Preparing for 2011 –
Where are we and where are we going
Cathie Biga
President/CEO
Cardiovascular Management of Illinois
Agenda
•
•
•
•
•
•
•
2010 in review
Technical Correction
2011 Physician Fee Schedule
2011 HOPPS
Private Payers in 2011
HCR/ACA – its impact
Core 2011 concepts: PQRS/eRx….
Legal
Primary Issues
•
•
•
•
•
HCR/ACA
Threats to physician ownership/in-office imaging
SGR – will it ever be fixed
IPAB
CMI
Secondary Issues
• Key topics – 1) Disclosure requirements for CT, PET, MRI, 2)
PECOS, 3) POS/DOS, 4) Timely filing
• 2012 Accreditation of labs and 2010 IAC changes
• Meaningful use – stretch or a barrier?
Regulatory
• PFS 2011
–
–
–
–
2nd year of PPIS implementation
Bundling continues
Rebase for MEI
RUC focus
• HOPPS 2011
– Reductions beginning?
• Quality focus continues to grow
• Ongoing scrutiny of imaging and IOE
• EP becomes its own specialty 4/4/11
– ENROLLMENT NEEDED
Economic
• Gap in technical
– Bundling of nucs ’10
– Bundling of caths ’11
– Massive PV bundling
• RAC’s, MACs, and other attacks
• Revenue wherever you can find it
–
–
–
–
Clinical integration
PQRI
eRx
Meaningful use
• Operational efficiencies
• New product lines
Technical Correction
•
•
•
•
What is it
What do we do
What have people done
Current status
What is the real story
• In May of 2010 the updated files also contained updates to
RVU units. This has a range of .60 refunds to $50 –$60
increases for some services
CPT
78452
92980
93510-26
93620
Short Description
Rest stress SPECT
Coronary Stent
Left cath in hospital
Comprehensive EP Study
Decreases
Will there be refunds/recoups?
99214
Established pt level 4 office visit
93295
ICD remote per 90 days
93279-26 PM program eval – single, MD only
January 2010 RVU
10.52
22.69
6.52
17.56
May Updated RVU
12.19
24.34
7.00
18.81
2.73
2.28
.98
2.71
1.94
.88
Refund Request
Technical Correction
• $2M just
appropriated for refiling
• How to handle both
the upside….and the
downside
• Patient responsibility
• Secondary's
• You have to love it…
2011 Fee Schedule
• Be sure you have downloaded the
one with the $33.97 CF
• Let’s walk through the key elements
and lo lights
Medicare formula
Resource Based Relative Value Scale
Payment =
{(RVU work x GPCI work) +
(RVU practice expense x GPCI
practice expense) + (RVU
malpractice x GPCI malpractice)}
X
conversion
factor x BN
RVU = Relative Value Unit
GPCI = Geographic Practice Cost Indices
SGR…..
• SGR ….
• Rollercoaster throughout 2011
• 13 month “fix”
– That only cost $19 BILLION
– No increase for physicians
• After the May technical correction the CF was
$36.8729
• Sunset – Dec 1, 2010 (was to be a 23.6% hit)
• Sunset – Jan. 1, 2011 – 12 month extension
• 2011: Conversion Factor = $33.9764
MEI …impact
• CMS is rebasing and revising the MEI to
use a 2006 base year in place of a 2000
base year.
– This update to the MEI is the first time it has
been rebased and revised since 2004.
• For practices with high technical this will
result in an increase
• Total RVU’s attributed to work will see a
decrease
• Bottom line – mitigated a bit of the PPIS hit
– Resulted in a major CF change
Why do my fees keep changing
RVU changes
• This is the last year of a 4 yr phase in on how
PE are determined – we are DONE with this
• This is the 2nd yr (of a 4 yr plan) due to the
PPIS
• This is the 1st time MEI has been re-based
• The RUC keeps messing with us
– Bundling
– Revaluing
Other key factors of
2011 Fee schedule
• Financial Disclosure letter and sites
– MRI, CT, PET
– Time of referral
– 5 suppliers within 25 miles
– Document compliance
• EU rate – 75%
• Multiple procedure reduction
– Affects technical component
– 25% increases to 50%
MEI…PPIS…CF….
Just tell me what it means
Treadmill
Hopps
• Echo payment reduced – 13.5%
• PET reduced
• Supervision re-defined
– Hospital outpt on campus
– Hospital outpt off campus
Cardiac Nuclear Study
Medicare Reimbursement - Technical Component
2006 - 2010 CPT vs. APC
$800.00
$742.68
$743.61
APC
$724.19
$700.00
$600.00
Reimbursemnt
$568.63
$552.70
$560.93
$504.50
$500.00
$484.61
$423.90
$400.00
$300.00
$264.64
CPT
$200.00
2006
2007
2008
2009
2010
HOPPS changes
CARDIOVASCULAR MANAGEMENT OF ILLINOIS
HOPPS '10 - '11
AUGUST 10, 2010
APC
377
99
100
269
269
270
CPT
Description
78452 Nuclear
93005 EKG
93017 Stress
93306 Echo
93350 S/E
93351 S/E
$
$
$
$
$
$
National HOPPS
2010
2011
Change
775.09 $ 768.38
-0.9%
26.56 $
27.29
2.7%
176.17 $ 179.55
1.9%
450.97 $ 389.25
-13.7%
450.97 $ 389.25
-13.7%
596.04 $ 559.41
-6.1%
$
$
$
$
$
$
Local 15
2010
MPFS
386.32
11.76
56.46
179.38
133.52
156.85
Private payor shenanigans
• Highmark…..
– Substitute echo for nuc
• United pre-notification
• Humana pre-notification
• Report cards
HCR aka ACA
•
•
•
•
Grandfathered and non-grandfathered plans
Coverage
Lifetime limits
Equipment Utilization: The ACA overrules the
fee schedule and will lock this rate at 75%
• House energy and commerce – J.Pitts
• my first legislative priority will be wholesale repeal of the
health law, which will pass the House, I'm sure, but
realistically won't get past the Senate or the president.
• ACA law requires that PCMHs be exclusively
primary physician based, how do we ensure
specialty based PCMH models can be
authorized
Integration
• Drivers
– HCR
– MedPac and imaging scrutiny
– Payment reform mandates
– HOPPS vs PFS
• Is it here to stay?????
ACC’s survey
Integrate with hospital….
Or
Other practices
Integrated Practices
ACO’s…..
• Rules due out in Jan
• ACA attributes patients to ACOs (by virtue of
the doctors and hospitals they currently use) --patients do not enroll in them.
– This is confusing, because if patients do not want to
be in an ACO and instead stay with their doctor who
chooses not to participate, they may. But if their
doctor is in, so is the patient. This issue may need
to be amended somehow
AUC…..where is it going
• Midei case in Baltimore
– ACE from SCAI (accreditation for cardiovascular excellence)
• JAMA article on ICD
• FOCUS – nuclear
• Lab accreditation
– MIPPA
– IAC – focus on use of AUC
Quality …where is it going?
• Recent CMS report
– 3 demo projects
• Hospital Quality Incentive Demonstration
(HQID)
• the Physician Group Practice (PGP)
• 500 small and solo physician practices
participating in the Medicare Care
Management Performance (MCMP
– http://www.cms.hhs.gov/DemoProjectsEv
alRpts/MD/list.asp.
Physician Compare
•
•
•
•
Public reporting of data
Starts 1/1/13
Mandated by ACA
Physicians need to be able to update
their contact info
• Comment period is now
Few more….
• Sunshine Act
– 2012
– Anything over $10 will be reported
• PECOS
– CMS is working “diligently”
– Edit not turned on for referring MD
– NO DATE has been announced
• Red Flag – finally gone
What is this “new” MOC
• MOC = Maintenance of certification
• Additional .5% in PQRS payments if
enrolled in MOC
• Must submit PQRS data for 12 months,
participate in MOC, and complete MOC
practice assessment
– FOCUS and CPIP
PQRS aka PQRI
•
•
•
•
•
•
PVRP was initial program in 2006
PQRI - 7/1/07 – 1.5% incentive payment
2008 – Few structural changes
2009 and 2010 - 2% incentive payment
Yes you can do this + Meaningful use
2011 – Physician Quality Reporting
System
• 194 measures
PQRS Resources
A Guide for Understanding the 2011 Physician Quality
Reporting System (PQRS) Incentive Payment
• www.cms.gov/pqrs
• https://www.cms.gov/PQRI/15_MeasuresCodes.a
sp#TopOfPage
• http://www.cms.hhs.gov/MedicareProviderSupEn
roll
• http://www.cms.hhs.gov/IACS
• https://www.cms.gov/PQRI/30_EducationalResou
rces.asp#TopOfPage
Key Changes
•
•
•
•
Penalties start in 2015
2011 – 1% payment
2012 – 2014 - 0.5% payment
Reporting sample reduced from 80% to
50% for claims ONLY
– Registry still must meet 80% on 3 measures
• Registries no longer can report on nonMedicare FFS
• Measures with 0% will not be counted
• New group reporting option <200
– 26 measures
Changes to Structure and
Function
•
•
•
•
•
•
In response to ACA
Penalty: 1.5% in 2015 & 2.0% after
Timely feedback
Interim reports
Informal appeal process
Physician Compare Website
– Reports 2012 PQRS
• Integration with MU
Measures
• 170 measures continue (24 new)
• 45 registry measures continue
– 11 new registry only
• 14 Measure Groups
• EHR current 10 + 10 new
PQRI 2011
No Changes
#6 – CAD on Antiplatelet
#7 – CAD prior MI on BB
#47 – Advance Care Plan
#124 – Use of EMR
#201 - IVD & BP Control
#202 - IVD & Lipid Profile
#203 – IVD & LDL
New
#128 – BMI Screening &
Follow
Up
#226 –Tobacco Screening &
Cessation
#235 – HTN Plan of Care
Changes
#5 – HF on ACE/ARB
#8 – HF on BB
(remove Cardiomyopathy
codes)
#114 – Smoking Screening
#115 – Smoking Cessation
(retired)
#118 – CAD on ACE/ARB &
DM and/or LVSD
(remove Pregnancy
Diabetes codes)
Summary 2011 changes
No changes for 2011
Changes for 2011
Retired for 2011
#6 - CAD
#5 –HF c ACE/ARB
#114 -
#7-CAD c BB
#8 – HF c BB
#115 -cessation
#47 – ACP
#118 – CAD c…
Other non cardiac
#201 – IVD/BP
#124 - EHR
#136
#202 – IVD/lipid
#128 - BMI
#139
#203 – IVD/LDL
#197 –CAD c lipid
#174
screening
eRx for 2011
•
•
•
•
•
•
Can NOT do in addition to MU
You can do eRx + PQRI
1% Incentive payment
Need to do 25 instances
2011 report for entire year
Penalties start in 2012
BUT
****IMPORTANT****
• See pgs 1305 to 1307
• MUST have an approved system
• 10 instances per provider from Jan1 –
June 30, 2011
– Must do even with MU
– Must do via CLAIMS
– Submit the G code to prevent penalty
• Not only does 2011eRx determine
2012...but it also locks you in for the
penalty!
THE Penalty
• You can NOT use EHR or registries to submit
– Yes you can receive incentive money……..and
still be penalized
• Penalties will be NPI specific
• CMS needs info by 12/21/11
• Are they reaching beyond their legal scope?
Note the 2013 penalty
Are there any exceptions…
•
Provider does not have at least 100 cases containing an encounter
code in the measure denominator
• Provider does not meet the 10% denominator threshold
• For the 2012 eRx payment adjustment, the following
circumstances would constitute a hardship:
– The eligible professional practices in rural area with limited highspeed internet access, or
– The eligible professional practices in an area with limited available
pharmacies for electronic prescribing
•
G-codes have been created to address two hardship circumstances
(G8642 and G8643)
• To request a hardship exemption for 2012 payment adjustment:
An eligible professional must report the appropriate G-code on
at least 1 claim prior to June 30, 2011
eRx Comparison
eRx Incentive 2011
• Attached to an E&M code
• Use Code G8553
• Must submit 25 eRx Medicare
patients to get 1% incentive
• Reported on claims or Registry
eRx Penalty 2012 & 2013
• Attached to an E&M code
• Use Code G8553
• Must submit 10 eRx Medicare
patients between January and
June 30, 2011 to avoid 1%
adjustment in 2012
– Report on Claims only
•
Must submit 25 eRx Medicare
patients between January and
December 31, 2011 to avoid 1.5%
adjustment in 2013
– Report on Claims or Registry
eRx Meaningful Use
• Does not tie to an E&M code
• Doesn’t use G codes
• Must have more than 40% of
all permissible prescriptions
transmitted electronically
• Tracks faxed, printed or eprescribed prescriptions
• Excludes Controlled
Substances
• Applies to all patients, not
specific to Medicare
Qualified eRx system is…
• Must do ALL of the following
– Generate an Active medication list
• Incorporates e data from pharmacies and pharmacy
benefit managers
• Select meds, print prescriptions, transfer
electronically, and conduct ALL alerts:
– Provide info on lower cost alternatives
• Tiered formulary info is sufficient in 2010
– Provide info on formulary or tiered formulary medications, pt.
eligibility, and authorization requirements received
electronically from pt’s drug plan
Lessons learned
• Remember the 10% rule
• Don’t forget mid levels
• How penalty will be applied…
www.cms.gov/erxincentive
Is it worth it???
•
•
•
•
•
•
Clinical Integration
Clinical Integration
PQRI @ 2%
PQRI @ 2%
eRx @ 2%
eRx @ 2%
Personally I think that is REAL money
$134,940
$272,114
$219,175
$167,915
$174,473
$168,652
$1,137,269
Meaningful Use
25 Objectives and Measures
– 15 Core Mandatory Measures
– 10 Menu Measures (Must meet 5 out of 10)
– 6 Total Clinical Quality Measures
• 3 Core
• 3 out of 38 from Menu set
Reporting
– 8 Measures reported through Attestation
– 1 Measure reported with Numerator and Denominator and Exclusion
through Attestation (Clinical Quality Measures)
– 16 Measures reported through Numerator and Denominator
Reporting Period
• First year of demonstration: Any continuous 90-day period within
the payment year in which you successfully demonstrate
Meaningful Use
•
Second payment year and beyond: The EHR reporting period will
mean the entire payment year
Meaningful Use = Core Measures
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
CPOE = 30%
Drug-Drug and Drug-Allergy Interaction Checks
Up-to-Date Active Diagnoses List = 80%
eRx = 40%
Active Medication List = 80%
Active Allergy List = 80%
Demographics (Race, Ethnicity, Preferred Language, DOB,
Gender) = 50%
Vital Signs (Height, Weight, BP) = 50%
Smoking Status = 50%
Clinical Quality Measures
One Clinical Decision Support Rule
Electronic Copy of Health Information upon Request within
3 business days (Patients only) = 50%
Clinical Summaries each OV = 50%
One Test to Electronically Exchange Clinical Information
Security Risk Analysis
Meaningful Use = Menu Measures
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Drug Formulary Checks ***
Lab Results = 40%
Patient Report with Specific Condition ***
Reminders for Preventive/Follow Up Care
= 20%***
Electronic Access to Health Information
within 4 business days = 10%
Patient Education = 10% ***
Medication Reconciliation = 50%
Summary Care Record with Transition of
Care = 50%
Immunization Registry ***
Public Health Surveillance
Getting Ready
• Smoking Changes
– Risk Factor
– Cessation Pick list
Measure 7 - Demographics
• Need all fields filled in
–
–
–
–
–
DOB
Gender
Preferred Language
Race
Ethnicity
• Goal = 50% or better
A = 44%
C = 38%
H = 29%
Reports
Report Cards
THANK YOU
QUESTIONS???