Alabama Internal Medicine Meeting

June 07, 2016

Together we can make a difference!

Minutes

Board Recertification –Dr. Joe Shepherd– To recertify for boards through ABIMis a horrendousand unnecessary process. Fortunately an alternative for recertification has emerged through the National Board of Physicians and Surgeons.

GET RID OF MOC, by Dr. Joe Shepherd

A few years ago, AAPS (American Association of Physicians and Surgeons) did a survey of about 200 doctors at random across the country, asking about MOC. How many doctors do you suppose went negative on the survey? 91%

Why are boards so unpopular? Is it because modules, board review courses, and tests are expensive, time-consuming, and stressful?

Is it because they’re offensive? (Most people have to travel; you’re finger-printed and photographed; you must remove wallet/phone/watch; you can’t be trusted to use #2 pencils anymore; you must use “magic” erasable boards.)

And is it because, in the end, we know that repeating the boards is irrelevant? When ABMS themselves compared doctors who are MOC-current vs. those who aren’t, their own studies found no positive difference in clinical practice, lawsuits filed, or patient satisfaction.

Less than 1/10 of one percent of complaints to state boards are about “incompetence” due to lack of knowledge. Conclusion: Our system of med school, residency, initial board certification, and continuing education works very well.

And then there’s the money:

ABMS is composed of 24 corporations. One of these corporations is ABIM.

Since 1998, ABIM alone has pocketed more than half a billion dollars.

The yearly amount has nearly quintupled from 1999 to 2015.

Though ostensibly non-profit, these corporations pay salaries to their executives that often exceed $700K / year.

If MOC has its way, recertification will wrap itself around insurance reimbursement, hospital privileges, and licensure.

No other profession does this: accountants, attorneys, dentists, pilots, engineers. No one demands – or even allows this.

This is not about board certification. I don’t think any of us are against that. BUT SHOULDN’T WE ALL STRONGLY OPPOSE INVOLUNTARYCOERCEDRECERTIFICATION?

For Internal Medicine, 1990 was the first year of involuntary recertification. That happened to be the year I was boarded. In 2002, I got re-certified. Like a good shepherd I play along. But I will never be re-re-certified by ABMS.

This is not about life-long learning. We all love that -- learning new things. And, like other professions, we use CE for that.

Recently, ABMS has tried to coop the term “life-long learning,” convince politicians and the public that they (ABMS) have a monopoly on our CE.

Aren’t YOU, as the professional you are, best equipped to know what you need to learn next? (Better equipped than some overpaid suit that might not even see patients for a living?)

We are good doctors. That is why we get board certified. We are not good doctors because we got board certified.

GET RID OF MOC

“And I said, that's good! One less thing.” -- Forrest Gump

DO NOT ENROLL IN THE CURRENT MOC PROGRAM!

Competition is what caused ABIM to send the “we screwed up” letter

Alternative board certification

NBPAS – National Board of Physicians and Surgeons

Brainchild of Dr. Paul Tierstein, cardiologist at Scripps Hospital, San Diego

Website:

Criteria for NBPAS certification:

1) Previous certification by an ABMS or AOA member board

2) Valid license to practice medicine

3) At least 50 hours of ACCME accredited CME within the past 24 months

(re-entry for lapsed certification requires 100 hours)

4) For selected specialties, active hospital privileges in that specialty

5) Clinical privileges in certified specialty have not been permanently revoked

Cost: $169 for a 2 year certificate ($84.50 per year)

BMC Princeton is the only hospital in Birmingham that accepts NBPAS … so far!

Be aware of “Trojan horses” for MOC

The Interstate Compact (FSMB)

Ostensibly facilitates multi-state licensure for doctors practicing telemedicine

Reality is that the definition of “physician” is changed

The instant you stop participating in MOC, you are no longer a physician!

Makes it easier for boards to discipline

If a complaint is generated in one state, all states get the information

Do not, under any circumstances, obtain a medical license via the FSMB

Instead, obtain license the old fashioned way: state by state

Ask your legislators and state medical board to withdraw from FSMB

Reference…

Homework assignment:

“What to do about MOC” video: (30 min)

Dr. Tierstein’s video: (30 min)

Join the American Association of Physicians and Surgeons:

(This is the only national organization on your side!)

Bottom Line

DON’T SEND NBME ANY MORE OF YOUR CASH

(This enables them to come after you that much harder)

Become NBPAS certified yourself

Spread the word amongst colleagues and your hospital medical executive committee.

  • ACP (American College of Physicians) Society – Dr. Andrea White– Our primary care/internal medicine society is primarily driven by UAB. This is great for lobbying on a Federal level just not on a private practice level. The ACP in GA and TN are primarily driven by private practice and they are more attended and making a difference. We need to get involved with the ACP or start our own independent society for primary care/internal medicine.
  • Ancillary Services – Dr. Robert Frederickson – For in house x-ray/labs we lost revenue in 2016 from BCBS of AL; and Quest is theirpreferred lab for all exchange patients. Referrals to have tests performed elsewhere increases cost and have a negative impact in patient care. Our practice sent a letter to BCBS addressing the rise in cost associated with the shift of these ancillary services being referred to an outside entity. Our concerns have not been addressed.
  • Emdeon Rejections – Dr. Charles Boackle – Rejection of claims based on
    CPT codes alone. If billing levels 4 & 5 Emdeon clearing house is rejecting claims when going over a certain threshold based on CPT code alone.
  • ACO/Patient Center Medical Home – Dr. Andrea White –

Accountable Care Organizations (ACO)

Payment and care delivery model in whichprovider’s payment is tied to quality metrics and total cost reduction for care of assigned groups of patients.

  • Capitation verses fee for service
  • ACO collectively accountable to CMS
  • Providers – lead organization
  • Places financial responsibility on providers in hopes of improving management and limiting costs while allowing patients some freedom on selecting medical services.
  • Ideally ACO incentivizes providers and hospitals and rehabs to link and coordinate care.
  • CMS estimates ACO’s could save $470M (Pioneer ACO savings data was mixed 2012-2015)
  • 5K beneficiaries
  • Sufficient PCP’s, promote evidence based medicine through processes, engage patients, monitor and evaluate cost and quality, meet patient satisfaction, and coordinate care across continuum/spectrum.
  • Financial mixture payments determined by comparative ACO’s annual inward costs relative to CMS benchmarks (benchmarks based on estimation of total FFS expenditures associated with management in traditional FFS setting).
  • There is also a minimum savings rate that is calculated as a percentage of benchmark which ACO savings must exceed in order to qualify for shared savings. Less 1% of a 1 sided model average % if 2 sided model.
  • Quality measures have decreased from 65 – 33.
  • 1 sided model: Savings shared >21 shared over 2 years + savings + losses shared over 1 year = 50% max.
  • 2 sided model: Savings + losses over 3 years = 60% max.
  • ACO quality measures: 5 Domains: patient care gives experience, care coordination; patient safety, prevention, at-risk population/frail in the elderly.

Caveats: High start up cost, lack of specificity, CBT implementation, and high annual maintenance costs, risk, anti-trust laws, EHR challenges to reporting/advanced reporting, disease registry, patient population, and care management.

Value-based Reimbursement – Dr. Todd Schultz – Value Based Payment

Outline Value Based Payment

Currently only about 6% of payment tied to quality measures.

Declined between 2012 and 2-16 by about 16%.

Will grow to 10% in next few years, and in some cases as much as 20% - Ultimate goal for CMS is 50%.

It’s here to stay!

In part being driving by the Merit-based Incentive Pay System (MIPS – More like fee-for-service) and Alternative Payment Models (APM – Like ACOs) called for under the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA). This legislation was signed into law as an alternative to a huge reimbursement cut for Medicare.

Comprehensive Primary Care + (CPC +) = 2 tracks. Track 1 – Monthly management fee along with fee for service. Track 2 – Monthly management fee with reduced fee for service in lieu of upfront comprehensive primary care payments for evaluation and management claims.

Circle of Care

Experts say the most successful practices will be ones thinking of the changes a part of a more holistic performance improvement strategy, rather than just an exercise in completing forms

Suggestions:

1)Heads Up - Be aware of legislation

2)Deputize staff – Brainstorm creative ways to improve patient flow and patient care.

3)Work with Payors – Discuss alternative pay models.

4)Get Involved – Bet more involved in compensation discussions.

5)Embrace Data – May be organizations to help physicians utilize data in a more meaningful way.

6)Align pay with Goals – For practices with salaried physicians.

7)Think like a Team –

8)Prepare for the future financially – There may be some salary volatility

9)Know When to say No – Probably not practical in our situation.

10)Brush up on soft metrics – Improve physician/patient relationships

Quality Payment Program: Delivery System Reform, Medicare Payment Reform, & MACRA

The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs)

How does the Medicare Access &CHIPReauthorization Act of 2015 (MACRA) reform Medicare payment?

  • TheMACRAmakes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes create a Quality Payment Program (QPP):
  • Ending theSustainable Growth Rate(SGR) formula for determining Medicare payments for health care providers’ services.
  • Making a new framework for rewarding health care providers for giving better care not more just more care.
  • Combining our existing quality reporting programs into one new system.

These proposed changes, which we’ve named the Quality Payment Program, replace a patchwork system of Medicare reporting programs with a flexible system that allows you to choose from two paths that link quality to payments: the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models.

What's the MACRA Quality Payment Program?

The MACRA QPP will help us to move more quickly toward ourgoalof paying for value and better care.TheQuality Payment Programhastwo paths:

  1. Merit-Based Incentive Payment System (MIPS)
  2. Alternative Payment Models (APMs)

MIPS and APMs will go into effect over atimelinefrom 2015 through 2021 and beyond.

What’s the Merit-Based Incentive Payment System (MIPS)?

The MIPS is a new program that combines parts of thePhysician Quality Reporting System(PQRS), theValue Modifier(VM orValue-based Payment Modifier), and theMedicare Electronic Health Record(EHR) incentive program into one single program in whichEligible Professionals (EPs)will be measured on:

  • Quality
  • Resource use
  • Clinical practice improvement
  • Meaningful use of certified EHR technology

What are Alternative Payment Models (APMs)?

APMs give us new ways to pay health care providers for the care they give Medicare beneficiaries. For example:

  • From 2019-2024, pay some participating health care providers a lump-sumincentive payment.
  • Increased transparency of physician-focused payment models.
  • Starting in 2026, offers some participating health care providers higher annual payments.

Accountable Care Organizations(ACOs), Patient Centered Medical Homes, andbundled payment modelsare some examples of APMs.

Commentary by physician organizations

In the United States, most professional medical societies have been nominally supportive of incentive programs to increase the quality of health care. However, these organizations also express concern over the choice and validity of measurements of improvement. TheAmerican Medical Association(AMA) has published principles for pay-for performance programs, with emphasis on voluntary participation, data accuracy, positive incentives and fostering thedoctor-patient relationship,[10]and detailed guidelines for designing and implementing these programs.[11]Positions by other physician organizations question the validity of performance measures, and whether it will preserve an individual physician’s clinical judgment, a patient's preferences, autonomy and privacy. They question whether it will lower costs, although it will increase administrative costs.

  • American Academy of Family Physicians: "there are a multitude of organizational, technical, legal and ethical challenges to designing and implementing pay for performance programs"[12]
  • American College of Physicians: "adoption of appropriate quality improvement strategies, if done right, will result in higher quality patient care leading to increased physician and patient satisfaction. But the College is also concerned that these changes could lead to more paperwork, more expense, and less revenue; detract from the time that internists spend with patients, and have unintended adverse consequences for sicker and non-compliant patients."[13]"... concerned about using a limited set of clinical practice parameters to assess quality, especially if payment for good performance is grafted onto the current payment system, which does not reward robust comprehensive care."[14]
  • American Geriatrics Society: "quality measures (must) target not only care for specific diseases, but also care that addresses multiple, concurrent illnesses and (are) tested among vulnerable older adults. Using indicators that have been developed for a commercially insured population...may not be relevant"[15]
  • American Academy of Neurology(AAN): "An unintended consequence is that current relative payments are distorted and represent a misaligned incentive system, encouraging diagnostic tests over thoughtful and skilled patient care. The AAN recommends addressing these underlying inequities before a P4P program is adopted.[16]
  • TheEndocrine Society: "it is difficult to develop standardized measure across medical specialties...variations must be allowed to meet the unique needs of the individual patient...P4P programs should not place financial or administrative burdens on practices that care for underserved patient populations”

Aaron E. Carroll, a professor of pediatrics who writes a column for the New York Times, said after reviewing the medical literature in 2014 that pay for performance in the U.S. and U.K. has brought "disappointingly mixed results." Sometimes even large incentives don't change the way doctors practice medicine. Sometimes incentives do change practice, but even when they do, clinical outcomes don't improve. Critics say that pay for performance is a technique borrowed from corporate management, where the main outcome of concern is profit. In medical practice, many important outcomes and processes, such as spending time with patients, can't be quantified.[1]

Also known as "P4P" or "value-based purchasing," this payment model rewards physicians, hospitals, medical groups, and other healthcare providers for meeting certain performance measures for quality and efficiency. It penalizes caregivers for poor outcomes,medical errors, or increased costs.

Studies in several large healthcare systems have shown modest improvements in specific outcomes, but these have been short-lived, and reduce performance in outcomes that were not measured. They also failed to save money.

Professional societies have given qualified approval to incentive programs, but express concern with the validity of quality indicators, patient and physician autonomy and privacy, and increased administrative burdens.

  • BlueCross BlueShield of AL “Circle of Care Program” – Who has signed contracts for this program? Lost revenue from ancillary services is being shifted to E&M reimbursements if enrolled in this program.
  • Star Ratings– Print and work snapshots to close gaps. Colonoscopy screenings with dates of when they were performed along with results needs to be documented. Personal and/or family history of certain conditions needs to be clear. Insulin use for type II diabetics. Link hypertension with CKD. Include all chronic diagnosis codes on E&M and AWV. Prescribe generic medications as often as possible. See attached presentation
  • Wellness visits – closing gaps – Dr. LaDonna Richardson – Problem with other physicians and non-physicians doing wellness visits and being reimbursed. Publix pharmacy had a sign get your wellness visits here. When asked, pharmacists stated we have a form the patient fills out and we submit to insurance for payment and are getting reimbursed. Primary Care physicians are getting reimbursed based on closing gaps. This is not closing gaps in care if anyone can complete the forms and get reimbursed.
  • Chronic Care Management – Dr. Charles Boackle –

CHRONIC CARE MANAGEMENT SERVICES (CCM)

The CCM services began on Jan. 1, 2015. This is intended to allow payment to physicians for non-face-to-face care coordination for services provided to Medicare beneficiaries with two or more chronic medical conditions that are expected to last at least 12 months (examples include CHF, CAD, hypertension, DM, asthma, COPD, etc). The chronic conditions must place the patient at significant risk of death, acute exacerbations/decompensation or functional decline. To bill for CCM services requires at least 20 minutes of clinical staff time directed by the physician per calendar month. This can be billed by nurse practitioners or physician assistants as well as MD’s. The practitioner must inform eligible patients of the availability of this service, and obtain a written consent for this service before billing for it. There should be documentation in the medical record that that CCM services were explained and offered to the patient and whether or not they accepted or declined. They have to be informed about how to revoke the agreement. Only one practitioner can be paid for CCM during a calendar month, and the patient should be informed of this. There are specific details that are required in the agreement.