Practice Management: Pay for Performance Trends

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Practice Management Pay for Performance Trends

• Jama Allers, Practice Consultant
• MedChi, The Maryland State Medical Society

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Change

• Monitor

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Change

• Assess

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Impact of Change

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Controlling Cost of Care

• What criteria are insurance carriers using to
  calculate cost of care?
• Claims Data
• Disease
• Utilization
• Outcomes
• COST

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Claims Data Collected

• Physicians, Ambulatory Surgery Centers,
  Hospitals, Pharmacies, Laboratories, Diagnostic
  Centers, DME Suppliers, Skilled Nursing
  Facilities
• Insurance carriers have been collecting this
  information for the last THREE to FIVE years.

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Take a closer look at claims

• ICD-9
• Level of specificity
• CPT
• Level of encounter
• POS
• Level of care

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ICD-9 Highest Level of Specificity

• Diabetes 250. ? ___
• 0 without mention of complication
• 1 with ketoacidosis
• 2 with hypersmolarity
• 3 with other coma
• 4 with renal manifestations
• 5 with ophthalmic manifestations

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Diabetes

• Diabetes 250. __?_ ____
• 6 with neurological manifestations
• 7 with peripheral circulatory disorders
• 8 other unspecified manifestations
• 9 with unspecified complications

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Diabetes

• Diabetes 250.___ __?__
• 0 type II or unspecified, not stated as
  uncontrolled
• 1 type I juvenile, not stated as uncontrolled
• 2 type II or unspecified, uncontrolled
• 3 type I juvenile, uncontrolled

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Super Bills, Fee Tickets

• New ICD-9 codes effective October 1 each year
• Leave 4th/5th digit ___ ___
• Be familiar with your most used codes

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Super Bills, Fee Tickets

• Number your diagnoses
• 1.) Reason for todays encounter
• 2.) Other disease processes that impact your
  medical decision making
• Diagnoses should be numbered the same way they
  are listed in assessment

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Documentation of Quality Measures

• Document in the patient record
• Physicians are doing the work of the quality
  measure
• Create templates
• Incorporate into EMR
• May be documented by ancillary staff

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Physicians and P4P

• 1998 First seen in Maryland
• 2005 AMA released guidelines for evaluating P4P
  programs
• 2005 MGMA released guidelines for P4P programs

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Insurance and P4P

• May offer employers
• Lower premiums
• Influences patients by
• Lower out of pocket expenses
• Website designation

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CareFirst

• 1998 PCP and Specialty Recognition Program
• 2005 Bridges to Excellence Pilot Program
• Practices financially rewarded for completing
  modules

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CareFirst

• 2009 CareFirst Quality Rewards
• NCQA Accreditation
• Cost for materials and per physician
• Primary Care
• Heart/Stroke
• Diabetes
• Back Pain

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Aetna

• 2004 AEXCEL Designation
• Tiered Networks
• Targets high cost specialties
• Invitation only

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United Healthcare

• 2008 Premium Designation Program
• Tiered Networks
• Specialty and Primary Care
• Evaluates efficiency
• Unit price
• Utilization rates
• Physician comparisons

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Medicare

• 2006 Physician Voluntary Reporting Program
• 2007 Physician Quality Reporting Initiative
• Pay For REPORTING
• Based on 74 initiatives
• Report directly on CMS 1500 form
• Modifiers
• 2008 Physician Quality Reporting Initiative

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PQRI pay ?

• 2008 Professionals that report successfully are
  eligible for a 1.5 percent bonus payment
• 2009 Funds have been allocated for PQRI

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Worksheet

• Example in your handout

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PQRI -modifiers

• 1P- Performance Measure Exclusion Modifier due to
  Medical Reasons
• 2P- Performance Measure Exclusion Modifier used
  due to Patient Reason
• 3P- Performance Measure Exclusion Modifier used
  due to System Reason

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PQRI

• Website and Downloads
• Measures and codes
• Reporting
• Educational resources
• PQRI Tool Kit
• www.cms.hhs.gov/pqri

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Winds of change for 2009

• All insurance carriers watching PQRI
• Specialty Societies working with CMS to create
  initiatives
• Volunteer vs. Mandatory????