Connected Care in a Value-Based World: Aligning Strategy to Reimbursement

1. Connected Care in a Value-Based World: Aligning Strategy to Reimbursement Georgia Osteopathic Medical Association C.M.E. Weekend October 27, 2019 Randy E Durbin, DO, MSPH Vice President – Medical Affairs and Federal Programs Karna, LLC

2. DISCLOSURE I am the Principal Investigator of a 3-year CDC research project exploring the utility of using remote patient engagement on patient performance on adherence to diabetes education in rural Georgia using ChronicCare IQ’s electronic engagement platform (https://chroniccareiq.com/).

3. LEARNING OBJECTIVES • Understand basics of Value-Based Care System and the anticipated CMS 2020 value-based agenda changes, including MIPS Value Pathways proposal. • Define characteristics of Chronic Care Management and Remote Patient Monitoring as part of a larger “Connected Care” strategy. • Understand requirements for reimbursement for Chronic Care Management and Remote Patient Monitoring. • Explore how Connected Care strategies may improve patient care outcomes, reduce cost, and increase practice reimbursement.

4. EPISODIC CARE LEAVES PATIENTS ‘INVISIBLE’ ? Physicians know what to do, but do weknowwhen? 7 / 10 deaths, 99% of Medicare payments, and 86% of overall US healthcare costs are attributable to non-lethal chronic diseases. 1/5 Seniors are readmitted to the hospital within 30 days.

5. HEALTHCARE VALUE = QUALITY/COST

6. HOW DID WE GET HERE? • 2006 - Tax Relief and Health Care Act which offered a 1.5% incentive payment for PQRI (Physician Quality Reporting Initiative) - “pay for performance (reporting)” • 2008 - Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) - created the Physician Quality Reporting System (PQRS) - 2% incentives for reporting • 2009- Health Information Technology for Economic and Clinical Health Act (HITECH) – “Meaningful Use” • 2010-Affordable Care Act (ACA) - risk added to PQRS - 2% penalty • 2014- Repeal of Sustainable Growth Rate (SGR) Formula

7. HOW DID WE GET HERE? (CONTINUED) • 2015 - Chronic Care Management (CCM) Billing Codes introduced • 2015 -Value Based Modifier (VBM) and Quality Resource and Utilization Report (QRUR) Differential payments based on quality and cost outcomes • 2015 - Medicare Access and CHIP Reauthorization Act (MACRA) and Quality Payment Program – created Alternative Payment Models (APM) and Merit Based Incentive Payments System (MIPS) • 2017 - MIPS fully melds MU, PQRS and VBM

8. HOW DID WE GET HERE? (TODAY) • 2019 - Remote Patient Monitoring (RPM) (3 codes) and CCM (4 codes) • 2019 - Network of Quality Improvement and Innovation Contractors (NQIIC) grants of $25 Billion over 10 years to transform • 2019- Goal of CMS/Medicare is value-based reimbursement models

9. The MEDICARE TRACK OPTIONS QPP APM MIPS

10. NOT IN AN APM? MIPS IS YOUR DEFAULT.

11. 2019 MIPS CATEGORIES AND SCORING

12. COST PERFORMANCE CATEGORIES: 10 Cost Performance Category Comprised of 10 Measures 1. Medicare Spending Per Beneficiary (MSPB) • Medicare Part A and Part B claims submitted for services from 3 days prior to 30 days after an inpatient hospitalization and attributes all of these costs to the physician with the most Part B charges during the period from the patient’s inpatient admission to discharge date. The minimum number of eligible cases for the MSPB Cost category is thirty-five (35). 2. Total Per Capita Cost (TPCC) • All Medicare Part A and Part B costs for patients attributed to the individual primary care clinician with the most allowed charges for primary care services during the 2019 performance period. The minimum number of eligible cases for the TPCC category is twenty (20). • If a beneficiary did not receive a primary care service from a primary care clinician, he or she may be attributed to a specialist physician who provided the plurality of primary care services to the beneficiary. 3. Eight Episode-Based Measures • Episode-based measures are calculated using Medicare Parts A and B fee-for-service claims data and are based on episode groups that represent a clinically cohesive set of medical services rendered to treat a given medical condition. • CMS aggregates the cost of all items and services provided for a defined patient cohort to assess the total cost of care.

14. ADDITIONAL COST MEASURES (UNDER DEVELOPMENT) Additional Cost Measures (Under Development)

15. CONNECTED CARE & SUCCESS IN VALUE AND QPP Virtual Check-ins G2012 - $10 (new 2019) G2010 - $13 (new 2019)

16. WHEN WILL TRIPLE AIM QUADRUPLE? Patient Experience Clinician Experience Lower Costs Quality Outcomes • Value-Based Care supports Quadruple Aim • Improve the patient experience • Improve population health • Reduce per capita cost • Improve work life of clinicians & staff

17. Financial & Strategic returns of vbc Financial and Strategic Returns of Value-Based Care: but how will we know when? Experience and Satisfaction Returns: TCM, CCM, RPM, MIPS Value-BasedCare Strategic Returns TCM, CCM, RPM, MIPS Pt Satisfaction, Experiences, Safety, Wellness, Accessibility, Connected care, Lower costs, Increase Quality: APM Ready Financial Returns TCM, CCM, RPM, BPCI, MIPS: APM Prepared

18. CHRONIC CARE MANAGEMENT 99490 - $42 • Chronic care management services, at least 20 minutes of clinical staff time 99487 - $94 • Complex chronic care management services, including 60 minutes of clinical staff time 99489 - $47 • Each additional 30 minutes of clinical staff time G0506 - $64 • Comprehensive assessment of and care planning (1 time fee)

19. REMOTE PATIENT MONITORING 99457 - $54 (new 2019) • Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month. 99453 - $21 (new 2019) • Remote monitoring of physiologic parameters (e.g., weight, blood pressure, pulse oximetry, etc) initial; setup and patient education on use of equipment. 99454 - $69 (new 2019) • Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.

20. WHY 99457? Remote Patient Monitoring: 99457 • March 14th 2019 CMS clarified that CPT code 99457 may be billed “incident to’. • Specialists involved (where CCM 99091 largely was to be billed by the PCP). • CMS did this to open the doors to more broad based use of technology by offering billing of these codes under general supervision. • Nurses and staff can now triage patients using RPM and code 99457 and focus on patients who need more immediate intervention- to know “WHEN”

21. COMMUNICATION TECHNOLOGY-BASED G2012 - $10 (new 2019) • Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management (E/M) services, 5-10 minutes of medical discussion) G2010 - $13 (new 2019) • Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours

22. TRANSITIONAL CARE MANAGEMENT 99495 - $165 • Transitional care management services with moderate medical decision complexity (face-to face visit within 14 days of discharge) 99496 - $234 • Transitional care management services with high medical decision complexity (face-to-face visit within 7 days of discharge)

23. THE PROPROSED FUTURE MIPS • Increase: Performance threshold from 30 points in 2019 to 45 points in 2020 and 60 points in 2021 • Increase the additional performance threshold for exceptional performance to 80 points in 2020 and to 85 points in 2021 • Reduce the Quality performance category weight to 40 percent in 2020, 35 percent in 2021, and 30 percent in 2022 • Increase the Cost performance category weight to 20 percent in 2020, 25 percent in 2021, and 30 percent in 2022

24. MIPS VALUE PATHWAYS: FOCUS IS COST, IMPROVEMENT

25. Cloud-based smart phone accessible engagement Healthy ? Unhealthy Critical Outside the hospital or practice, patients are invisible and in-actionable In the hospital or practice patients are visible and actionable Smart engagement illuminates patient status wherever they are

26. The Workflow

27. Better Outcomes & Lower costs Better Outcomes

28. Sample Revenue PrO forma

29. Connected care final questions Connect Care Final Questions • Will physicians and practices adopt? • Will patients engage? • Will practices be fairly reimbursed? • Will clinical outcomes improve? • Will it save money?

30. Thank you!