As healthcare is a language “all its own,” PYA Principal David McMillan presented “Learning the New Language of Healthcare" at the Georgia Society of CPAs' 2014 Healthcare Conference.
1. Learning the New
Language of Healthcare
February 7, 2014
9:35am – 10:25am
The Georgia Society of CPAs
February 7, 2014
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2. What am I Trying to Say?
Everyone knows these…
FYI For your information
LOL Laughing out loud
SMH Shaking my head
BRB Be right back
JK
Just kidding
But what about these?
EBP
Evidence-Based
Protocol
CQM
Clinical Quality
Measures
GPRO Group Practice
Reporting Option
BFF Best friends forever
BTW By the way
CIN
Clinically Integrated
Network
The Georgia Society of CPAs
February 7, 2014
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3. Are We Speaking the
Same Language?
PQRS
PHO
VBP
CIN
ACO
The Georgia Society of CPAs
February 7, 2014
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4. PERFORMANCE
The Curve
First Curve
Fee-for-Service
Quality Not Rewarded
Pay for Volume
Fragmented Care
Acute Hospital Focus
Stand Alone Providers Thrive
Straddle
The Curve
Second Curve
Value Payment
Continuity of Care Required
Systems of Care
Providers at Risk for Payment
IT Centric
Physician Alignment
Revenue Drops
Minimal Reward for Quality
Volume Decreases
No Decisive Payment Change
Pay for Volume Continues
High Cost IT Infrastructure
Physicians in Disarray
TIME
The Georgia Society of CPAs
February 7, 2014
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5. Old Healthcare
New Healthcare
• Sickness System
• Wellness System
• Health: No Disease
• Health: Wellness
• Acute Disease
• Chronic Disease
• Fee for Service
• Value Based Payment
• Hospital Beds Full
• Hospital Beds Empty
• Hospital Centric
• Community Centric
• Doctor Centric
• Patient Centric
• Doctor Decides
• Shared Decision Making
• Quality Decided by Doc
• Measurable Metrics
The Georgia Society of CPAs
February 7, 2014
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6. Old Healthcare
New Healthcare
• Cost not considered
• Decreased cost
• Independent doctors
• Integrated doctors
• Independent hospital
• Integrated delivery sys.
• Medical record secret
• Open access record
• Opaque
• Transparent
• Artificial harmony
• Cognitive conflict
• Analogue
• Digital
• Hypothesis driven clinical
trials
• Predictive analytics
actionable correlations
The Georgia Society of CPAs
February 7, 2014
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8. The Healthcare System of the Past
Physicians/Providers
Patients
Payers
Inefficiency
Lack of
Coordinated
Information
Unsupportable
Economics
Hospitals & Other
Providers
The Georgia Society of CPAs
February 7, 2014
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9. Hypothetical:
Martha is a 67 year old women who needs a hip replacement
Episodes of Care
Hip Replacement
• Orthopedic Surgeon (payment)
• Surgery
- Anesthesia (payment)
- Pathology (payment)
• Acute Care (payment)
• Rehabilitation
- PT(payment)
Nine months later
• ED
• Admitted for pneumonia
(payment)
• Treated by hospitalist (payment)
• Consulted by cardiologist (payment)
Six months later –
Well Check
• Gaping hole in information
• Information from previous
two episodes of care may
never reach primary care
provider
- Drug interactions
- Duplicative testing
The Georgia Society of CPAs
February 7, 2014
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10. The Road to Clinical Integration
PHO
OLD
IPA
Payer
Physician
Narrow
Network
Physician
Bundled
Payment
Primary Care
Physician
Patient-Centered
Medical Home
Specialist
Shared
Savings
Capitation
NEW
+ Coordinated Care
+ $ for Coord. Care
ACO
11. What Does “Value” Look Like?
+
QUALITY
=
COST
+
EFFICIENCY
VALUE
The Georgia Society of CPAs
February 7, 2014
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12. What is a “Value-Based
Payment” Model?
Efficiency: The state or quality of achieving
maximum productivity with minimum
wasted effort or expense
Quality: The standard of something as
measured against other things of a similar
kind; the degree of excellence of
something “quality of life” also the general Value: The regard that something is held to
excellence of standard or level
deserve; the importance or preciousness
of something: “Your support is of great
value”
Value-Based Payment:
A payment model which rewards healthcare providers
for meeting certain predetermined performance
measures related to quality and efficiency
The Georgia Society of CPAs
February 7, 2014
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13. Hospital Value-Based Purchasing
(“HVBP”)
• Rewards and penalties based on quality
measures and patient satisfaction scores
• Penalties for high readmission rates
– FY12-14 for AMI, heart failure, and pneumonia;
expand list in FY15
– Reduce overall inpatient payment by 1%-3%
• Penalties for Hospital Acquired Conditions (HACs)/Never
Events
– In FY15, top 25% in HACs will have payments reduced by 1%
The Georgia Society of CPAs
February 7, 2014
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14. Value: PVBP
PVBP: Physician Value-Based Purchasing
• Physician feedback program
– Individual reports on resource use and quality of care
as compared to peer group
• Physician value-based payment modifier
– Phased in between 2015 and 2017
– 2014 performance determines 2016 modifier
– Budget neutral
– wRVU x conversion factor x VBPM
• Positive number = paid more
• Negative number = paid less
The Georgia Society of CPAs
February 7, 2014
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15. PVBP vs. SGR
The Georgia Society of CPAs
February 7, 2014
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16. Sustainable Growth Rate
(“SGR”) Fix
• On October 30, 2013 the Senate Finance Committee and the House
Ways and Means Committee released a discussion draft of a SGR fix,
offering a comprehensive approach to MPFS payment reform.
•
Key provisions include:
– Payment freeze
– Termination of payment penalty programs (PQRS, MU)
– New value-based performance (VBP) program
– Alternative payment model (“APM”) participation
– Complex chronic care management
– Appropriate use criteria
– Valuation of services
The Georgia Society of CPAs
February 7, 2014
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17. Physician Quality Reporting System
(PQRS)
• 2014: 201 quality measure available for
reporting
• Paid for reporting (pay-for-reporting or P4R),
not attaining certain scores (pay-forperformance or P4P)
• Carrots followed by sticks
– 0.5% bonus for 2012-2014
– 1.5% penalty for 2015
– 2.0% penalty for 2016 and thereafter
The Georgia Society of CPAs
February 7, 2014
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18. PQRS: How Patients are Identified
Patients whose care you directed: you billed 35% or more
of all their outpatient E&M visits
Patients whose care you influenced: you billed less than
35% of outpatient E&M visits but 20% or more of their
costs
Patients whose care you contributed are those you billed
less than 35% of visits and less than 20% of their total cost
The Georgia Society of CPAs
February 7, 2014
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19. Tiered Value-Based Payment Modifier
Assessment
Low Cost
Average Cost
High Cost
High Quality
2.0%*
1.0%*
0.0%
Average
Quality
1.0%*
0.0%
-0.5%
Low Quality
0.0%
-0.5%
-1.0%
* Physicians who score in these categories who treat high-risk beneficiaries could receive an additional one percentage point in bonus money.
Source: Proposed 2013 physician fee schedule, Centers for Medicare & Medicaid Services, Federal Register, July 30.
The Georgia Society of CPAs
February 7, 2014
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20. Other Forms of PQI
Meaningful Use Incentives/Penalties
- Stage One objectives and clinical quality measures
MU
- Stage 2 delayed – if attested Stage 1 in 2011 attest
Stage 2 in 2014 (instead of 2013)
- 1% penalty in 2015 if not MU in 2014; 2% in 2016; 3% in
2017; 4% in 2018 or 2019
eRx
Electronic Prescription Incentive Program
- 2.0% penalty in 2014 unless used eRx 10x by 06/30/13
(only receive 98% of Medicare Part B PFS amount for
covered professional service in 2014)
The Georgia Society of CPAs
February 7, 2014
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23. Plotting Your Course on the way to
Managing Population Health
The Georgia Society of CPAs
February 7, 2014
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24. PCMH
PCMH: Patient-Centered Medical Home
• Improves primary care through patientcentered care, cooperation among physicians,
and coordination and tracking care over time
• Facilitates partnerships among patients, their
physicians and the patient’s family members
• Care is facilitated by registries, health
information technology (HIT), health
information exchange (HIE), etc. to ensure
that patients receive the appropriate care at
the appropriate time in the appropriate manner
Primary Care
Physician
Patient-Centered Medical
Home
+ Coordinated Care
+ $ for Coordinated Care
The Georgia Society of CPAs
February 7, 2014
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25. IPA
IPA: Independent Practice association
• Association of medical doctors
(primary care physicians and
specialists) and other healthcare
professionals that have contracted
with most PPO, POS, and HMO
insurance plans
Physician
Physician
Primary Care
Physician
Specialist
The Georgia Society of CPAs
February 7, 2014
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26. PHO
PHO: Physician Hospital Organization
• Joint venture between hospital(s)
and physician group(s)
• Acts as a single agent for managed
care contracting
• Aligns interests of hospitals and
physicians but allows each to retain
autonomy
• Opportunity to act as a vehicle to
advance clinical integration network
initiatives
Physician
Primary
Care
Physician
Physician
Specialist
The Georgia Society of CPAs
February 7, 2014
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27. CIN
What is a CIN?
A network of physicians working in collaboration with a hospital, using
a performance management infrastructure to develop and implement
initiatives to improve the quality and efficiency of healthcare services
Network negotiates and contracts with payers for improved
reimbursement based on quality and efficiency
The Georgia Society of CPAs
February 7, 2014
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29. What Does a CIN Do?
The Georgia Society of CPAs
February 7, 2014
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30. ACO
ACO: Accountable Care Organization
•
“Under the program, primary care physicians are
encouraged to join together with other providers to take
responsibility for the full continuum of their primary care
patients’ care.”
•
“[Physicians] must commit to reporting comprehensive
measures of the quality and -- eventually -- outcomes of
care. If they are able to improve quality and thereby
reduce costs, they will receive a share of the savings
achieved.”
•
“The term “accountable” is intended to mean just that;
ACOs should only receive additional payments to the
extent that they are demonstrably improving care for their
patients.”
– The Dartmouth Atlas of Health Care –
The Georgia Society of CPAs
February 7, 2014
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31. MSSP ACO
MSSP ACO: Medicare Shared Savings Program ACO
• Clinically integrated networks that have contracted with
CMS to share in whatever money the community saves
– To be eligible for shared savings, must meet
minimum performance standards for 33 ACO quality
measures.
– How do we know if they have “saved”?
– CMS reviews the historic costs of the patients in the
network and uses that as the baseline to determine
savings.
– As of January 1, 2014, 343 MSSP ACOs approved
by CMS.
The Georgia Society of CPAs
February 7, 2014
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32. MSSP ACO Functions
What Really Matters
Establish and maintain
quality assurance and
improvement program
Promote evidence-based
medicine, patient
engagement, care
coordination, patientcenteredness
Compile and report
participants’ quality
measure scores
Distribute shared savings
and assess shared losses
The Georgia Society of CPAs
February 7, 2014
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33. Calculating Shared Savings/Losses
Each ACO participant continues to bill fee-for-service independently
Eligibility for and level of shared savings based on performance score
Calculate actual annual Medicare spent for assigned beneficiaries
against pre-determined benchmark
Apply formula to determine share of savings (losses)
The Georgia Society of CPAs
February 7, 2014
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34. BPP
BPP: Bundled Payment
Program
• A single “bundled”
payment covers the entire
range of services
delivered by two or more
healthcare providers that
are rendered during a
single episode of care or
over a specified time
period
Episode 1: Hip Replacement
•
•
•
•
Orthopedic Surgeon
Surgery
o Anesthesia
o Pathology
Acute Care
Rehabilitation Facility
o PT
- payment
- payment
- payment
- payment
- payment
- payment
Single payment
The Georgia Society of CPAs
February 7, 2014
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35. Success in Bundling for
Episodes of Care
Create
Efficiencies
Decrease Costs
• Re-design Care
Model
Improve Care
• Financial/Gainsharing Model
• Quality Focus
Successful
Bundling for
episode of
care
The Georgia Society of CPAs
February 7, 2014
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39. Terms
ACO
Accountable Care Organization
BPP
Bundled Payment Program
CIN
Clinical Integrated Network
eRx
Electronic Prescription
MU
Meaningful Use
P4P
Pay-for-Performance
P4R
Pay-for-Reporting
PCMH
PHO
Physician Hospital Organization
PQI
FFS
Patient Centered Medical Home
Physician Quality Incentives
Fee-for-Service
HACs
Hospital Acquired Conditions
HIE
Health Information Exchange
HIT
Health Information Technology
PQRS
HVBP
Hospital Value-Based Purchasing
IPA
Independent Practice Association
IQR
Inpatient Quality Reporting
MSSP
Patient Quality Reporting System
PQRS
Physician Quality Reporting System
PVBP
Physician Value-Based Purchasing
VBP
Value-Based Purchasing
Medicare Shared Savings Program
The Georgia Society of CPAs
February 7, 2014
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