Reimbursement Challenges and Solutions for Cardiovascular ...

1. Reimbursement Challenges and Solutions for Cardiovascular Specialists:Building Collaborative Payer Relationships to Support Quality Care Kathleen Flood Director, Payer Advocacy October 14, 2007

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3. 3 The “Crisis” Environment Affordability Crisis: Unsustainable cost trends Quality Crisis: Variation in medical practice Limited scope of the “evidence” in evidence-based medicine Gaps in quality / failure to implement what works Medical errors Information Crisis: Limited information on performance Numerous unrelated initiatives to address the issue Source: Steven Uderhelyi, MD CMO, IBC This is the environment as defined by payers. These are the three major area they feel need to addresses. Not too far off from ACC but perhaps the solutions are.This is the environment as defined by payers. These are the three major area they feel need to addresses. Not too far off from ACC but perhaps the solutions are.

4. 4 Health Care Largest Single Benefit Cost for EmployersAll Private Employees-March 2006 8/26/05 Updated DOL data on employer costs for employee compensation 10/27/05 Duplicates 15a pg.1 11/2/05 Revised yellow box. 5/2/06 Updated to 2006 data. Health insurance includes long and short term disability. Other includes Workers Comp. Not sure where these items were included previously (or if they were included). 5/8/06 Moved yellow box. Changed one segment color. 10/27/06 Change titles. 8/26/05 Updated DOL data on employer costs for employee compensation 10/27/05 Duplicates 15a pg.1 11/2/05 Revised yellow box. 5/2/06 Updated to 2006 data. Health insurance includes long and short term disability. Other includes Workers Comp. Not sure where these items were included previously (or if they were included). 5/8/06 Moved yellow box. Changed one segment color. 10/27/06 Change titles.

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6. 6 Imaging:One of the top 11 medical developments of the past 1000 years - NEJM

7. 7 How can ACC and chapters address the crisis? Lead (v): to influence the positions of others Innovate (v): to recommend a new way of doing things Advocate (v): to recommend, to be in favor of; to speak on behalf of another

8. 8 ACC-ChapterOpportunities to Influence Payers Imaging Appropriateness Criteria--Pilots Measurement NCDR/Registries Performance Assessment PAR-3 - Strategy Performance Measures—Cost of Care Measurement---Outcomes Measurement Transparency—Rules of the Road Dialogue Build on Chapter Relationships Medical Directors’ Institute Payer Roundtables Second Wednesday Audio-conferences---2008 Patient – Centered Approach Internal Review for Patient-Centered Approach Patient-Centered Medical Home Initiative

9. 9 Cardiovascular Imaging The Issue: Imaging growth is complex and not always “black and white.” Claims of inappropriate imaging are largely unsupported and clinical benefits are often ignored in the growth debate. Patient care and access are at stake! Lewin Report shows radiology dominates the 4 fast growing categories of imaging services (May 2005) Lewin Report shows radiology dominates the 4 fast growing categories of imaging services (May 2005)

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11. 11 Cardiovascular ImagingPayer Efforts Released model LCDs for, SPECT, CCT, and CCTA. Cardiac MRI Model LCD-Due Fall 2007 Developed RBM Talking Points to deliver consistent message. MDI brings together payers and physicians to address appropriate use of imaging. Working with UnitedHealthcare to develop pilot program using Appropriateness Criteria for SPECT-MPI. Addressing the next generation of RBMs, specialty specific. Efforts also at State and Federal Level: Federal 1. Continue to meet with key lawmakers to minimize the impacts of imaging cuts included in the Deficit Reduction Act of 2005 and ensure future legislation does not include additional cuts. State 1. Held two successful state lobby days in 2006 to fight state legislation in California and Washington. 2. Closely monitoring state legislative activity in more than seven states, including Maryland where the ACC and MD Chapter are working with others to overturn self-referral law. Efforts also at State and Federal Level: Federal 1. Continue to meet with key lawmakers to minimize the impacts of imaging cuts included in the Deficit Reduction Act of 2005 and ensure future legislation does not include additional cuts. State 1. Held two successful state lobby days in 2006 to fight state legislation in California and Washington. 2. Closely monitoring state legislative activity in more than seven states, including Maryland where the ACC and MD Chapter are working with others to overturn self-referral law.

12. 12 Chapter Case Studiesin Addressing Payer Issues:Keys To Success Physician-Patient Relationship Communication Engagement – Advisory Committees Role of the Specialty – Expertise Take Charge – Lead - Innovate Back to basicsBack to basics

13. 13 Impact on Diagnostic Imaging Programs Pennsylvania-Highmark and IBC Adjusted Highmark’s comprehensive prior-authorization and privileging program to reflect CV concerns Almost 2 year process, confirmed PaACC appointments on Imaging Committees Worked with IBC to ensure prior-authorization process for CV specialists was acceptable

14. 14 HighmarkIssues

15. 15 Impact on Diagnostic Imaging Programs North Carolina – BCBS Engaged plan prior to launch of prior-authorization program Worked with chapter to support communication Program started in February 2007 Chapter is planning to regroup with plan Fall 2007 to review data and develop a “gold-card” program

16. 16 Impact on Diagnostic Imaging Programs New York-GHI and HIP (downstate) Working with Chapter to address alternative approach for SPECT-MPI Proposing NY-ACC members be reviewers of SPECT-MPI - provide feedback to primary care. Exploring development an educational module for PCPs ordering SPECT Review of HIP prior-authorization program

17. 17 Impact for Diagnostic Imaging Programs Idaho - Blue Cross Proactively restructured privileging program to ensure appropriate CV training and accreditation standards ACC Governor member of Imaging Committee Participate in CCTA Focus Group

18. 18 Success Factors Chapter Engagement – Key with local/Blue plans Chapter and ACC Collaboration Dialogue – Meetings and/or Conference calls Scientific information source for plan Medical Director ACC commitment to quality

19. 19 Clinical Policy Development-Issue Scrutiny of the evidence base Resulting in limited coverage policies and reimbursement Redefine medically necessary services Limited understanding of the science

20. 20 Clinical Policy Development ACC working to review all major health plans clinical policies that affect cardiovascular specialists UHC, Aetna, CIGNA BCBSA TEC WellPoint, Wellmark, Regence More than 20 policies in 2006

21. 21 Aetna-Color Flow Doppler Policy October 2005 - Aetna released revised CFD policy with limited diagnoses as medically necessary to reimburse 93325 ACC/ASE respond – meetings throughout 2006 to explain value of technology and the context of the guideline Incremental changes throughout process

22. 22 Aetna-Color Flow Doppler Policy Summer 2007-Aetna reverses its decision on unspecified murmur (785.2) – becomes a covered diagnosis. ACC/ASE continue to challenge CFD policy for more diagnoses

23. 23 Action Steps to Engage Establish formal communication with health plan Update Plans of new governors Have members appointed to CV committees Invite to MDI and MDI at Scientific Session Host quarterly/bi-annual meetings Review medical policies Coordinate with ACC

24. 24 Is the process worth it? Yes! Not always fast but results in change Be engaged with health plans to prevent onerous restrictions and changes Opportunities for innovation and leading change – Improving the system and delivery of CV care

25. ACC’s Appropriateness Criteria: SPECT-MPICardiac CTCardiac MRIEcho: TTE/TEE & Stress Coronary Revascularization: PCI/CABG

26. 26 What are Appropriateness Criteria? Define “what to do”, “when to do”, and “how often to do” in the context of local care environments combined with patient and family preferences and values Address misuse, overuse and underuse Connected to guideline content Imply a level of detail and complexity that extends beyond the current recommendations

27. Pilot Study:Evaluation of Appropriatenessof SPECT MPI The American College of Cardiology The American Society of Nuclear Cardiology

28. 28 ACC Pilot: Evaluation of Appropriateness SPECT MPI Develop a data collection mechanism to evaluate appropriateness Create a process to implement awareness of appropriateness criteria in practice Provide feedback reports to improve both practice-level and individual physician-level adherence to the criteria Establish benchmarks to guide performance improvement Pilot is underway— Purpose Facilitate quality improvements Efficient, effective patient care Long-term alternative to prior authorization Inform decision making: Correlation between SPECT MPI study appropriateness and image resultsPilot is underway— Purpose Facilitate quality improvements Efficient, effective patient care Long-term alternative to prior authorization Inform decision making: Correlation between SPECT MPI study appropriateness and image results

29. Tools for Achieving Quality in Imaging Overview of ACC efforts to achieve quality in imaging, coming from Duke/ACC Summit in 2006. Pamela Douglas and group led the effort to map this strategy. Well underway, follow up summit planned for October 8-10, 2007. ACR is an active participant in this effort. Overview of ACC efforts to achieve quality in imaging, coming from Duke/ACC Summit in 2006. Pamela Douglas and group led the effort to map this strategy. Well underway, follow up summit planned for October 8-10, 2007. ACR is an active participant in this effort.

30. 30 Project Timeline

31. 31 How is this Project Different from RBM? RBM No Imaging results available Focus solely on individual tests Pilot Study Imaging results are available Focus on practices and practice patterns Creates a feedback network for improvement with education component

32. 32 Why Will MDs Use the AC Implementation Tool? Advance the science and improving care “Connect the dots” between imaging and outcomes Quality improvement Payer Incentives: Waive preauthorization Recognition programs

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34. 34 Next Generation RBM Specialty Management Will include ALL imaging modalities ICD Catheterization

35. 35 Medical Directors’ Institute 2007 Partnerships for Transformation: Systematic Assessment, Recognition, and Reporting -Identifying gaps in performance, assessment, recognition, and reporting and develop clear, collaborative recommendations for improvements that can be implemented in 2009. October 24-25, 2007 Phoenix, Arizona Example: Moving forward-MDI Focus of meeting to define high quality cv md Explore how to incentivize hit adoption, use of rhios etcExample: Moving forward-MDI Focus of meeting to define high quality cv md Explore how to incentivize hit adoption, use of rhios etc

36. 36 Blue Cross Blue Shield Settlement How to get your share! ACC Dues statement

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38. 38 ACC Payer Advocacy