FLS in the USA
ISCD Annual Meeting
February 26-28, 2015
Chicago, IL, USA
E. Michael Lewiecki, MD
New Mexico Clinical Research & Osteoporosis Center
University of New Mexico School of Medicine
Albuquerque, NM
Disclosure
Institutional Grant / Research Support
Amgen, Eli Lilly, Merck
Scientific Advisory Boards / Consulting
Amgen, Eli Lilly, Merck, Radius Health, AgNovos Healthcare,
NPS
Outline
• Identify incentives and barriers for FLS
in the USA
• Describe strategies for initiating FLS
• Understand available FLS resources
Why do we need FLS in the US?
• Current management of high risk
patients is poor
• FLS can reduce fracture risk in high risk
patients
• It is cost-effective
• Financial penalties for not doing it and
incentives for doing it well
Osteoporosis Treatment After Hip Fx
Review of US insurance claims data (commercial + Medicare)
in 96,887 patients hospitalized with hip fracture, 2002-2011
Solomon DH et al. J Bone Miner Res. 2014;29:1929–1937.
2014 HEDIS Report Card
HEDIS measure
The percentage of women
age ≥ 67 years with a
fracture who had either a
BMD test or prescription for
a drug to treat or prevent
osteoporosis in the 6
months after the fracture.
http://www.ncqa.org/ReportCards/HealthPlans/StateofHealthCareQuality/2014TableofContents/
Post-fracture Bermuda Triangle
Interested in surgery
Orthopedic
Surgeon
Limited time, clinical
uncertainty,
competing priorities
Limited availability,
patient not referred
Patient
Bone
Disease
Specialist
Primary
Care
Provider
Other Barriers to Osteoporosis
Care in the USA
• DXA
– Limitations of insurance overage
– Low reimbursement
• Bone turnover markers
– Declared experimental by major insurers
– High cost
• Medications
– Limitations of insurance coverage
– High cost for some
“Tex”
FLS is Cost-effective in
Integrated Healthcare Systems
• Kaiser Southern California Healthy Bones Program
– Identifying and treating high risk patients reduced hip
fracture risk by 37%, preventing 935 hip fractures in
2006, saving $30.8 million
– Dell R et al. J Bone Joint Surgery Am. 2008;980(Suppl
4):188-194
• Geisinger Health System Osteoporosis Disease
Management Program
– Identifying and treating high risk patients reduced
fracture-related expenses by $7.8 million over 5 years
– Newman ED et al. Osteoporos Int. 2003;14:146-151
Kaiser Permanente Estimation
of FLS Cost Savings
If implemented nationally, the Kaiser
strategy could reduce the annual number
of hip fractures in the USA by over
100,000 and save over $5 billion/year in
fracture related expenses
NBHA Estimation
of Cost Savings
• For every 100 patients in FLS, 1 hip
fracture and 2-3 other fractures are
prevented, with cost savings of $35,000
to $40,000
• If FLS coordinator manages 500
patients, then 5 hip fractures and 10-15
other fractures will be prevented, saving
$175,000 to $200,000
• Markov computer simulation model
• Projection of lifetime costs and benefits of FLS
in men and women with hip fracture
• Assumptions
– CNP FLS coordinator paid ~ $100,000/yr.
– 42% of patients treated with BP with 58%
adherence at 1 yr.
– Estimated that CNP could manage 500-1000
patients/yr.
Solomon DH et al. J Bone Miner Res. 2014;29:1667-1674.
FLS is Cost-effective in the USA
• FLS results in 153 fewer fractures, 37
more QALYs, and saves $66,879 per
10,000 post fracture patients compared
with typical care
• With 2.5 million osteoporotic fractures
per year in the USA, total annual cost
savings: up to $16.7 million
Solomon DH et al. J Bone Miner Res. 2014;29:1667-1674.
Financial Drivers of FLS
• US healthcare reform (“Affordable Care Act”) is
transforming the healthcare system from fee for service to
paying for quality, outcomes and care coordination
• Centers for Medicare & Medicaid Services (CMS)
initiatives include:
–
–
–
–
–
–
Accountable Care Organizations
Patient-Centered Medical Home model
Bundled payment initiatives
Qualified Clinical Data Registries (QCDR)
Medicare Advantage “5 Star” program
Meaningful use electronic medical record incentive program
FLS Effectiveness
Depends on Its Intensity
Review of published literature:
Fully coordinated, intensive models
of post-fracture care are more
effective in improving patient
outcomes than approaches
involving alerts and/or education only.
Ganda K et al. Osteoporos Int. 2013;24:393-406.
Osteoporosis Canada. “Make the FIRST break the LAST with Fracture Liaison Services”.
FLS Resources
• International Osteoporosis Foundation (IOF)
– Capture the Fracture
– www.iofbonehealth.org/capture-fracture
• National Bone Health Alliance (NBHA)
– Fracture Prevention Central
– www.nbha.org/fpc
• American Orthopaedic Association (AOA)
– Own the Bone
– www.ownthebone.org
History of NBHA
Created from 2 major bone health activities
2004
2008
FLS Timeline
NBHA
launch
2010
NBHA/Kaiser FLS
Summit
2Million2Many
launch
Fracture Prevention
CENTRAL launch
QCDR Osteoporosis
Registry launched
(September)
2011
2012
2013
2014
FLS Demonstration
Project
(December)
NBHA Now
• Public-private partnership to improve the bone health
of all Americans
• 55 organizational participants
– 35 non-profit member organizations
– 16 private sector member organizations
– 4 government agency liaisons (CDC, FDA, NASA,
NIH)
• Collective reach of over 100,000 health care
professionals and 10 million consumers
FLS Demonstration Project
• 15 month demonstration project to assess
performance improvement with FLS at 3 clinical
sites - started December 2013
• Sponsored by NBHA/NOF and CECity (software
company for healthcare performance improvement)
• Funded by grant from Merck
• Uses FLS app on CECity MedConcert platform
(suite of apps)
–
–
–
–
Automates data collection into central registry
Benchmarks performance against core measures
Enables transition of care from hospital to outpatient
Provides prompts to coordinators for next step in care
Demonstration Sites
• Alegent Creighton Health/Catholic Health
Initiatives (Omaha, NE)
– Robert Recker, MD
• Georgetown University Hospital/MedStar
Health (Washington, DC)
– Andrea Singer, MD
• University of Pittsburgh Medical Center
(Pittsburgh, PA)
– Susan Greenspan, MD
Completion date: April 2015
Report and manuscript: June 2015
Ostonics Quality Solutions
• Joint venture LLC with NOF and CECity
• Goal: 20% reduction in osteoporotic
fractures in the US by 2020 (20/20)
• Methods: Develop FLS software tools
based on experience from demonstration
sites
Achieving 20/20 Vision
• Currently 200 FLS programs in the USA
• Need 800 more (1000 total) to reach the
goal of 20% fracture reduction by 2020
• American Orthopedic Association FLS quality
improvement initiative launched in 2009
• Currently implemented in more than 140 hospitals and
medical practices
• OTB subscribers receive …..
– Comprehensive start-up materials
– Access to a national Web-based registry with reporting and
benchmarking capabilities
– Best practice library
– Patient and physicians education tools
– Public relations tools)
– Web-based training
– Ongoing best-practice sharing
– E-newsletters
www.ownthebone.org
Challenge: Healthcare Capitalism
• Convincing hospital administrators with
limited resources and competing
priorities
• Convincing physicians this is not
competition for patients
• Conflicting financial interests with open
(fragmented) healthcare delivery
Funding Questions
• Who pays for the nurse coordinator and
computer systems to identify and manage
fracture patients?
• What is the return on investment for a
hospital?
• Won’t the hospital, orthopedists, and
surgical support staff lose money if there
are fewer admissions for fractures?
Business Considerations
with Initiation of FLS
• Income at risk with current care
– Medicare incentives and disincentives
• FLS expenses
– Nurse coordinator
– Computer and software
• Potential new income sources
– Reimbursement for DXA
– Reimbursement for coordinator services
Projected Income and Expenses
Capital Expenses
Computer hardware and software (assume DXA already owned by hospital)
$
Recurring Expenses
FLS coordinator salary and benefits
$
Clerical support
$
IT support
$
Patient education materials (development and distribution)
$
Facility overhead (room, equipment, supplies, etc.)
$
Revenue
FLS coordinator insurance billing
$
Additional DXA studies
$
Additional outpatient appointments
$
Additional treatment (injectables)
$
Medicare penalties avoided and incentives received
$
Revenue Surplus
$
Intangible benefits: fractures prevented, community goodwill, public relations
Hospital-based FLS
From Fracture Prevention Central. NBHA Business Plan Template.
FLS Coordinator Reimbursement Model
Fracture patient admitted to
ER or physician’s office
• Hospital: EMR diagnosis
and age trigger FLS
Coordinator
• Physician office: Office
alerts FLS Coordinator
Patient admitted to
hospital for surgery
(e.g. hip fracture)
Upon identification, FLS Coordinator:
• Meets with patient to review program,
possible cost sharing
• Collects patient medical history and enrolls
patient through the FLS program website;
an ID number is assigned to the patient
• Begins patient tracking
Osteoporosis / low
bone mass
confirmed by
medical history
FLS coordinator1 visit for
osteoporosis assessment
Patient treated for
fracture and released
(e.g., wrist fracture)
Fracture patient
discharged to home
or FAC facility
Osteoporosis /
osteopenia not
confirmed by
medical history
• If confirmed, assess patient’s
treatment plan and adherence
• If not confirmed, order tests and
begin optimal treatment regimen as
necessary
FLS Coordinator services may be performed in person or over the phone.
• If in person, report the appropriate CPT code(s) from the following range:
‒ 99204, 99205, 99211-99215 (Office or outpatient)2
‒ 99218-99226, 99231-99236 (Inpatient hospital)
‒ 99238-99239 (Hospital discharge day management)
‒ 99241-99245, 99251-99255 (Office and inpatient consultation)3
‒ 99281-99285 (Emergency department)
‒ 99304-99310, 99315-99316, 99318 (Nursing facility management)
‒ 99324-99328, 99334-99337 (Long-term care facility E/M)
‒ 99341-99345, 99347-99350 (Home visit E/M)
‒ 99386, 99387, 99396, 99397, 99401-99404 (Prevention & risk factor reduction)3
‒ 99495-99496 (Transitional care management)4
• If by phone, report the appropriate CPT code(s) from the following range:
‒ 99441-99443 (Telephone E/M service)3
‒ 99487-99489 (Complex chronic care coordination)3
‒ 99495-99496 (Transitional care management)4
** Appended appropriate modifiers as necessary. Providers should confirm with
facility and payers that services are reimbursable; if services are not reimbursable,
FLS Coordinator must inform patient of potential financial responsibility**
≤4 weeks of
discharge
Obtain and interpret testing,
determine appropriate
management and initiate
treatments in consultation
with patient’s healthcare
provider
At discharge, FLS Coordinator:
• Determines patient’s post-fracture location (i.e., inpatient stay, home, other PAC facility) and
performs a fracture prevention assessment
• Identifies patient’s PCP or other appropriate chronic care professional to order post-fracture tests,
medications and develops patient care plan
• Distributes patient education material from FLS stakeholders and champions
1 FLS
Coordinator should be an allied health professional certified by CMS or other organization to be determined
CPT codes 99213 and 99214 are typically used by specialists and may require 24 modifier (unrelated E/M
service by same physician or qualified health professional during a postoperative period)
3 Not currently reimbursed by Medicare
4 Typically reported by PCPs
2
≤8 weeks of
discharge (and
every 6 weeks
until 6 months)
Contact patient by
phone to
encourage
medication
adherence,
answer questions
and discuss fall
prevention
≤6 months
of discharge
At 6 months
and 1 year
Obtain
appropriate
laboratory
testing (e.g.,
BMD test,
blood and
urine)
Ongoing
patient
assessment
(i.e., reevaluation,
repeat BMD
tests,
chronic
health
visits)
EMR: Electronic Medical Record
PAC: Post-Acute Care
PCP: Primary Care Physician
BMD: Bone Mineral Density
E/M: Evaluation and Management
Current Procedural
Terminology (CPT®) is a
registered trademark of
the American Medical
Association (AMA).
Reimbursement for FLS
Coordinator Services
•
CPT codes for face-to-face services
–
–
–
–
–
–
–
–
–
–
•
99204, 99205, 99211-99215 (Office or putpatient)
99218-99226, 99231-99236 (Inpatient hospital)
99238-99239 (Hospital discharge day management)
99241-99245, 99251-99255 (Office and inpatient consultation)
99281-99285 (Emergency department)
99304-99310, 99315-99316, 99318 (Nursing facility management)
99324-99328, 99334-99337 (Long-term care facility E/M)
99341-99345, 99347-99350 (Home visit E/M)
99386, 99387, 99396, 99397, 99401-99404 (Prevention & risk factor reduction)
99495-99496 (Transitional care management)
CPT codes for telephone services
– 99441-99443 (Telephone E/M service)
– 99487-99489 (Complex chronic care coordination)
– 99495-99496 (Transitional care management)
Use appropriate modifiers as necessary. Providers should confirm with facility and payers that
services are reimbursable; if services are not reimbursable, FLS Coordinator must inform patient
of potential financial responsibility.
Pathway to FLS
Local Champion
Passionate, Perseverant, Persuasive
Medical Director
(Medical Rationale)
Nurse
Coordinator
Hospital Administrator
(Business Model)
Systems
Infrastructure
Community
Support
Archived Webinar Series Available on Demand
•
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Introduction to Fracture Prevention CENTRAL/the Fracture Liaison Service
Model
Implementing a Secondary Fracture Prevention Program
Convincing Administration to Support Your Fracture Prevention Program
FLS Implementation in an Orthopaedic Practice Setting
FLS Implementation in a Rheumatology/Endocrinology Practice Setting
2014/FLS Implementation in a Primary Care Setting
Setting Up Your Fracture Liaison Service Program for Success
Health Care Quality 101: What, Why and How
How Transitioning to ICD-10 Coding Will Impact Your Osteoporosis
Practice
NBHA/NOF Qualified Clinical Data Registry (2 webinars)
www.nbha.org/fpc/educational-webinars
Learn More About FLS
• ISCD Annual Meeting – Chicago, IL
– Postconference Symposium
– NOF FLS Model of Care Training
– Sunday, March 1, 2015 (8:00 AM – 12:30 PM)
• NOF Interdisciplinary Symposium on
Osteoporosis (ISO) – Washington, DC
– Preconference Symposium
– NOF FLS Model of Care Training
– Tuesday, May 19, 2015 (7:30 – 12:30 pm)