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KEYNOTE ADDRESS – TENNESSEE SLEEP SOCIETY 2013. Moving Forward In Challenging Times: The Future of Sleep Medicine Amy J. Aronsky, DO, FAASM. Objectives. Provide An Update on the Most Current Governmental Issues Impacting Health Care Providers - PowerPoint PPT Presentation
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Moving Forward In Challenging Times:The Future of Sleep
MedicineAmy J. Aronsky, DO, FAASM
KEYNOTE ADDRESS – TENNESSEE SLEEP SOCIETY
2013
ObjectivesProvide An Update on the Most
Current Governmental Issues Impacting Health Care Providers
Understand the Effect of Quality, Cost, Access & Efficiency on New Health Care Models
Discuss Emerging Clinical & Business Trends in Sleep Medicine
Anticipate Future Paradigms of Care Delivery for Sleep Medicine
2
DisclosuresRelative Value Scale Update
Committee (RUC)American Academy of Sleep Medicine
(AASM) Primary AdvisorRelativity Assessment Workgroup (RAW)
Current Procedure Terminology (CPT)AASM Primary Advisor
AASM Board of DirectorsFinance Committee
Episode of Care Grouper ProjectCenters for Medicare & Medicaid
Services (CMS)3
Growth in Medicare Utilization
4
Medicare Beneficiaries by year
5
Washington Update15th Year Under SGRRecent SGR Patch Prevented 26.5% CutMedicare Sustainable Growth Rate (SGR)
CMS method to control spending for physicians
Ensures the yearly increase in Medicare spending per beneficiary does not exceed growth in GDP
“Doc Fix”CMS fee schedule adjusted to meet targeted
SGRAttempts to Repeal SGR6
Washington Update – CMS Initiatives
• Improved Patient Care• Safety• Quality• Outcomes measurements
• Reduce Cost• Reduce unnecessary & unjustified
medical cost• Reduce administrative cost through
process simplification• Improve Population Health
• Improve chronic care management • Improve community health status7
Washington Update – CMS Initiatives
Affordable Care Act Implemented – 2014
32 million people enter health care poolState Health Care ExchangesHow will the influx affect sleep specialists?
Shift From Traditional Fee-for-Service Models
Special Consideration for “Bundling” of Services
Emphasis on Value vs. Volume8
Washington Update – CMS Initiatives
Development of New Health Care Delivery ModelsAccountable Care Organizations (ACO)Patient Centered Medical Home (PCMH)
Strethens the patient/provider relationshipLong-term quality careSystems based approach to quality & safetyPrimary care as Principal ProviderSleep center as Neighbor Provider
o DME
9
Washington Update – CMS Initiatives PCMH• Group Health Cooperative of Puget Sound• 29% ↓ in ER visits, 11% ↓ in admissions
• Community Care of North Carolina• 40% ↓ in asthma hospitalizations & 16%
↓ ER visits• Health Partners Medical Group Best Care PCMH• 39% ↓ in ER visits, 24% ↓ admissions
10
Washington Update – Physician Based
InitiativesPayment Should Include Quality & Efficiency
Transitions Should Include Physician Choices & Incremental Change
Reward System for Health SavingsPlan Should Encourage Systems of Care, But Preserve Physician Choice
Hardship Exemptions Available
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12
Health Care Value = Quality/Cost +
Access + Efficiency
13
Quality - PQRSPhysician Quality Reporting System (PQRS)
Any Health Care Provider With An NPI Number Must Participate
1 Measurement Group Per Provider Per Year
Report Data to CMSClaims-BasedElectronic Health Record (EHR) CMS-Approved Registry
In Addition to Other Quality Incentives14
Quality - PQRS2013 - Report 20 Patients Total
11 traditional Medicare Part B patients
9 patients with other insurances or
80% of Total Eligible Medicare B Patients
Group Reporting Option
15
CMS. 2011 Reporting Experience, Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive program , 4/09/2013
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Quality - PQRSReporting Year
Positive Incentive
Negative Adjustment
2012 0.5% of all Medicare PFS charges
2013 0.5% of all PFS charges
1.5% negative adjustment on all 2015 PFS
2014 0.5% of all PFS charges
2.0 % negative adjustment on all 2016 PFS charges
2015 & beyond
2.0 % negative adjustment on all 2017 & beyond PFS charges
PFS = Physician Fee Schedule17
Quality - PQRSObstructive Sleep Apnea Measurement
GroupSeverity Assessment
Documented OSA by AHI or RDI Positive Airway Pressure Therapy Prescribed
If AHI or RDI > 15 Adherence to Positive Airway Pressure Therapy
Objectively measured adherence to PAPAssessment of Sleep Symptoms
Assessment of sleep symptoms documented, including presence or absence of snoring & daytime sleepiness
2 or 3 additional measures for CY 2014 proposed18
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Quality – Physician Compare Website
Reports Location & Specialty Information of Each Physician
Reports Physician Participation in Quality Incentive Programs
CY 2014 & 2015Report individual physician performance data
Report group performance data Report ACO data
www.medicare.gov/physiciancompare 20
Quality – Value Based Modifier
“Pay for Value”Based Upon PQRS & Cost MeasuresCalculate Performance ScoreQuality Tiering Compares Group
Performance vs. National MeanImplemented for Groups > 100 –
2015Implemented for Individuals – 20171% Incentive or 1% PenaltyBudget Neutral21
Quality – Physician Feedback
ProgramPhysician Quality & Resource Use
ReportsComparative Performance InformationAttempt to Improve Quality Care
Delivered2013 – CMS Provides Group Reports >
25 Providers for Comparison
Reimbursement Reward for Value Rather Than Volume
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Other Quality Measures
23
Electronic Health Record (EHR)Electronic Prescribing Incentive
Program (eRx)Meaningful Use (MU)
Demonstration EHR is being used “meaningfully”
Stages 1 &214 required core objectives5 additional menu objectives6 total clinical quality measures
Cost – CMS Proposed Rule CY 2014
Reduced Practice Expense Most Specialties 10% Proposed for CY 2014
CMS Accepting 60 – 70% of RUC Recommended Values
Practice Expense Cuts for Sleep Medicine Totaling 20% Reduction Over 3 Years
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Code Descriptor Work RVU
PE RVU
Total RVU
2013 National Payment
95872 PSG <6 yrs 2.60 27.83 30.72 $1066.62
95873 PSG w/ PAP < 6yrs 2.83 29.63 32.79 $1116.98
95800 Slp stdy unattended 1.05 4.26 5.36 $182.70
95801 Slp stdy unattended 1.00 1.75 2.80 $95.26
95803 Actigraphy 0.90 3.53 4.48 $152.42
95805 MSLT/MWT 1.20 11.34 12.62 $429.37
95806 Slp stdy unattended 1.25 4.06 5.39 $183.38
95807 Slp stdy attend 1.28 13.26 14.69 $499.80
95808 PSG any age 1-3 param
1.74 17.32 19.23 $654.26
95810 PSG > 6yrs 4+ param 2.50 16.27 18.98 $646.10
95811 PSG w/ PAP > 6yrs 4+ param
2.60 17.08 19.91 $677.74
2013 Conversion Factor = $34.0230
25
Code Descriptor % Proposed Total RVU Change CY 2014
95872 PSG <6 yrs -12%
95873 PSG w/ PAP < 6yrs -10%
95800 Slp stdy unattended -7%
95801 Slp stdy unattended -5%
95803 Actigraphy -25%
95805 MSLT/MWT -7%
95806 Slp stdy unattended -12%
95807 Slp stdy attend -11%
95808 PSG any age 1-3 param -8%
95810 PSG > 6yrs 4+ param -10%
95811 PSG w/ PAP > 6yrs 4+ param -10%
26
Access - TelemedicineE/M Codes Use Telemedicine
Modifier-GT
Via live interaction-GC
Via asynchronous technologySame reimbursement as E/M
Expansion of Rural Health Professional Shortage Area
Utilization for Sleep Medicine?27
Efficiency – New E/M Codes
Transition Care Management CPT Codes - 99495 & 99496Communication with the patient or caregiver
within 2 business days of discharge (or documentation of 2 unsuccessful attempts)Via phone, email or in-person
Face-to-face visit requiredMedical decision making is at least moderate
or highMedication reconciliation & management
documented no later than time of face-to-face visit28
Efficiency – New E/M Codes
Transition Care Management CPT CodesTransition Care From
Inpatient hospital setting or ERObservation status in a hospitalSkilled nursing facility Rehabilitation hospital
Transition Care ToHomeDomiciliaryRest homeAssisted living facility29
30
Efficiency – New E/M Codes
Complex Care Coordination Services Codes99487
1st hour clinical staff time spent coordinating patient care per calendar month
Directed by physician or other qualified health care professional
No face-to-face physician or other qualified health care professional visit required
1.00 wRVU 99488
One face-to-face visit per calendar month required
2.50 wRVU99489
Additional 30 minute increments over initial hour of care coordination
0.5 wRVU31
Efficiency – New E/M Codes
Complex Care Coordination Services CodesProposed CMS Payment CY 2015Patients Have At Least 2 Chronic
Conditions That Are Expected to Last At Least 12 Months
The Chronic Conditions Place The Patient At Risk for Death, Acute Exacerbation, Decompensation or Functional Decline
The Patient Must Receive Annual Wellness Visit Within Past 12 Months By Same Health Care Provider32
Original Sleep Laboratory
Emphasis On In-Lab Testing
Some Consultations &
Occasional Follow-Up Care
33
Sleep Center Comprehensive Care
34
35
The Future of Sleep Medicine
Shift From Sleep Testing Paradigm to Longitudinal CarePartnerships with primary care Satellite offices with other specialtiesEmphasis on other co-morbid
conditionsHypertensionDiabetes
DME AffiliationImproved quality of careAdherence measurements
36
The Future of Sleep Medicine
Emphasis on Out of Center Sleep TestingAASM members report fewer than 25% of
sleep testing is OCST (2011)Greater amount of OCST in the east &
westIncreased demands for OCST
Prior authorizations required for nearly all commercial payers for in-lab testing
Prior authorizations required for many commercial payers for OCST
Redefining personnel rolesRPSGT/RSTOther personnelPhysician peer-to-peer reviews
37
The Future of Sleep Medicine
38
The Future of Sleep Medicine
Emphasis on Out of Center Sleep TestingPrimary care physicians ordering more
OCST
Some insurances require OCST to be interpreted remotely by contracted companiesData provided to physicians
39
The Future of Sleep Medicine
40
Role of the Sleep Specialist?Become an OCST interpreting physician
for your center for some commercial payers
Become an OCST interpreting physician for other centers through some commercial payers
Achieve AASM OCST accreditationConsider an AASM-Approved OCST
Provider (AOCST)“Point: Should Board Certification Be Required for Sleep Test Interpretation? Yes", Chest. 2013; 144(1):9-11
There will always be a need for sleep professionals
41
The Future of Sleep Medicine
42
AASM Preauthorization Survey – 2013Preliminary Data Trends
Good response from Tennessee AASM membersAetna’s authorization process is most time-
consumingCIGNA rejects in-lab testing most oftenAppeals approved more than 50% of the time
Final Data Report – Mid-October 2013www.aasmnet.org
The Future of Sleep Medicine
Create of New Sleep Medicine CPT CodesSplit night polysomnographyAdaptive servoventilation titrationBundled code for PAP managementCSF hypocretin/orexin measurementNew technologies
Define Outcome Measures for Sleep DisordersAASM workgroupsApplication to reimbursement43
The Future of Sleep Medicine
Discuss Testing With Commercial PayersStreamline insurance authorization processAppropriate use of OCST
Achieve Widespread Reimbursement for 98503
Consider Telemedicine UtilizationMaximize Use of Physician ExtendersRedefine Personnel Roles
RPSGT/RST
44
The Future of Sleep Medicine
Reduction in Number Sleep Medicine Fellowship Training Programs
Reduction in Available NIH Grants
Sleep Medicine Coding is Aggressively Audited by CMS & Commercial Payers
45
ConclusionsHealth Care is Rapidly Changing With the
Implementation of the Affordable Care ActThere is a Shift From Volume to Value
CareThere Are New Opportunities for Sleep
Medicine to Reinvent ItselfSleep Medicine Will Continue to be a
Viable Specialty & Health Care Professionals Will Deliver Excellent Care in Challenging Times
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