MedicarePlus Bridges Case Study

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Delivering Integrative Healthcare Under
Consumer-Driven Health Plans Using ABC Codes to
Improve Care, Claims Outcomes Second Annual
Conference - January 22-24, 2004 Integrative
Medicine for Healthcare OrganizationsHealth
Forum InnoVision Communications San Diego,
California
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Integrative Healthcare in Consumer-Driven Health
Plans Use ABC Codes to Improve Care, Claims
Outcomes

• Rationale for ABC Codes
• ABC Coding Solutions
• A Case Study Take Home Lessons

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Rationale for ABC Codes
Need for Better Health, Healthcare Health
Policy Decisions

• Identify best practices
• to ensure more Americans get the right care in
  the right place at the right time...at a
  rational cost.

• Unbiased Measurement!

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Rationale for ABC Codes Fill Critical Gaps in the
NHII Older HIPAA Code Sets
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Rationale for ABC Codes Support a Consumer-Driven
Healthcare Marketplace

• CAM office visits 629 million
• PCP office visits 386 million
• Source http//www.medinfo.ufl.edu/cme/grounds/pau
  ly/ Eisenberg,et al, JAMA,Nov11,1998, Vol 280,
  No 18

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Rationale for ABC Codes
Characterize, Evaluate Facilitate Care
Need for Research Tools to Identify the Most
Cost-Effective Approaches to Care
Need for Management Tools to Improve Business
Processes in Healthcare
Need for Commerce Tools to Support Industry
Efficiencies
Need for Expanded Standards to Support Consumer
Demand for Integrative Healthcare
Need for Complete Standards to Support the
National Health Information Infrastructure
Need to Resolve U.S. Healthcare Challenges
Access, Quality Costs
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Rationale for ABC Codes Establish Open Unbiased
Clinical Administrative Code Sets

• Conventional physicians have had
  government-sanctioned codes owned by the
  American Medical Association.
• Until ABC codes were authorized under HIPAA,
  other practitioners lacked adequate codes.
• Complete coding is essential for controlling
  healthcare access, quality costs.
• Trade association control supports cartel-like
  behavior. (An analogy illustrates.)
• Assume an American Food Association (not a
  Uniform Code Council) controlled bar codes on all
  food products.
• Could the AFA unfairly code international food
  products?
• Would fewer international food products reach the
  grocery store shelves?
• Could the AFA limit competition largely dictate
  pricing consumption?

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Rationale for ABC Codes Support Cost-Effective
Contracting, UM Claims Adjudication

• ABC Codes describe alternative medicine, nursing
  other integrative healthcare practitioners
  interventions.
• Relative Value Units (RVUs/RBRVS data) establish
  the financial value of those interventions.
• Legal Billing Guidelines (with legal scope of
  practice information) indicate who can legally
  provide those interventions under what
  circumstances in each state.
• The HealthIntel Database contains these other
  data elements supports health insurance
  benefit plan design, managed care provider
  contracting, utilization clinical practice
  management, claims processing, outcomes research
  actuarial analyses. It is the only
  health-related data set that supports
  cost-effective adjudication of integrative
  healthcare claims on a per intervention, per
  practitioner per state basis.

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Rationale Support Cost-Effective Contracting, UM
Claims Adjudication
Financial Value
ABC Code
Hierarchic Description
Legal?
Detailed Description of Intervention
(A Cross Section of the HealthIntel Database)
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Rationale for ABC Codes Support Credentialing
Network Development

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Rationale for ABC CodesCharacterize Document
Integrative Healthcare Practices
Source http//www.medinfo.ufl.edu/cme/grounds/pau
ly/ Eisenberg,et al, JAMA,Nov11,1998, Vol 280,
No 18
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Rationale for ABC CodesImprove Revenues, Reduce
Costs Enhance Brand Equity

• Research
• Conducting outcomes studies
• Economic, health, quality of life, satisfaction,
  etc.
• Management
• Forecasting demand, managing operations
  maintaining medical records
• (Scheduling patients, optimizing workflow,
  managing cases, conducting activity-based or
  standard costing, setting fees/prices,
  establishing contracts, credentialing, etc.
• Commerce
• Conducting manual eligibility determinations,
  prior authorizations, claims submissions, etc
• Conducting electronic eligibility determinations,
  prior authorizations, claims submissions, etc

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Rationale for ABC Codes
Improve Healthcare Decisions, Practices Outcomes
ABC codes were authorized by HHS as a proposed
modificationto the HIPAA transaction code set
standards. They are HIPAA-compliant for code
set registrants their trading partners.ABC
codes support research, management commerce
for alternative medicine, nursing other
integrative healthcare interventions. ABC
codes have the exact infrastructure functionality
social benefits that the National Foundation
for Women Legislators calls for in the 2003 NFWL
Access to Care Resolution.
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Rationale for ABC Codes Ensure Integrative
Healthcare Claims Are Not Too Expensive to Process
ABC Codes, Relative Values Legal Billing
Guidelines help justify payment
decisionswithout expensive utilization
reviews. Without ABC codes, older HIPAA code
sets do not provide sufficient information to
verify the legality, necessity
cost-effectiveness of integrative healthcare
products services.
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ABC Coding Solutions Consider Resources for
Integrative Healthcare Program Implementation

• ABC Coding Manual for Integrative Healthcare
  
• Practitioner Guides to Billable Interventions
  Using ABC Codes
• Relative Values for Integrative Healthcare Using
  ABC Codes
• Superbills for Integrative Healthcare
• HealthIntel Database
• ABC / CPT / HCPCS II Crosswalk
• CAM Market Report
• Consulting Services
• Beta Testing Co-Development

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Context for the Case Study Create Next
Generation High Value Integrative Healthcare
Programs

• Competing Quick Dirty Approaches Their
  Competitive Vulnerabilities
• Higher deductibles. A deductible is a total
  dollar amount that the consumer must pay before
  the insurer begins making payments for
  treatments. Under this type of policy,
  integrative healthcare coverage is offered, but
  the consumer pays a higher deductible.
• Policy riders. A rider is an amendment to an
  insurance policy that may change coverage in some
  way (such as increasing or decreasing benefits).
  A consumer may be able to purchase a rider that
  adds or expands coverage in the area of
  integrative healthcare.
• Discounted fee-for-service networks. Some
  insurers work with a group of integrative
  healthcare practitioners who agree to offer
  services to group members at a rate lower than
  that offered to nonmembers. A consumer pays out
  of pocket for treatment, but at a discounted
  rate.

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Context for the Case Study Create Next
Generation High Value Integrative Healthcare
Programs

• The Holy Grail Seamless integration to support
  data collection drive best practices.
• Use ABC codes in conjunction with the older HIPAA
  code sets to support integrative healthcare
  research, management commerce.

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Context for the Case StudyImprove Revenues,
Cost-Management the Bottom Line

• Reduce the total cost of care by directing
  MedicarePlus patients with high cost
  integrative healthcare-responsive diagnoses
  through an integrative healthcare program to
  avoid costly conventional interventions.
• Expand savings by utilizing the MedicarePlus
  integrative healthcare model as a prototype for
  other plans by targeting high cost diagnoses
  (associated with both conventional
  unconventional interventions) to further reduce
  the total cost of care.
• Attract healthier beneficiaries, increase
  revenues reduce corresponding medical costs by
  increasing interest of wellness-oriented
  populationsin integrative healthcare products
  programs.
• Promote a unique brand image enhance overall
  market share by extending the most cost-effective
  integrative healthcare solutions into other plans.

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Context for the Case StudyShift Coverage
Reimbursement Policies Incrementally

• Use qualitative research actuarial data to
  identify high cost high incidence diagnoses
  responsive to integrative healthcare.
• Enhance claims adjudication rules engines to
  accommodate claims that include ABC, CPT, HCPCS
  II, CDT NDC.
• Establish integrative healthcare practitioner
  contracting credentialing initiatives.
• Expand integrative healthcare benefits to
  targeted ICD-9s beneficiaries.
• Compile, analyze disseminate cost-effectiveness
  data.

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Context for the Case StudyLead the Integrative
Healthcare Market Preemptively

• Support research, management commerce for
  integrative healthcare using ABC codes.
• Identify practitioner type, using special coding
  modifiers.
• Establish financial value on a per intervention
  basis, using RVUs.
• Establish legal compliance on a per intervention,
  per practitioner per state basis, using
  practitioner guides legal billing guidelines
• Support improvements in insurance benefit plan
  design, managed care provider contracting,
  utilization clinical practice management,
  claims processing, outcomes research actuarial
  analyses on a per intervention, per practitioner
  per state basis, using the HealthIntel
  Database.
• Help prevent fraud abuse in integrative
  healthcare claims.

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Case Study MedicarePlus Bridges in
MedicineAlign Goals of Patients, Practitioners
Payors

• Jeffrey S. Sollins, MD
• Bridges in Medicine (Integrative Healthcare)
• Ardent Lovelace Sandia Health System
  (MedicarePlus/Senior Plan)
• ABC Codes Best Practices
• 5 Years
• Pioneering Integrative Medicine Program Within
  Medicare

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Case Study MedicarePlus Bridges in
MedicineAddress Clinical Delivery,
Administration Financing Concurrently

• Clinical Delivery
• Improved patient-practitioner
  practitioner-practitioner relationships
• Improved understanding of optimal treatment
  pathways (e.g., equally or more effective, less
  invasive interventions with lower costs)
• Improved outcomes, esp. for chronic conditions
  (e.g., fewer side effects)
• Administration
• Constructive inter- intra-organizational
  interactions
• Optimal allocation of organizational resources
• Financing
• Improved contracts revenues
• Improved operating efficiencies
• Improved bottom line

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Case Study MedicarePlus Bridges in
MedicineUnderstand Were at an Early Stage,
Dealing with a Global Movement
Morris studies the lower right hand corner of the
big picture.
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Case Study MedicarePlus Bridges in
MedicineConsider the Context for Care Before the
Enabling Technology
It Is All About Health Healing
We are not human beings having a spiritual
experience. We are spiritual beings having
a human experience. (Pierre Teilhard de
Chardin, 1881-1955)
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Case Study MedicarePlus Bridges in
MedicineRemember Enabling Technologies Dont
Substitute for Good Thinking Practice

• Understand the terms holistic, natural,
  complementary, alternative integrative
  medicine.
• Recognize integrative medicine is not adding a
  non-conventional modality to conventional
  Western medicinemind shift.
• Learn to build your own bridge.
• Appreciate strengths recognize limitations..

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Case Study MedicarePlus Bridges in
MedicineRemember, In Healthcare, Healthy People
are the Product
HELPING
Rachel Naomi Remen, MD
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Case Study MedicarePlus Bridges in
MedicineAnticipate Significant Shifts from
Planned Program Design
Vision vs. Reality

• Who Benefits from Bridges in Medicine?
• What Is the Bridges T.E.A.M.?
• Why Does Bridges Work?
• How Is Bridges Evolving?
• Where Are the Remaining Challenges?

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Case Study MedicarePlus Bridges in
MedicineBenefit From Lessons Learned

• Missed diagnosesKEN atypical angina
• Delayed definitive treatmentCw Diverticulitis vs
  bladder Ca
• Unrecognized interactions anticoagulationGinko,
  feverfew, ginger, vitamin E, garlic Omega 3
  fish oil
• ContraindicationsSt. Johns Wort, Cyclosporin,
  SAM-e Bipolar Disorder
• Exploitation...Max the cap
• Milt Hammerly, MD, Med. Dir., CAM at
  Centura Health, Denver, Colo., 1998

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Case Study MedicarePlus Bridges in
MedicineCreate a Win-Win Situation Patients

• Provide patients with knowledge ability to
  adopt a proactive approach to their total well
  being.
• Deliver healthcare education for more informed
  decision making.
• Take a patient-centric approach use a
  professional healthcare team.
• Promote open communication between patient
  practitioners in a highly supportive
  environment.
• Assure active participation by the patient in
  his/her own healthcare.
• Commit to long-term healthcare through a focus on
  restoring maintaining good health, wellness
  education follow up visits.

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Case Study MedicarePlus Bridges in
MedicineCreate a Win-Win Situation Practitioners

• Give practitioners a mechanism for integrating a
  care plan.
• Improve patient records.
• ID outcomes of care develop best practice
  pathways.
• Prove legality, necessity cost-effectiveness.
• Use payors language show whats in it for
  them.
• Reduce contracting, credentialing, coverage,
  claims management reimbursement concerns.
• Focus on the patient.

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Case Study MedicarePlus Bridges in
MedicineCreate a Win-Win Situation Payors

• Improve benefit plan design.
• Streamline contracting.
• Optimize utilization care practices.
• Cost-effectively adjudicate integrative
  healthcare claims.
• Conduct outcomes research.
• Characterize integrative healthcare models,
  previously not clearly delineated.
• Collect hard data on care-effective
  cost-efficient models useful in managing resource
  intensive conditions.
• Support risk management other actuarial needs.

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Conclusion
Need for Better Health, Healthcare Health
Policy Decisions

• ABC codes, RVUs legal billing guidelines
  support research, management commerce help
  stakeholders identify best practices
• to ensure more Americans get the right care in
  the right place at the right time...at a
  rational cost.

• Unbiased Measurement!

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A Tibetan Monk went to a hot dog stand in New
York said, Make Me One With Everything. He
handed the vendor a 20 bill. The vendor took
the 20 but proceeded to turn to the next
customer take his order. After a while, the
Monk spoke up asked for the change. The
vendor replied,
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Change Comes From Within
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Bridges in Medicine integrates conventional
complementary medicine, using a
multi-dimensional model, to create balance
wholeness in individuals, caregivers health
plans the communities in which they live. 3924
Carlisle Blvd. NE Albuquerque, NM 87107 USA Tel
505-855-5545 Fax [phone] Email
the1beamer_at_aol.com Web Site www.bridgesinmedicin
e.com
Ardent Health Services / Lovelace Sandia Health
System is a leading healthcare provider in New
Mexico. 601 Dr. Martin Luther King Jr. Ave.
NEAlbuquerque, NM 87102 USATel
505-727-8000Web Site www.lovelacesandia.com
Alternative Link delivers information products
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individual public health, business industry
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Indian School Road NE, Suite 131 Albuquerque, NM
87110 USA Tel [phone] Fax
505-875-0002 Email mail_at_alternativelink.com Web
Site www.alternativelink.com