BILLION OVER 10 YEARS ONE YEAR PATCH COSTS $18 BILLION HOUSE ENERGY &COMMERCE/HOUSE WAYS AND MEANS/SENATE FINANCE COMMITTEES AGREED ON FEB. 6, 2014 TO A NEW PAYMENT SYSTEM. Copyright 2014 American College of Gastroenterology 35

36 H.R REPLACES SGR PHASE 1 ANNUAL 0.5% PAYMENT UPDATES FROM PHASE 2 STARTING IN 2019, ANNUAL PAYMENT UPDATES AND PHYSICIAN PAYMENTS WILL BE BASED ON A NEW MERIT BASED INCENTIVE PAYMENT SYSTEM (MIPS) MIPS WILL COMBINE AND MODIFY THE PQRS AND THE VALUE BASED PAYMENT MODIFER. PROVIDERS WILL RECEIVE A SCORE ON PERFORMANCE IN 4 CATEGORIES: QUALITY, RESOURCE USE, MEANINGFUL USE, CLINICAL PRACTIVE IMPROVEMENT ACTIVITIES Copyright 2014 American College of Gastroenterology 36

37 MIPS PROVIDERS WOULD ALSO GET CREDIT FOR IMPROVING 0NE YEAR TO THE NEXT IN THE QUALITY AND RESOURCE USE CATEGORIES. PAYMENTS BASED ON RELATION TO THE PERFORMANCE THRESHOLD. POSITIVE UPDATES ABOVE THE THRESHOLD AND NEGATIVE BELOW ALTERNATIVE PAYMENT MODEL (APM) STARTING IN 2024 PHYSICIANS CAN CHOOSE TO BE PAID UNDER ALTERNATIVE MODEL. PROVIDERS WILL SUBMIT PROPOSED MODELS TO HHS. MODELS TO DEMONSTRATE REDUCED SPENDING AND /OR IMPROVED QUALITY OF CARE Copyright 2014 American College of Gastroenterology 37

38 APMS AFTER 2024 APMS WILL GET 1% UPDATES AND OTHERS.5% ELIGIBLE APM S WILL BE EXEMPT FROM MIPS PROVIDERS WILL ALSO RECEIVE A 5% BONUS IF THEY GET MOST OF THEIR PAY VIA AN APM PATIENT CENTERED MEDICAL HOME TIMELINE 2014 JAN: HEALTH EXCHANGES STARTED JAN: MEDICARE PHYSICIAN FEE SCHEDULE AND MISVALUED CODES UGI (8-21% CUTS) APRIL: 2% CUT DUE TO SEQUESTRATION IPAB: RECOMMENDATIONS TO SLOW MEDICARE COSTS Copyright 2014 American College of Gastroenterology 38

39 TIMELINE 2014 STAGE 2 MEANINGFUL USE TO BEGIN NOVEMBER: MIDTERM CONGRESSIONAL ELECTIONS JAN-DEC MEDICARE QUALITY REPORTING IMPACTING 2016 REIMBURSMENTS TIMELINE 2015 JAN: SGR UPDATE? JAN: ANOTHER 2% CUT DUE TO SEQUESTRATION JAN: MISVALUED CODES CUTS TO COLONOSCOPY AND OTHERS? JAN: 1.5% CUT FOR MEDICARE PROVIDERS NOT SUCCESSFULLY REPORTING PQRS MEASURE IN 2013 Copyright 2014 American College of Gastroenterology 39

40 TIMELINE 2015 JAN:1% CUT FOR THOSE NOT DEMONSTRATING STAGE 1 MEANINGFUL USE OF HIT IN 2013 JAN-DEC: REPORTING YEAR TO DETERMINE 2017 VALUE BASED PURCHASING MODIFER FOR ALL MEDICARE PROVIDERS JAN-DEC: QUALITY REPORTING FOR 2017 REIMBURSMENT Join GIQUIC Take Home Points Make ACG your Professional Home Keep Balance in your life (avoid burnout) Strive for high reliability (Quality) in your practice Measure it, Report it, Market it (Your Quality) GIQUIC AND ACG will do all of that for you! Copyright 2014 American College of Gastroenterology 40