How Does the Treatment and Management of Diabetes Fit Within the Scope of Reimbursements & Policy? NOVEMBER 17, 2017 JANELLE ALI-DINAR, PHD

Transcription

1 How Does the Treatment and Management of Diabetes Fit Within the Scope of Reimbursements & Policy? NOVEMBER 17, 2017 JANELLE ALI-DINAR, PHD

2 Key Topic Take-Aways : 1. Diabetes Disparities Details 2. Statistics and Social Determinants of Health 3. The HealthCare Knowns & Unknowns DRIVERS: 4. Maximizing Reimbursement Models Based on Policy 5. Toolkit of Reference Resource Information to use.

3 Diabetes Fast Facts: 30.3 million people have diabetes (9.4% of the US population) 23.1 million people diagnosed 7.2 million people (23.8% of people with diabetes are undiagnosed) 84.1 million adults aged 18 years or older have pre-diabetes (33.9% of the adult US population) 23.1 million adults aged 65 years or older have pre-diabetes The CDC also reports that people with pre-diabetes who take part in a structured lifestyle change program can cut the risk of developing type 2 diabetes by as much as 58%.

4 Health Inequities: The burden much greater for minority populations than the Caucasian population: 10.8% of Non-Hispanic blacks, 10.6% Mexican Americans, & 9.0% of American Indians have diabetes, compared to 6.2% Caucasians. Additionally many minorities have much higher rates: diabetes-related complications & death; in some by as much as 50% more than the total population.

5 High Diabetes Rates for Minority Populations: African Americans are from 1.4 to 2.2 times more likely to have diabetes than Caucasians. Hispanic Americans have a higher prevalence of diabetes than Non-Hispanic people, highest rates for Type 2 diabetes among Puerto Ricans and Hispanic people living in the Southwest and the lowest rate among Cubans. The prevalence of diabetes among American Indians is 2.8 times the overall rate. Major groups within the Asian and Pacific Islander communities (Japanese Americans, Chinese Americans, Filipino Americans, and Korean Americans) all had higher prevalence than Caucasians.

6 Minority Populations Health Risk Factors:

7 Social Determinants of Health & Diabetes:

8 Diabetes & Risk Factors: 1. Overweight & Obesity 2. Poor Diet 3. Older Age 4. Family History & Genetics 5. Race & Ethnicity 6. Historical Trauma 7. Natural Disasters/Stressful Circumstances 8. Behavioral Choices 9. Smoking 10. Lack of Physical Activity 11. Hypertension 12. High Cholesterol 13. High Blood Glucose

9 DIABETES POLICY & CARE MANAGEMENT: With nearly 2 million new cases diagnosed annually, Type 2 diabetes is a costly public health issue that challenges our capacity to respond at the patient level in a comprehensive and system-wide manner. Advocacy Grants Collaborative Initiatives Training Leadership

10 Diabetes Economic Burden-Costs & Drivers: 1. $74 billion, with $116 billion in excess medical expenditures and $58 billion in reduced productivity in 5 health care $$ is attributed to diabetes. 3. Average medical expenses for patients with diabetes are nearly twice as high as those for patients who do not have diabetes. 4. As Type 2 diabetes approaches an epidemic level in our country, its increase is typically attributed to biologic characteristics and behavioral influences.

11 Diabetes Economic Burden-Costs & Drivers = Multi-Factor: 5. Biologic factors are related to genetic predispositions for the condition or treatment for other medical conditions and include factors such as age, family history, testosterone deficiency, and use of atypical antipsychotics or statins. Behavioral influences include factors such as physical inactivity and inadequate sleep. 6. Type 2 diabetes and obesity is multifactorial and can further complicate prevention and management. 7. Type 2 diabetes is also associated = hypertension, cardiovascular disease, stroke, kidney failure, and blindness, further intensifying health care utilization and associated expenditures.

12 Diabetes Staggering Impact:

13 Policy & Reimbursements:

14 Policy & Reimbursements:

15 Nothing in HealthCare Is A Straight Line:

16 Policy Shapers & Reimbursements: 1. Status of Affordable Care Act - HealthCare Reform 2. Status of Insurance Exchanges & Premium Increases 3. Moving from Fee for Service to Fee For Value 4. New models of reimbursement CCM, ACO s 5. Administration/Congress & Funding Cuts 6. Medicare and Medicaid Numbers 7. Pharmaceutical Companies/Insurance 8. Economy

17 Policy Shapers & Reimbursements: 9. Opioid, Hepatitis C 10. Pubic Health 11. Rural Hospital Closures = Access Barriers 12. Issues of Workforce and Recruitment of Providers 13. Need for more comprehensive services to care for chronically ill patients. 14. Social Determinants of Health 15. Innovation

18 Caring for Populations During Change: 1. Triple Aim & Quadruple Aim 2. Population Health 3. Creating A Culture of Health 4. Meeting Diverse Population Needs 5. Challenge & Risk Equal Opportunity to Innovate 6. Shift in Fee For Service to Fee For Value

19 Population Risks & Relevancy: The patient-to- primary care physician ratio in rural areas is only 39.8 physicians per 100,000 people, compared to 53.3 physicians per 100,000 in urban areas. There are 30 generalist dentists per 100,000 residents in urban areas versus 22 per 100,000 in rural areas. Increased elderly population More chronic diseases More multi-cultural populations and diverse needs.

20 Medicare Diabetes Prevention Program/MDPP: HIGHLIGHTS: November 2, 2017 issues 2018 Physician Fee Schedule/PFS final rule. 1. Gain access to evidence based diabetes prevention services with goal of lowing rate of progression of Type 2 diabetes create improved health and reduced spending. 2. It is an expansion of the DPP Model Test out of CMMI. 3. Structured intervention goal of preventing progression of Type 2 diabetes 4. Contains 16 intensive core sessions 5. Goal of 5% weight loss by participants. 6. Final rule contains detail for AAPMs Advanced Alternative Payment Models.

21 Medicare Diabetes Prevention Program/MDPP: HIGHLIGHTS: 7. Final rule contains detail for AAPMs Advanced Alternative Payment Models clinicians can receive credit for payment bonuses via participation of APM s. 8. More details for demonstration project forthcoming in Medicare Advantage plans that meet criteria. 9. MDDP suppliers start enrolling 1/1/2018 on rolling basis USING a new specific application which will be available prior to 1/1/ Approved applications submitted prior to 4/1/2018, the effective date of billing will begin 4/1/2018. For those received after 4/1/2018, the billing privilege will be date of application submittal. 11. If there is a Corrective Action Plan (meaning first denied) billing will be the CAP date submitted.

22 Medicare Diabetes Prevention Program/MDPP: HIGHLIGHTS: 12. If a beneficiary develops diabetes during the MDPP services, this diagnosis doesn t prevent beneficiary from continuing MDPP services. 13. For ongoing maintenance- there is a 1 year limit on ongoing maintenance sessions making total MDPP services 2 years. 14. MDPP beneficiaries must attend at least 2 of 3 monthly sessions & maintain 5% weight loss to be eligible for additional intervals.

23 MDPP Payments: 15. Performance-based payment ties payment to performance goals based on attendance and/or weight loss. 16. Final payment structure focuses heavily on beneficiary weight loss. 17. Greater focus on beneficiary attendance. 18. Suppliers will receive payment for beneficiaries who attend 2-3 monthly sessions within core OR ongoing maintenance interval. ** See Handout of MDPP Chart**

24 MDPP Payments: 19. One Time Bridge Payment to supplier if beneficiary changes suppliers after first session. 20. MDPP Supplier Enrollment Compliance Enrollment CMS finalized entity may be eligible to enroll in Medicare as a supplier if achieved MDPP preliminary recognition or CDC full recognition. 21. CMS will screen new suppliers at high categorical risk they finalized that MDPP suppliers revalidating enrollment will be screened at moderate categorical risk. So if revalidating you don t have to go through same rigorous process; Revalidate every 5 years. 22. May provide in-kind engagement incentives. 23. Can provide limited number of make-up virtual sessions.

25 RHC & FQHC Reimbursement Opps: Effective January 1, 2018: Only about 20% of these services are optimized today: FQHCs can receive payment for Chronic Care Management (CCM) or General Behavioral Health Integration (BHI) services when 20 minutes or more of CCM or general BHI services are furnished and G0511 is billed either alone or with other payable services on an FQHC claim. FQHCs can receive payment for psychiatric Collaborative Care Model (CoCM) services when 70 minutes or more of initial psychiatric CoCM services or 60 minutes or more of subsequent psychiatric CoCM services are furnished and G0512 is billed either alone or with other payable services on an FQHC claim. CCM services furnished on or before December 31, 2017 will continue to be processed and paid when CPT code is billed alone or with other payable services on an FQHC claim. Service lines reported with CPT code will be denied for dates of service on or after January 1, 2018.

26 RHC & FQHC Reimbursement Opps: Effective January 1, 2018: 1. TCM same payment for an RHC or FQHC visit. 2. CCM The 2018 rate will be added when the PFS rates are finalized. 3. General BHI The 2018 rate will be added when the PFS rates are finalized. 4. Psychiatric CoCM The 2018 rate will be added when the PFS rates are finalized. **See Proposed 2018 Services Rate Handout**

27 RHC & FQHC Reimbursement Opps: January 1, After this dates CPT codes of 99487, and will not be paid as they are to be coded as G0511 or G Coinsurance and deductibles apply to all CCM services at both clinic and center sites. 3. Coinsurance cannot be waived but you can offer financial assistance on both the FQHC and RHC site for patients who qualify.

28 Telehealth: November 3, 2017: The CMS has once again declined to cover virtual coaching platforms in the MDPP, saying the mhealth and Telehealth platform isn t reliable enough to warrant reimbursement. RHC S & FQHC S are not authorized to serve as distant sites for telehealth for CCM or BHI services. Possible 2018 Innovation models.

29 10,000 FT view of MACRA Repeals the flawed Medicare sustainable growth rate (SGR) formula Two tracks for payment: Merit-based Incentive Payment System (MIPS), and Advanced Alternative Payment Models (AAPMs) Consolidates three existing quality reporting programs Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VBPM), and Meaningful Use (MU)}, plus adds a new performance category, called improvement activities (IA), into a single system through MIPS.

30 MIPS and How will YOU be Scored? Scores from four categories Quality - based on PQRS; Resource Use - based on VBPM; Advancing Care Information (ACI); and Clinical practice improvement activities-new performance category Performance Category QUALITY 60% 50% 30% COST 0% 10% 30% ACI 25%* 25%* 25%* IA 15% 15% 15% *This weight may be reduced based upon EHR users greater than 75%

31 Areas & Penalties & Bonuses: 1. Quality 2. Advancing Care Information 3. Improvement Activities 4. Cost MIPS Adjustment Year 2019 = +/-4% 2020 = +/-5% 2021 = +/-7% 2022 and beyond = +/-9%

32 MIPPS Measures: Quality Replaces PQRS Track at least 6 quality measures (one must be an outcome measure) If reporting through an APM, providers are not required to submit through MIPS as well Providers can score three to 10 points per quality measure Potential bonus points Practices can use only one mechanism for reporting the quality measures in 2018 but won t implement until 2019.

33 MIPPS Measures: Resource Use No reporting requirement for Eligible Clinicians Calculated by CMS utilizing claims data 2017 reweighted at 0% Performance year 2018 (Payment year 2020) Total per capita costs and Medicare spending per beneficiary Will be given feedback during transition year by CMS

34 MIPPS Measures: Advancing Care Information (ACI) Replaces MU EHR Incentive Program Required reporting (5 measures): Security risk analysis, E-prescribing, Providing patient access, Sending summaries of care, and Receiving summary of care Earn up to 155%, capping at 100%, 50% for required reporting (0 points for not reporting required) Earn additional 90% based on performance, additional 15% for reporting beyond required Possible Hardship exclusion Hurricanes and Fires no paperwork

35 MIPPS Measures: Improvement Activities (IA) Is a New Category 93 measures, Providers select 4 21 new improvement activities (some modified) have been added & CMS made changes to 27 previously adopted activities for Groups less than 15 and Rural or MUAs 2 measures 90 days Score 10 points medium-activity Score 20 points high-activity measures Values doubled for MUAs or non-patient facing providers

36 MIPPS Measures: Cost The reporting period for the quality and cost measures is 12 months in Cost weighted at 10%. It is calculated based on Medicare Spending per beneficiary. And total per capital cost measure, an the announcement also confirmed CMS commitment to a 30% weighting of the cost component for 2019 and beyond.

37 Opportunities for Bonus & Change: Five bonus points are available for treatment of complex patients Small practices with 15 or fewer clinicians receive an automatic extra 5 bonus points. They also don t have to work about data completeness for quality measures, as they receive an automatic 3 points per measure. Small practices also exempts one activity from the ACI category with an end of year due date for the application for this exception. Can have Virtual Group Agreements.

38 Navigation & Connection Point: Reporting Methods Claims Qualified Clinical Data Registry (QCDR) Qualified Registry EHR For Groups: QCDR, Qualified Registry, EHR, CMS Web Interface, and CMSapproved survey vendor ACI and IA categories attestation options No data submission Cost Performance (Resource) category

39 Can You participate without having an EHR? You can, HOWEVER: NOT eligible for ANY of the points under the ACI performance category Use of EHR technology that is not certified will result in a ZERO for the category More burdensome Reporting options Claims data Qualified registry

40 How Will We Be Paid? Beginning 2019 (Participants in MIPS) Eligible for positive or negative Part B adjustments starting at 4% and gradually increase to 9% (2022) Distribution on sliding scale and budget neutral Payment Adjustments: Final score at threshold- Neutral Final score above threshold- Positive (in payment year) Final score below threshold- Negative (in payment year) Final score in lowest quartile- AUTOMATICALLY adjusted to MAXIMUM negative adjustment on EACH Medicare Part B Claim in payment year How is it applied? What if Provider changes groups?

41 Do I Qualify? Exemptions: Providers in their first year billing Medicare Providers with their volume of Medicare payments or patients falling below the low-volume threshold 100 Medicare patients OR $30,000 or less in Part B charges Resident providers in their second year of Medicare billing and who are billing under their own NPI would be subject to MIPS adjustment. Resident providers in their first year of billing would be considered NEW to Medicare and would be excluded. FQHCs and RHCs Exempt under all-inclusive payment However, any Medicare Part B that is billed outside of the all-inclusive will be subject to MIPS Attribution

42 PICK YOUR PACE (2017) Ease into transition to MIPS 4 options to avoid negative payment adjustment (2019) Test Partial Participation Full Participation Participate in an Advanced APM Failure to report any data to CMS, subject to full negative payment adjustment of 4%

43 Now & Future: 1. Begin application of risk stratification, data analytics. 2. Begin application of precision medicine managing all populations. 3. Look at Payer Groups as they focus on social determinants of health providing Whole Care like United Diabetic Care, Waivers and Housing. 4. More CLAS Standards, Social Determinants of Health mainstream care. 5. Waiting on CMS on final proposed rule for polypharmacy. 6. CMMI Innovation Center more opportunity 7. Rural Health Primary Care Services Grant December 2017 HRSA.gov. Check out Primary Care Digest

44 Telehealth: November 3, 2017: The CMS has once again declined to cover virtual coaching platforms in the MDPP, saying the mhealth and telehealth platform isn t reliable enough to warrant reimbursement. RHC S & FQHC S are not authorized to serve as distant sites for telehealth for CCM or BHI services. Future CMMI innovation pilot project.

45 Unprecedented HealthCare Cross Roads:

46 Your Work In Diabetes Will Make A World Of Difference

47 Toolkit of Resource Information: -Clinics-Center.html Care Management Services in RHCs and FQHCs - FAQs [PDF, 198KB] Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program Rural Health Information Hub. National Rural Health Association RAC Monitor

48 Contact Information: Janelle Ali-Dinar, PhD VP Population Health, Rural Health & Global Health Initiatives Phone: (615) (402)