5/15/2017. Payment Issues Impacting the Practice of Physical Therapy in CA GLAD Town Hall Meeting May 17, 2017

Transcription

1 1990 Del Paso Rd Sacramento, CA (916) Payment Issues Impacting the Practice of Physical Therapy in CA GLAD Town Hall Meeting May 17, 2017 Rick Katz, PT, DPT, MA ATI Physical Therapy, V.P. Contracting/Operations CPTA Board of Directors CPTA Payment Policy Committee. Chairperson APTA Private Practice Section Payment Policy Committee 1

2 Topics Current State of ACA ACA Reform- House Bill Medi-Cal Third Party Administrators/Middlemen Mis-valued Codes Comprehensive Joint Replacement Merit Incentive Payment System (MIPS) Locum Tenens Payment Is Changing! Fee for service being slowly replaced Value is the buzzword- Access, Price, Outcomes Episodic vs. time based payment Shared financial risk with the Patient Payer Provider 2

3 Value of PT to the Payer Traditional Thought Emerging Model CMS Accelerates Alternative Payments The coming years of data collection You are being profiled! Functional outcome tools used across all payers Merit based payment coming to Medicare Bundled payment tied to outcomes Third party administrators, networks, repayment companies will collect data on you 3

4 And here is the reason... Premium and Co-Pay tiers based on income level PT as an Essential Benefit Guaranteed Coverage for Pre-existing conditions Coverage until age 26 Medi-Caid expansion Payer coverage for Insurance losses Mandated purchase of insurance Medical Loss Ratio AFFORDABLE CARE ACT 4

5 Themes in the Affordable Care Act Expansion of Coverage Health Insurance Marketplaces Medicaid Expansion Essential health benefits Non-discrimination Collaborative Models of Care - Innovation in Programs Accountable Care Organizations Medical Homes Payment Changes and Linking Payment to Quality Cuts in payment rates Refinements to payment systems Patient assessment instruments Program Integrity Provider Enrollment Funding Increases for Enforcement Expansion of Audits (RACs) Source: American Physical Therapy Learning Center. Healthcare Reform 2014 Progress Report. Kaiser family foundation California 3/17 Physical Therapy Association (CPTA) 2017 Enrollment by Age- California <18, 6.0% 18-25, 10% 55-64, 28.0% < % , 24.0% %

6 Current State of the ACA Current State of ACA Current State of ACA 6

7 The ACA is in Play Guaranteed Issue until age 26 Coverage for pre-existing conditions Stipends and assistance with premiums and copayments based on income level. Insurance portability Expansion and financial support for Medicaid Penalties for non-coverage Physical Therapy defined as an Essential Benefit American Health Care Act Modify ACA Premium Tax Credits for increase amount for younger adults and reduce for older adults, also to apply to coverage sold outside of exchanges and to catastrophic policies. In 2020, replace ACA income-based tax credits with flat tax credits adjusted for age. Eligibility for new tax credits phases out at income levels between $75,000 and $115,000 Repeal mandates for premium and cost sharing subsidies starting in 2020 Retain Private Market Rules including requirement to guarantee issue coverage, prohibition on pre-existing condition exclusions, requirement to extend dependent coverage to age 26. Modify age rating limit to permit variation of 5:1, unless states adopt different ratios, effective 2018 American Health Care Act Retain health insurance marketplaces and open enrollment periods Impose late enrollment penalty for people who don t stay continuously covered Establish a State Patient Stability Fund federal funding of $130 billion over 9 years, and additional funding of $8 billion over 5 years for states that elect community rating waivers. States may use funds to provide financial help to high-risk individuals, promote access to preventive services, provide cost sharing subsidies, and for other purposes. Encourage Use of Health Savings Accounts Increase annual tax free contributions Medical Loss Ratio unchanged 7

8 American Health Care Act Limit enhanced Medicaid expansion to states that adopted the expansion as of 3/1/17 and sunset those states as of 1/1/20 Convert federal Medicaid funding to a per capita allotment and allow states to receive a block grant for non-expansion adults/children Prohibit federal Meicaid funding for Planned Parenthood clinics. Eliminate the Individual Mandate penalty States can apply for a waiver to re-define the 10 essential health plan benefits No change to provisions for maximal lifetime benefits or out of pocket limits MEDI-CAL California Medi-Cal California pays less per beneficiary than almost any other state, and its compensation to doctors is among the lowest in the nation. 2.7 million enrollees since January surprised healthcare experts and created unforeseen challenges for state officials. Altogether, there are now about 11 million Medi-Cal beneficiaries, constituting nearly 30% of the state's population. A. Gorman- LA Times 8/13/

9 Federal Share of Costs for ACA Optional Expansion Population Calendar Year Federal Medical Assistance Percentage a % and thereafter 90 a Determines federal share of costs for covered services in state Medicaid programs. ACA = Patient Protection and Affordable Care Act. ACA Federal Funding to California (In Millions) Payments to the State Government Medi-Cal optional expansion funding $17,335 Other enhanced federal financial participation in Medi-Cal Prevention and Public Health Fund grants Subtotal ($18,313) Payments for Insured Individuals Calendar Year 2017 Covered California premium subsidies $4,600 Subtotal ($4,600) Payments to Insurers Calendar Year 2017 Covered California cost-sharing reductions $800 Subtotal ($800) Grand Total $23,713 ACA = Patient Protection and Affordable Care Act. 9

10 Affordable Care Act- Medi-Cal Expanded Eligibility to those up to 133% of the Federal Poverty Level Individuals with an annual income of up to $15,654 or families with income of up to $32,252 would qualify. Eliminates Asset test for qualification Qualifications based on Income level

11 Affordable Care Act- Medi-Cal Medi-Cal insures about 1 out of every 3 CA residents 2.7 million people have signed up for Medi-Cal through the exchange through January 2016 CA accounts for 17% of the nations Medicaid enrollment. Medi-Cal costs the state about $18.6 billion, about 16% of the states general fund Source :AP 2/16/15 Healthcare Marketplace, Exchanges- CA Anthem Blue Cross of California Blue Shield of California Chinese Community Health Plan Contra Costa Health Plan Health Net Kaiser Permanente L.A. Care Health Plan Molina Healthcare Sharp Health Plan Valley Health Plan Western Health Advantage 32 THIRD PARTY ADMINISTRATORS/MIDDLEMEN 11

12 PT Payment Issues in California Third Party Administrators, Utilization Review Companies, Repricing Companies and Middlemen Discounts on the CA Official Medical Fee Schedule (workers compensation) Transparency in disclosure of patient benefits Unfair protection of payer networks for anticompetitive behaviors Interpretation of the ACA s Medical Loss Ratio Third Party Administrators (TPAs), etc What are they? Serve as intermediaries between the payer and provider Creates and/or manages provider network (contract negotiations) on behalf of the payer Manages utilization of treatment via pre-authorization and re-authorization Create a narrow network of providers to direct care Provides prospective/retrospective treatment medical review (peer-to-peer and non-peer review) May negotiate a separate payment arrangement with the provider One Reason Why They Exist- Medical Loss Ratio The Affordable Care Act established the ability for payers to appropriate expenses to utilization management to patient care services vs the 15-20% they are allowed to consider administrative costs. In essence this creates the incentive for payers to hire these TPAs to and categorize services as patient related. (CA may choose to keep this even if the ACA is repealed) 12

13 TPAs and Outcomes Functional outcomes are not currently being used to direct care. Outcome tracking is used as a mechanism to deny payment for non-compliance Visit authorization is arbitrary Each TPA may have established their own guidelines for determining medical necessity TPA/Middlemen Talking Points The CA Workers Compensation Official Medical Fee schedule was adopted to stimulate the participation of more providers in the delivery of care to the injured worker Third party administrators, middlemen and utilization/repricing companies are creating narrow networks based on pricing. Discounts on the OMFS should be limited in order to prevent a reoccurrence of the mass exodus of providers from the Medical Provider Networks. Discounts are being made at 50% of the fee schedule and are not disclosed to the payer. Entities should not be classified as providing patient care under the Medical Loss Ratio 13

14 Transparancy for the Patient Benefit disclosures don t clearly tell the patient that their benefits may be reduced based upon a third party s opinion on the medical necessity for treatment The PT has to justify the plan of care that they developed, possibly in conjunction with a referral source and then explain it to a third party who will determine if the patient is eligible to receive the benefits paid for through their premium dollar. Transparency Talking Points Authorization of care should be established based upon the patient s diagnosis and recommended plan of care, not by a third party who is not involved in the patient s care. Patient s should be allowed to access their full purchased benefits if they have not achieved the goals established by the patient, provider and referral source (if one exists} Authorizations for care beyond the initial plan should occur within 48 hours of submission of requested data. The medical provider making decisions on utilization should retain professional liability for decisions that result in an adverse outcome due to the limitation of services. Anti-competitive business practices These aggressive networks are pitting one provider against their direct competitor. Letters are being sent that inform a close competitor that if they accept the next lower rate in their tier system that patients will be re-directed from the competitor to their facility. As this occurs; the TPA/middleman benefits via increased profits while providing absolutely no enhanced medical benefit to the injured worker. Currently these entities take many different forms in CA and are afforded the same exemptions to anti-trust actions as those provided to insurers. 14

15 The Ploy I think that it will be very feasible to increase your patient volumes by 10%. I know that if you return the attached patient update sheets, renegotiate your rate down to $60, and work on getting your utilization rate down to 8.70 at all of your locations, which you are already at for the majority of your locations you will become the number one preferred provider in every location which means you will be at the number one spot on our provider map. -Letter from Align to provider I will pay you less and send you more.. My name is Jeff and I work for Align. Networks, your worker s compensation claims and referral provider. Below I have included a recap of your 2015 numbers along with how we can move forward to help increase them in 2016! them. In 2015, Fountain Valley had 111 referrals and your office only received 11 of them. Costa Mesa had 323 referrals and your office only received 12 of them. Newport Beach had 330 referrals and your office only received 11 of Irvine had 1368 referrals and your office only received 3 of them. Huntington Beach had 817 referrals and your office only received 8 of them. I know that you all have the opportunity to move up higher on our map of Providers and in return your offices will be utilized more often for sending our patients to if we can work on renegotiating one aspect of your contract. Your office is currently contracted at 23% off of the worker s compensation fee schedule up to a daily maximum of $84. There are competitors in your area that have more competitively leveraged their daily rate to increase their probability of being utilized. I know that if we renegotiate your daily maximum we can put you in a much more competitive position. Therefore, if we can renegotiate your daily rate down to 25% off of the worker s compensation fee schedule up to a daily maximum of $79 you will have a much more competitive rate thus increasing the likelihood you will be utilized by Align Networks! I have attached the proposed addendum for you all to look over. If you all are comfortable with the changes please sign the addendum and either or fax it back to me. I look forward to hearing from you and if you have any questions please do not hesitate to call or me. Discounts in Exchange for Volume 2016 OFMS Rate TPA Discounted Rate Percentage Discount $135 per visit Tier 1 --$65 51% $135 per visit Tier 2 -- $70 48% $135 per visit Tier 3 -- $75 44% $135 per visit Tier 4 --$ 80 40% 15

16 Anti-Competitive Talking Points There is no legal remedy in CA for anti-competitive activities of these networks Legal research has determined that the public is not protected against such anti-competitive behavior under B & P Code section (unfair competition law). Networks operate in a type of kick-back scheme that escapes scrutiny and enforcement. They drive providers out of business and profit from moving care to lower cost providers. Specialty narrow networks are being created based on cost of care without regard to outcomes or quality. The TPA s, Utilization management and middlemen must be made to demonstrate that their networks demonstrate quality outcomes and high patient satisfaction Arizona Proposed Regulations A provider that participates in a healthcare, preferred provider, outcome-based, or specialty network and that delivers medical treatment and/or services to an injured worker in Arizona s workers compensation system must receive no less than ninety percent (90%) of: (1) the Arizona Physicians and Pharmaceutical Fee Schedule allowable amount for the provided medical treatment and/or services, Utilization Review The TPA/middlemen UR companies set arbitrary standards for review. One visit?, Five visits? They may be making a determination of medical necessity without the involvement of a PT 16

17 MIS-VALUED CODES Mis-valued Codes The Affordable Care Act requires CMS in its annual physician fee schedule to periodically identify potentially misvalued codes and adjust them appropriately. Mis-valued Codes CMS identified 10 physical therapy codes: Electrical stimulation, Ultrasound therapy, Therapeutic exercises, Neuromuscular reeducation, Aquatic therapy/exercises, Gait training therapy, Manual therapy 1/regions, Therapeutic activities, Self-care management training, G0283 Electrical stimulation other than wound 17

18 BUNDLED PAYMENT CJR Implementation CMS has many bundled payment projects CJR is very different Mandatory in 67 Metropolitan Statistical Areas (MSA s) Implementation date April 1, 2016 No application process California Physical Therapy Association Source: (CPTA) CMS

19 Source: CMS Graphic: HFMA The Rules Elective primary hip and knee replacement patients. Medicare as the primary payer. DRG 469- Major joint replacement with major complications or comorbidities. DRG 470-Major joint replacement without major complications or comorbidities. DRGs 480,481,482- Hip fracture Begins January 1, 2016 and last for 5 years. All hospitals paid under IPPS in the target MSA s must participate. Does not apply to Medicare Managed Care plans Services Bundles all costs including inpatient stay and post discharge care for 90 days. All Part A and Part B services except clinically unrelated. Excluded services Acute clinical conditions not arising from existing episode. Chronic conditions that are generally not affected by the LEJR procedure. 19

20 Services Physicians' services Inpatient hospitalization (including readmissions) Inpatient Psychiatric Facility (IPF) Long-term care hospital (LTCH) Inpatient rehabilitation facility (IRF) Skilled nursing facility (SNF) Home health agency (HHA) Hospital outpatient services Free standing outpatient therapy Clinical laboratory Durable medical equipment (DME) Part B drugs Hospice Proposed Payment and Pricing: Retrospective, two-sided risk model with hospitals bearing financial responsibility Providers and suppliers continue to be paid via Medicare Fee for Service After a performance year, actual episode spending would be compared to the episode target prices. Hospital Financial Gain/Risk Target price set as 98% of historical price, 2% is retained by Medicare. CMS portion is reduced from 2% to 1.7% if hospital submits voluntary quality and patient functional outcomes data. Loss repayment (downside risk) doesn t start until CY

21 Proposed Target Price Setting CMS intends to establish for each participant hospital prior to start of applicable performance period Based on blend of hospital-specific and regional episode data (US Census Division), transitioning to regional pricing Years 1&2: 2/3 hospital-specific, 1/3 regional Year 3: 1/3 hospital-specific, 2/3 regional Years 4&5: 100% regional pricing Proposed Financial Arrangements Hospitals can have financial relations with collaborators and can share the upside gain or downside loss. Must actually furnish services during episode to be a collaborator. Collaborators 21

22 Patient Choice and Quality Beneficiaries can select any provider of choice with no restrictions. Require notifications. Hospitals can not mandate, steer or offer inducements to patients. Minimum threshold on Quality must be met: Readmission Rate (RSRR) Complication Rate (RSCR) Consumer Survey (HCAHPS) Optional patient reported outcome reduces the Medicare discount from 2.0% to 1.7% Waivers SNF 3 day rule if SNF is rated 3 stars or higher on Nursing Home Compare Incident to that will allow clinical staff of a physician to furnish home visits (non-hha). 9 visit max. Telehealth-waives originating site requirements so service can be originated in patient home. OIG to evaluate financial arrangements with collaborators. 1 Data sources: the 2013 Medicare Standard Analytic Files (SAFs) for inpatient, hospital outpatient, skilled nursing, home health, and inpatient rehabilitation facilities; the 5% sample SAF for physician Part B and other carrier claims. Excluded from the DRG 470 analysis are ankle replacements.-datagen Healthcare Analytics 22

23 What does this mean? PT s have an opportunity to add value to the equation. Physician s have the opportunity to control more of the total joint rehabilitation process PTs will eventually have to assume some financial risk with both upside and downside potential PT will have more of an impact on post operative care and costs than any other healthcare professional Practices must know their costs to provide services Practices will have to participate in standardized outcome measurement programs. MERIT-BASED INCENTIVE PAYMENT SYSTEM MIPS CMS Notification QPP intends to shift reimbursement from the volume of services provided toward a payment system that rewards clinicians for their overall work in delivering the best care for patients. It replaces the Sustainable Growth Rate formula and streamlines the Legacy Programs - Physician Quality Reporting System, the Value-based Payment Modifier, and the Medicare Electronic Health Records Incentive Program. During this first year of the program, CMS is committed to working with you to streamline the process as much as possible. Our goal is to further reduce burdensome requirements so that you can deliver the best possible care to patients. Learn more about the Quality Payment Program. (4/27/17) 23

24 CMS Notification- News & Announcements Clinicians: MIPS Participation Status Letter CMS is reviewing claims and letting practices know which clinicians need to take part in the Merit-based Incentive Payment System (MIPS), an important part of the new Quality Payment Program (QPP). In late April through May, you will get a letter from your Medicare Administrative Contractor that processes Medicare Part B claims, providing the participation status of each MIPS clinician associated with your Taxpayer Identification Number (TIN). Clinicians should participate in MIPS in the 2017 transition year if they: Bill more than $30,000 in Medicare Part B allowed charges a year and Provide care for more than 100 Part B-enrolled Medicare beneficiaries a year MIPS for Physicians 24

25 MIPS Payment Performance: The first performance period opens January 1, 2017 and closes December 31, During 2017, record quality data and how you used technology to support your practice. If an Advanced APM fits your practice, then you can join and provide care during the year through that model. Send in performance data: To potentially earn a positive payment adjustment under MIPS, send in data about the care you provided and how your practice used technology in 2017 to MIPS by the deadline, March 31, In order to earn the 5% incentive payment by significantly participating in an Advanced APM, just send quality data through your Advanced APM. Feedback: Medicare gives you feedback about your performance after you send your data. Payment: You may earn a positive MIPS payment adjustment for 2019 if you submit 2017 data by March 31, If you participate in an Advanced APM in 2017, then you may earn a 5% incentive payment in LOCUM TENENS Fill in PT Coverage Implement section of the 21st Century Cures Act, which allows outpatient physical therapy services furnished by physical therapists in a health professional shortage area (HPSA), a medically underserved area (MUA), or in a rural area to be billed under reciprocal billing and fee-for-time compensation arrangements in the same manner as physicians bill effective no later than June 13,

26 Fill in PT Coverage In the case of outpatient physical therapy services furnished by physical therapists in a HPSA, a MUA, or a rural area, the A/B MAC Part B may pay the patient s regular physical therapist for such services that are provided by a substitute physical therapist where the regular physical therapist pays the substitute on a per diem or similar fee-for-time basis, and certain other requirements are met. (See Service-Payment/AcuteInpatientPPS/FY2017-IPPS- Final-Rule-Home-Page-Items/FY2017-IPPS-Final-Rule- Data-Files.html Areas left blank in the excel sheet are designated as rural Ready for a Challenge? CPTA Payment Policy Committee Rick Katz, Chairperson and Board liaison Stephanie Kaplan Cam Lippincott Marilyn Washington Diane Blagojevich Leslie Torburn Dennis Langton Dave Power Mitch Kaye Tameka Island, Executive Associate, the wind beneath our wings 26

27 Questions? 27