©AAHCM

Robert Sowislo AAHCM Public Policy Committee

Academy Public Policy Year in Review

and Issues for Your Practice and the Field in Years

Ahead

©AAHCM

No Disclosures

Disclosures

©AAHCM

Public Policy Committee

Linda DeCherrie, MDBruce Kinosian, MD

Karl Eric DeJonge, MDMichael Benfield, MD

William Mills, MDRodney Hornbake, MD

Thomas Edes, MDNorman Vinn, DO

Robert Sowislo, MBA

George Taler, MDSteve Landers, MDJames Pyles, Esq.

Connie Row, Executive Director AAHCMGary Swartz, Esq.

©AAHCM

What does public policy mean for Academy Members – for a house call practice?

How does Academy public policy and advocacy work occur?

Public policy issues and demands now track transition from FFS to Value Based payment/population health management

Current and future issues important to the field

AAHCM Public Policy

©AAHCM

• Refers to the laws, the actions of government, the agency funding priorities, and the regulations

• Impacts your

◦ Practice organization and operation

◦ Practice revenue and success

What does public policy mean for Academy Members – for a house call practice

©AAHCM

• Service provided by volunteer public policy committee and Academy staff

• Relationships with alliances, coalitions and multi-specialty groups

• Augmented through Professional Services relationships ($)◦ Law/lobbying, data analytics

• Augmented through organizational relationships

◦ Corporate and professional alliances (AGS, AAHPM, etc.)

• Supported through practice level and individual voluntary action◦ Letters/E-mail, calls, visits, political support and letters to editor/journals

How does Academy public policy work occur?

©AAHCM

Policy area/issue

Academy effort and results

Traditional Fee Schedule • SGR – supported permanent repeal and signed onto letters, (offered IAH) • CCM -  advocated for chronic care management code and successful in changes to make it more

usable for housecalls (incident to relaxed and business cost increasing requirements generally dropped)

• ACP – advocating for coverage and payment for advanced care planning effective 2016 – Dr. DeCherrie representing Academy

These two services (CCM and ACP) may produce value for Academy members that is greater as a ratio to practice service and revenue than for MDs/NPs and PAs in other practice settings. 

Professional Fee Schedule

Home Health - payment rule and conditions of participation, face to face requirements, templates

Medicare Advantage/Advance Call Letter, and other letters regarding managed care

Shared Savings Programs (ACOs),

CMMI Request for Information  Re Advanced Primary Care Models

Impact Act 

Value Base Payment Modifier/risk adjustment for high risk patients

Standards Development

Telemedicine

Academy Comment Letters, and face to face meetings with CMS officials and Congressional staff Restrictive requirements eliminated (PCMH for CCM)

The Academy commented on an increased number and range of rule making and requests for comments and information as the impact of home care medicine is recognized and Academy capacity grows. Academy comments have been incorporated into final rules and policy. (Dr. Lauders leading)

Waiver recommendations included in ACO development

Home continues as location of service for Medicare Advantage assessments, diagnostic code acceptance. Patient attribution rules to include NP / PA, etc.

Public Policy Committee response

Public Policy Committee response

Meeting with MEDPAC. (Dr. Kinosian leading)

AAHCM Standards Committee Formed

AAHCM developed position paper on telemedicine for HBPC

2014-2015 Services and Outcomes

©AAHCM

Policy area/issue

Academy effort and results

Independence at Home

Academy “JEN analysis” of risk adjustment for IAH like population has been accepted within CMS and will inform HCC risk adjustment for Independence at Home. Academy will advocate that results be incorporated across all payment models, measures and the value based payment modifier program.

• Advocacy toward continuation/expansion.

• Advocate for accurate evaluation and payment

Managed Care and Dual Eligibles

The Academy is increasing the depth and breadth of managed care industry relationships. This includes relationships with executives and medical leadership of health plans as well as the representatives/trade associations and regulators of health plans. 

Regulation, Audits, and Practice Burden

The Academy continues to have influence in reducing practice burden and in protecting and expanding opportunities for housecalls. Continued audit intervention.

Publications, Media Requests, and Letters to the Editor , etc.

Academy members have produced increased number of peer review articles, Academy board and staff have responded to increase level of requests for interviews regarding home care medicine and generated an increased number of letters to the editor

2014-2015 Services and Outcomes

©AAHCM

Public policy issue of importance to your practice

Fee for service volume/code based issues

Value based payment and alternative payment models (APMs) issues

Patient volume – how is patient relationship established? “Attribution”

No requirements,

other than medical necessity and PCP relationship (unless preventive/screening)

Patient eligibility criteria/ attribution, so;

Need to influence the rules for patient assignment to your practice – otherwise threat to patient panel

Standards – what standards required to render service as primary care provider?

None,

other than basic state licensure, and Medicare program enrollment

Present in MACRA for APMS and “medical home,” so;

Need to influence what will be the standards and who certifies the practices

.Measures and outcomes Multiplicity of measures,not population based

No outcomes requirements und

Present in MACRA for professional fee schedule, APMS and “medical home,” so;

Need to influence what will be population appropriate measures and outcomes

Academy public policy will have to mirror the transition from FFS to VBP

©AAHCM

Public policy issue of importance to your practice

Fee for service volume/code based issues

Value based payment and alternative payment models (APMs) issues

Services recognized and covered for payment

Coverage, payment and RVUs “fought” for on code by code basis, e.g., RVUs for house call E and M codesTCM CCM ACP AWV in home setting

Need to participate to negotiate definition of deal, and what is the right bundle/risk/shared savings?

and

How to keep the budget/deal from shrinking in the future.

Payment and measure assessment risk adjusted based on patient condition?

No. Yes.

Need to influence in order to assure accurate risk adjustment for house call patient population regardless of payment model

Accountability – protection against over and underutilization

The micromanagement, burden and “hassle factor”

Fraud and abuse concerns and

Audits and medical record review

Will be embedded in evolving models based on outcomes and patient satisfaction. So, need to influence;

Who establishes/administers waivers?Who controls patient movement across settings? Who evaluates outcomes and patient satisfaction?

“Stark Exceptions”

Academy public policy will have to mirror the transition from FFS to VBP

Patient Enrollment /payment source Examples of Academy public policy efforts and influence requirement

Where will public policy efforts be required?

Medicare fee for service New services considered and covered – e.g., Advance care planning

Congress, CMS

Medicare Advantage Home continues as setting and focus for care coordination and care management

Eliminate barriers to house call contracting and NP credentialing

Risk adjustment

Congress, CMS

Medicare ACOs/shared savings and bundled payments

Beneficiary characteristicsBeneficiary attributionRisk adjustmentRisk/shared savings, bundled payment “deal”

Congress,CMS

Dual eligibles and Medicaid Managed Care Role of house calls in population networks

Beneficiary enrollmentOpt in or out?

Payment terms and levels

Congress, CMS, and

States;LegislativeMedicaid/Health DepartmentsInsurance departments

Commercial health plans Beneficiary enrollment “Attribution and Engagement”

Eliminate barriers to house call contracting

Eliminate barriers to NP credentialing

Address plans requirement for PCMH

Congress, CMS, and

States;LegislativeMedicaid/Health DepartmentsInsurance departmentsNAIC, NGA

Medicaid Beneficiary enrollment in ACOs, IAH like models adopted by MCOs

Straight Medicaid levels of payment need to move to Shared Savings

Congress, CMS, and

States;LegislativeMedicaid/Health Departments

Academy public policy efforts will have to expand to mirror the migration of house call population to Medicare/Medicaid commercial

plans