By Stephen C. Spain, MD, FAAFP, CPC
Angela “Annie” Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT
Part 2: As health care moves away from fee-for-service, quality care comes to the forefront.
Evidence-based medicine (EBM) and the Physician Quality Reporting System (PQRS) have brought the concept of pay for performance (P4P) to health care. The (r)evolutionary next step driving quality and value is the accountable care organization (ACO). The concept of accountable care begins where P4P ends: More than offering incentives for quality care, it requires quality care as a condition of reimbursement.
In October 2011, the U.S. Department of Health & Human Services (HHS) released a final rule governing the formation of ACOs. ACOs were implemented as a voluntary program in January 2012 as a result of the Affordable Care Act (ACA) and a modification to the Social Security Act (SSA), which established a funding source known as the Shared Savings Program. The ACO provisions represented only seven pages of the massive ACA; however, they were one of its most publicized provisions (along with the individual mandate).
Through the Shared Savings Program, the ACO initiative creates incentives for health care providers to work together to treat an individual patient across care settings, including physician offices, hospitals, and long-term care facilities.
Payers can form ACOs, and many have. UnitedHealthcare, Aetna, and Humana—each of which has vast experience with performance-driven care outcomes—have all formed ACOs. There are both commercial and Medicare ACOs. Many ACOs have been established by community-based programs and provider groups.
ACOs Require Performance Measure Reporting
ACOs seek to reduce health care costs, coordinate care, eliminate duplication of care, and prevent medical errors while ensuring better data integrity. ACOs meeting specific performance objectives over a three-year introductory period will share in any savings they create through lowered health care costs (versus estimated costs using a “traditional care” model). ACOs unable to meet the performance objectives will be penalized. The goal is to share in rewards and risk across all participants in the ACO.
Like PQRS and other quality monitoring programs, ACOs rely on data—much of which will be derived from patient charts by certified medical coders. The final rule adopts 33 individual measures of quality performance used to determine if an ACO qualifies for incentive shared savings. These performance measures span four quality domains:
- Patient Experience of Care
- Care Coordination/Patient Safety
- Preventive Health
- At-risk Populations
Reporting conditions such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery disease (CAD), vascular disease, risk for falls, diabetes, hypertension, tobacco cessation, depression, certain types of cancers, and immunizations all will depend on data provided by certified medical coders, and will help to determine if the ACO will share in savings or face penalties.
Moving Away from Fee-for-service
As a reimbursement methodology, ACOs are vastly different from traditional fee-for-service (FFS), which is the most common reimbursement methodology in the United States. In an FFS system, providers are paid based on the number of tests, treatments, surgeries, or studies they perform; hospitals are paid based on the number of beds they have occupied. The focus is on “how much” (quantity) care is provided, rather than “how good” (quality) the care is.
The concept of quality-based reimbursement (such as P4P) has existed for approximately 25 years, but has only begun to pick up steam in the past 10 years with the advent of the physician quality reimbursement initiative (now PQRS). If successful, the ACO model will revolutionize the way we receive, and pay for, health care in the United States.
ACO: HMO Take 2?
There are many differences between standard health maintenance organization (HMO) models and ACOs. When the Health Maintenance Organization Act of 1973 was passed and pioneered managed care, Americans were hesitant to allow Big Brother to oversee health care. It took nearly a decade for the managed care concept to catch on, but when it did, we learned that managing care saves money. There were, however, drawbacks in the way HMOs governed access to care. For example, HMOs are insurer driven and care can be fragmented; there is often little collaboration or cooperation in care delivery. There are gatekeepers—usually a provider that controls a patient’s access to higher levels of care (which raises the often worrisome in-network versus out-of-network dilemma)—and the overall focus of HMOs and managed care remains on quantity rather than quality.
Unlike the HMO or managed care model, the ACO model is provider driven. Care is intended to be fully integrated and should occur more collaboratively. Team-based care is a primary tenet of the ACO. There are no gatekeepers in ACOs, and the overall focus is on the quality and efficiency of care. Rather than being incentivized to deny expensive care, the ACO receives incentives for higher quality outcomes.
There are risks associated with the ACO model. Early participants in ACOs are not fully weaned from of the FFS system, so ACOs remain an unproven reimbursement system. We are not likely to see quality-based outcome measures or quality-based financial incentives for a year or more.
Another potential danger is ACOs will engage in “cherry picking,” or choosing only the healthiest patients to treat. The Centers for Medicare & Medicaid Services (CMS) has announced they will penalize any ACO caught cherry picking, and there are protections built into the final rule so cherry picking ACOs stand to lose money. Concerns remain that this may not be enough to combat the problem.
Perhaps the greatest risk is that there are no gatekeepers: There is nothing requiring a patient to remain with an ACO. In other words, if a patient wants to obtain health care from providers outside the ACO, he or she may do so using traditional Medicare insurance. The ACO would be penalized for these out-of-network expenditures (presumably, if the ACO’s quality of care and patient satisfaction are high enough, there would be no reason for a patient to seek health care elsewhere). This patient freedom represents a big gamble for fledgling ACOs.
The United States has yet to design a perfect health care system. If ACOs are to be successful, they must have a solid foundation with which to bridge the divide between FFS and accountable care.
Stephen Spain, MD, FAAFP, CPC, has been engaged in the full-time practice of family medicine for over 25 years. In 1998, he founded Doc-U-Chart, a practice management consulting firm specializing in medical documentation. Dr. Spain can be reached at firstname.lastname@example.org.
Annie Boynton, BS, CPC, CPC-H, CPC-P, CPC-I, RHIT, CCS, CCS-P, CPhT, is the director of 5010/ICD-10 communication, adoption and training for UnitedHealth Group. She is an adjunct faculty member at Massachusetts Bay Community College, and a developer and member of the AAPC’s ICD-10 training team. Ms. Boynton frequently speaks and writes about coding matters, including ICD-10 and 5010 implementation.
December 1st, 2012
By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA, CHCO
Changes to the Office of Inspector General’s (OIG) Work Plan for 2013 includes reviews of the use of commercial mailboxes, provision of motorized wheelchairs and prosthetics, payments to providers subject to debt collection, and continuous positive airway pressure (CPAP) and diabetes supplier. Special attention is being paid in 2013 to providers who are enrolling or reenrolling in Medicare, repeatedly submitting claims with errors, and submitting anesthesia claims for personally performed services.
The OIG publishes an annual work plan that identifies compliance and investigative initiatives that are ongoing or are planned for the upcoming year with respect to U.S. Department of Health & Human Services (HHS) programs. The Work Plan for Fiscal Year 2013 (Work Plan) defines the OIG’s responsibilities and its mission, which encompasses 300 programs, as this:
“Our organization was created to protect the integrity of HHS programs and operations and the wellbeing of beneficiaries by detecting and preventing fraud, waste, and abuse; identifying opportunities to improve program economy, efficiency, and effectiveness; and holding accountable those who do not meet program requirements or who violate Federal laws.”
The OIG’s Work Plan is a resource to help you understand which areas in your practice are identified as high risk. If the OIG feels the risk of errors is high enough to place a topic in their Work Plan, you should take heed and add to your compliance plan a process to inspect policies, procedures, coding, and billing in similar scenarios.
Some of the ongoing areas of interest the OIG has for physician practices include:
- Modifier usage during a global period
- Evaluation and management (E/M) services
- Incident-to billing
Medical record documentation and coding remains the foundation for “proving” claims submitted for adjudication accurately represent the medical services provided. As a compliance professional, you must identify weaknesses, explore areas of risk, recommend and implement improved practices, and educate staff and medical professionals about very complex issues. The OIG’s Work Plan can help you do this.
The OIG Work Plan for Fiscal Year 2013 is available for download on the OIG website.
October 12th, 2012
By Julie E. Chicoine, Esq., RN, CPC
New federal rules add additional responsibilities and accountabilities affecting those who allow a breach of privacy or security. Knowing these new rules and concepts in case patients’ information is released may ease a provider’s recovery from the crisis.
The Office of Civil Rights generally defines a breach as an impermissible use or disclosure under the Health Insurance Portability and Accountability Act (HIPAA) that compromises the security and privacy of personal health information (PHI) such that the subsequent use or disclosure poses a significant risk of financial, reputational, or other harm to the affected individual (see Breach Notification Rule). This definition has not changed; however, the Health Information Technology for Economic and Clinical Health (HITECH) Act adds the notion of willful neglect, defined as willfully disregarding knowledge of a privacy and security violation.
The HIPAA privacy rule imposed general requirements including investigation, mitigation, correction, and notification of privacy breaches under certain circumstances. HITECH amends those requirements to include three levels of reporting for breach that qualifies as a “wrongful use/disclosure” of PHI.
- Providers must send an individual notice to the affected patient(s) within 60 days following the discovery of an unsecured PHI breach. This notice must be in written form by first class mail, or via email when the affected patient has agreed to receive notices electronically.
- If the breach involves more than 500 patients, providers must take the additional step of providing notice to prominent media outlets serving that state or jurisdiction where the breach occurred. This notice can be accomplished in the form of a press release. As with individual notice, this must be accomplished within 60 days of discovery of the privacy breach and must include the same information provided in the individual notice.
- Providers must notify the secretary of the U.S. Department of Health & Human Services (HHS) of unsecured PHI breaches by submitting a breach report form (available on the HHS website). If the breach affects more than 500 patients, the practice must complete this task “without unreasonable delay,” but no later than 60 days following discovery. If the breach affects fewer than 500 patients, the practice can notify the secretary of the breach on an annual basis. Annual reports must be received no later than 60 days from the end of the calendar year when the breach(es) occurred.
October 10th, 2012
Stage 2 Meaningful Use guidelines become effective November 5. To take full advantage of financial incentives available to your practice, knowing what is expected will help.
The Centers for Medicare & Medicaid Services (CMS) announced a final rule after Labor Day specifying the Stage 2 criteria set for eligible professionals, eligible hospitals, and critical access hospitals (CAH) to quality for Medicare and Medicaid electronic health record (EHR) incentive payments. The rule also outlines payment adjustments made if program participants fail to meaningfully use EHR technology. However, the new rules provide a flexible reporting period for 2014 so providers will have sufficient time to adopt or upgrade to the latest technology available in 2014.
CMS said Meaningful Use, which is divided into three stages, affects one out of every five eligible health care professionals.
- Stage 1 sets the basic functionalities electronic health records must include, such as capturing data electronically and providing patients with electronic copies of health information.
- Stage 2 (which will begin as early as 2014) increases health information exchange between providers and promotes patient engagement by giving patients secure online access to their health information.
- Stage 3 will continue to expand meaningful use objectives to improve health care outcomes.
Remember that if your practice is not a facility, you must meet the measurements or quality for exclusion to 17 core objectives and three to six menu objectives. (If you are a hospital or critical access hospital (CAH), you must meet 16, with three to six menu items.) However, if you are using “2011 Edition Certified EHR Technology,” you may use it until 2014. Some new criteria include:
- Patient Engagement. CMS proposed two new core objectives providing patients online access to health information and secure messaging between patient and provider with measures that require patients to take specific actions for a provider to achieve meaningful use and receive an EHR incentive payment. For both objectives, the threshold was set at 10 percent of patients. While providers expressed concern, CMS is finalizing the proposed measures with reduced thresholds of 5 percent for both objectives. In addition, CMS introduced exclusions based on availability of broadband in a provider’s practice area.
- Electronic Exchange of Summary of Care Documents. To spur provider commitment to electronic exchange, CMS had initially proposed two ambitious measures for this objective in Stage 2. The first measure required that a provider send a summary of care record for more than 50 percent of transitions of care and referrals. The second measure required that a provider electronically transmit a summary of care for more than 10 percent of transitions of care and referrals. CMS is requiring at least one instance of exchange with a provider using EHR technology designed by a different EHR vendor or with a CMS-designated test EHR.
Prepare, too, for clinical quality measure (CQM) guidelines. The rule finalizes that providers must report on nine out of 64 CQMs. All providers must select CQMS from at least three of the six key health care policy domains from the Department of Health & Human Services (HHS) national quality strategy:
- Patient and family engagement
- Patient safety
- Care coordination
- Population and public health
- Efficient use of health care resources
- Clinical processes/effectiveness
For more information about this and hardship exceptions, review the Final Rule, published in the Federal Register Sept. 4.
September 12th, 2012