Payment Part 2 Policy Key Issues PDF

Payment: Part 2 Value-Based Payment and Prevention of Fraud, Waste, and Abuse Objectives Discuss current trends in the US healthcare system that are driving health plan model design. Recognize stakeholders who have risk in different health plan models. Apply the concept of risk-sharing to...

Payment: Part 2 Value-Based Payment and Prevention of Fraud, Waste, and Abuse Objectives Discuss current trends in the US healthcare system that are driving health plan model design. Recognize stakeholders who have risk in different health plan models. Apply the concept of risk-sharing to case examples of employee health plans. Discuss strategies to prevent fraud, waste, and abuse of health care resources. Review of Part 1 Key Terms PPO—more choice, incentivized to use in-network HMO—closed network, lower copays HDHP—cost shift to employee https://www.apta.org/your-practice/payment Copay—patient cost per visit (fixed) Deductible—patient out of pocket cost prior to insurance paying Prospective Payment—predetermined payment system In-network/Out of Network Fee for Service—a la carte; fixed fee for each service provided Payment Implications on PT Practice Problems with Current System? https://www.wsj.com/articles/how-much-does-a-c-section- cost-at-one-hospital-anywhere-from-6-241-to-60-584- 11613051137?mod=djem10point https://www.wsj.com/articles/how-much-does-a-c-section-cost-at-one-hospital-anywhere-from-6-241-to-60-584-11613051137?mod=djem10point https://www.wsj.com/articles/behind-your-rising-health-care- bills-secret-hospital-deals-that-squelch-competition- 1537281963?mod=article_inline https://www.wsj.com/articles/what-does-knee-surgery-cost-few-know-and-thats-a-problem-1534865358?mod=article_inline The Value Equation https://hbr.org/2013/10/the-strategy-that-will-fix-health-care Quality = Outcomes Service = Patient Experience Cost = Organization cost to provide services The Value Agenda The strategic agenda for moving to a high-value health care delivery system has six components. They are interdependent and mutually reinforcing. Progress will be greatest if multiple components are advanced together. Value Based Payment Providers (i.e. clinicians) are held accountable for both the COST and QUALITY of care Reward better, cost-effective care “Penalize” poor outcomes Examples: Readmission rates Hospital borne infections Retained surgical items https://hbr.org/2013/10/the-strategy-that-will-fix-health-care Contrast that with the approach taken by the IPU at Virginia Mason Medical Center, in Seattle. Patients with low back pain call one central phone number (206-41-SPINE), and most can be seen the same day. The “spine team” pairs a physical therapist with a physician who is board-certified in physical medicine and rehabilitation, and patients usually see both on their first visit. Those with serious causes of back pain (such as a malignancy or an infection) are quickly identified and enter a process designed to address the specific diagnosis. Other patients will require surgery and will enter a process for that. For most patients, however, physical therapy is the most effective next intervention, and their treatment often begins the same day. Virginia Mason did not address the problem of chaotic care by hiring coordinators to help patients navigate the existing system—a “solution” that does not work. Rather, it eliminated the chaos by creating a new system in which caregivers work together in an integrated way. The impact on value has been striking. Compared with regional averages, patients at Virginia Mason’s Spine Clinic miss fewer days of work (4.3 versus 9 per episode) and need fewer physical therapy visits (4.4 versus 8.8). In addition, the use of MRI scans to evaluate low back pain has decreased by 23% since the clinic’s launch, in 2005, even as outcomes have improved. Better care has actually lowered costs, a point we will return to later. Virginia Mason has also increased revenue through increased productivity, rather than depending on more fee-for-service visits to drive revenue from unneeded or duplicative tests and care. The clinic sees about 2,300 new patients per year compared with 1,404 under the old system, and it does so in the same space and with the same number of staff members. PT in PCMH Results Overview Access Quality Direct Access PT Pilot MAY 2015 Improved access to PT: 7-10 days Improved patient satisfaction Cost Added 2nd PT to Internal Medicine – JUN 2014 Combined improved HEDIS measure: 75th percentile Internal Medicine only HEDIS measure: 90th percentile Embedded PT Pilot SEPT 2013 Savings of $1M network cost FY13-FY14 35% reduction in network deferrals 13 COST: PT Embedded Pilot = Decreased Referrals in PCMH PHYSICAL THERAPY REFERRALS WRITTEN BY PCM IN PCMH 120 100 80 PT embedded in PCMH Sep 2013 60 105 40 82 59 52 20 41 37 28 22 22 19 12 13 11 0 APR13 MAY13 JUN13 JUL13 AUG13 SEP13 OCT13 NOV13 DEC13 JAN14 FEB14 MAR14 APR14 14 PT Embedded Pilot Cost Outcomes One PT embedded in PCMH Sep 2013 No increase in personnel (same FTE equivalent) Over 35% decrease in network deferrals and associated cost FY13 FY14 Reduction Percentage PT Purchased Care $ 2,521,971 $ 1,556,999 $ 964,972 38% PT Network Deferrals 2632 1706 926 35% Value Based Payment Models Pay for Performance: Under this model, physicians receive financial bonuses for achieving specific care-quality and cost targets. However, this model is typically deployed as an overlay to fee-for-service payments, which can incentivize the provision of costly, and sometimes unnecessary care. Also, bonuses have often proven insufficient to reward or enable the necessary changes in provider practice. Bundled Payments: An alternative to fee-for-service payments, providers working under this model are reimbursed a fixed, predetermined fee to perform all the services associated with a given procedure (e.g., knee replacement surgery), rather than an individual fee for each. So, providers benefit financially when they perform procedures most cost-efficiently and effectively, avoiding unnecessary procedures while prioritizing care for preventable complications. Capitation: Providers working within capitation models take full financial responsibility for the health of a defined patient population. Members pay a fixed, usually annual, premium, and those premiums are pooled together to fund care for the entire population. Unlike fee-for-service, this model enables providers to spend funds however they think best to maximize the health of their covered population. And the more successful they are at doing this, the more of the premium funds they can apply to the bottom line, rather than to direct care costs. So, capitation rewards delivery of high-quality and cost-effective care, rather than overutilization. Shared Savings: This model entails payers setting a budget for care-delivery costs, such that providers whose total costs fall below the budget share in the savings. Shared savings is not itself a payment model, but can be used in conjunction with a number of models, from fee-for-service to value-based models. Shared Risk: A step beyond Shared Savings, providers working under this model still share in any recognized savings but are also expected to pay for any care delivery costs exceeding the payer-set budget. https://www.christenseninstitute.org/blog/what-is-value-based-payment-and-what-does-it-mean-for-healthcare/ Managing Financial Risk Employers Increase employee premium cost, increase deductible Limited network of providers/plan types Require more co-pays Employees Use In-network providers High vs. Low-deductible Co-pays Payers Limit covered services Limit visits PT Clinic Documentation Deliver great outcomes—quality care, patient-centered, great experience  Preventing Fraud, Waste, and Abuse Examples and Implications? Improper Billing and Coding Claims: Billing for services you did not provide Billing for services that are not medically necessary Billing for physical therapy services provided by aides Billing for services provided by physical therapist assistants that were not properly supervised by a physical therapist Billing for excessive duration and frequency of services Using codes that pay a greater amount than the service provided (ie, upcoding) Billing for direct 1-on-1 services when they were provided to multiple patients at the same time with no direct 1-on-1 contact Billing for the incorrect level of evaluation From: PREVENTING FRAUD, ABUSE, AND WASTE: A Primer for Physical Therapists APTA, September 2017 Preventing Fraud, Waste, and Abuse Relationships with Referral Sources : A health care business Offers something to you for free or below fair market value Offers to pay you cash in exchange for referrals Offers you far above fair market value for products or services Example: if a DME supplier offers to pay you to recommend its DME items to your patients, it would most likely be a violation of anti-kickback laws. From: PREVENTING FRAUD, ABUSE, AND WASTE: A Primer for Physical Therapists APTA, September 2017 Preventing Fraud, Waste, and Abuse Relationships with Patients: If a health care provider offers their patients gifts, provides free services, or waives deductibles and coinsurance, there is a likelihood that the federal government and private payers would question the reason. OIG does allow the waiver of coinsurance and deductible amounts by a person if the following conditions are met: The waiver is not offered as part of any advertisement or solicitation. The physical therapist does not routinely waive coinsurance or deductible amounts. The physical therapist waives the coinsurance and deductible amounts after determining in good faith that the individual is in financial need, or failing to collect coinsurance or deductible amounts after making reasonable collection requests. From: PREVENTING FRAUD, ABUSE, AND WASTE: A Primer for Physical Therapists APTA, September 2017 Preventing Fraud, Waste, and Abuse Resources: Experienced health care lawyers Your state physical therapy board http://www.fsbpt.org/FreeResources/ LicensingAuthoritiesContactInformation.aspx APTA resources on specific risk areas http://www.apta.org/Compliance/ CMS local Medicare Administrative Contractors https://www.cms.gov/Medicare/Medicare- Contracting/Medicare-Administrative- Contractors/Who-are-the-MACs.html Office of Inspector General http://oig.hhs.gov/compliance/compliance-guidance/index.asp From: PREVENTING FRAUD, ABUSE, AND WASTE: A Primer for Physical Therapists APTA, September 2017 8-minute Rule—Medicare Part B To receive payment from Medicare for a time-based (or constant attendance) CPT code, a therapist must provide direct treatment for at least eight minutes. Service Based CPT Codes physical therapy evaluation (97161, 97162, or 97163) or re-evaluation (97164) hot/cold packs (97010) electrical stimulation (unattended) (97014) Time Based CPT Codes therapeutic exercise (97110) therapeutic activities (97530) manual therapy (97140) neuromuscular re-education (97112) gait training (97116) ultrasound (97035) iontophoresis (97033) electrical stimulation (manual) (97032) 8-minute Rule—Medicare Part B Medicare adds up the total minutes of skilled, one-on-one therapy and divides that total by 15. If eight or more minutes are left over, you can bill for one more unit; if seven or fewer minutes remain, you cannot bill an additional unit. 8 – 22 minutes 1 unit 23 – 37 minutes 2 units 38 – 52 minutes 3 units 53 – 67 minutes 4 units 68 – 82 minutes 5 units 83 minutes 6 units  “Regardless of the model, providers must work together to achieve the best outcomes at the lowest cost. PTs can’t isolate themselves. They must understand the system in which they work so they can see how all providers in VBP models contribute to the outcome.” “On a societal level, all health care providers must try to improve the value of care being delivered in the United States. There is a finite pot of money available to manage the health of as many people as possible. The level of waste in the system must be reduced. This includes unnecessary emergency room visits, health care fraud, and provision of services that have little or no value.” Ethical Challenges in Value Based Payment Refer to APTA Code of Ethics Principle 2 of the Code of Ethics establishes the backdrop for all patient interactions: "Physical therapists shall be trustworthy and compassionate in addressing the rights and needs of patients/clients.“ Principle 7 of the Code of Ethics offers guidance for interactions with organizations, coworkers, and employees as these changes evolve: "Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society.“ https://www.apta.org/apta-magazine/2020/07/01/the-ethics-of-value-based-payment-in-physical-therapy-models Ethical Challenges in Value Based Payment Refer to APTA Code of Ethics Principle 7A provides the template for decision making. PTs are compelled to accept the responsibility to be actively engaged in "promoting practice environments that support autonomous and accountable professional judgments.“ Principle 7F, meanwhile, reminds us that if we are unable to fulfill our professional obligations to patients/clients, we should refrain from that type of employment arrangement. Principle 8 speaks to our partnership with agencies outside physical therapy to "participate in efforts to meet the health needs of people locally, nationally or globally." https://www.apta.org/apta-magazine/2020/07/01/the-ethics-of-value-based-payment-in-physical-therapy-models Scenario—What would you do? During onboarding as a new home health PT, you receive training to enter your note in the computer and “lock” the note. After seeing patients for several weeks you are told to not lock the record, that the office had to review and finalize it. Nurse walking you through the computer system for your first discharged patient said that it didn’t matter what you marked on their outcome on various categories, just choose something higher than what they had at start of care. After several months, you noticed that there were errors in your finalized notes. For example, a patient who was wheelchair bound was noted to have improved in walking. You review all the records of multiple other patients you treated, and the patients got better in every outcome measure. These were changes to your original documentation. You check who locked the records and it was a leader of the home health division for the organization, not personnel from your local office. In addition… Some patients would get lightheaded upon standing and nearly faint secondary to their blood pressure dropping. The office wanted you to do all the medication changes-- calling the doctor, since you are with the patient, and would not have a nurse visit the patient or do the paperwork with the doctor for signature. Your employer would not have a nurse follow up including errors with medication management like duplicate prescriptions of medications of the same class from different doctors causing issues, or patient completely confused about their medications. Rather, they want you to do it since you are already there with the patient. Home Health Example Principle 7 of the Code of Ethics offers guidance for interactions with organizations, coworkers, and employees: "Physical therapists shall promote organizational behaviors and business practices that benefit patients/clients and society.“ Principle 7A provides the template for decision making. PTs are compelled to accept the responsibility to be actively engaged in "promoting practice environments that support autonomous and accountable professional judgments.“ Principle 7F, meanwhile, reminds us that if we are unable to fulfill our professional obligations to patients/clients, we should refrain from that type of employment arrangement. Key Points Documentation is critical to reimbursement for services provided Value-based models emerging https://www.strategiesforqualitycare.com/quadruple-aim/overview Quality divided by cost Be wary of potential fraud/waste/abuse Billing Relationships Professional Behaviors Ethics EBP Code of Conduct Scope of Practice Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-76. Next Class Friday, Dec 6 8-noon 5 x 5 Presentations and Peer Reviews Course Wrap Up Final Exam Review Professional Attire Holiday accessory