Hospice Regulatory Update Lisa Abicht-Swensen, M.H.A., LNHA Director of Home Health and Hospice Services

Transcription

1 Hospice Regulatory Update 2016 Lisa Abicht-Swensen, M.H.A., LNHA Director of Home Health and Hospice Services

2 Objectives Discuss the changes outlined in the FY2017 Wage Index Rule including the analysis of data trends in utilization, new quality measures and the development of a new comprehensive patient assessment instrument List at least three regulatory changes that will impact how hospice care is delivered in the future Discuss areas of increased scrutiny for hospice providers and changes that the hospice program should make to be in compliance with CMS and other federal regulations 2

3 Hospice Used to Be.. Diagnoses 52% Cancer Patients Budget dust 2000: $2.8 billion in Medicare spending Mostly care at home 2000: 513,000 patients Little scrutiny Stable and dependable daily per diem rates 3

4 Hospice Has Become.. Diagnoses <29% Cancer No longer budget dust 2015: $15.5 billion Patients 2015: 1,400,000 patients Hospice care delivered in many settings Nursing homes, assisted living, home Reform of hospice payments Increasing scrutiny 4

5 Hospice is Coping with Intense oversight and scrutiny of hospice regulatory compliance Hospice payment reform Hospice quality reporting (soon to be publicly reported data) Competition among hospices The evolution of healthcare reform Change, Change and More Change! 5

6 The list is long Trends in Hospice Utilization Monitoring for Hospice Payment Reform FY2017 Hospice Wage Index Final rule CAP Amount and CAP Calculation Current and New Quality Measures Hospice Compare Hospice PEPPER Reports Focus on General Inpatient Care 2015 survey deficiencies Advance Care Planning HIPAA Security Activity Future Hospice Issues

7 Trends in Hospice Utilization 7

8 Growth in Patients and Expenditures Patients Served 2000: 513, : 1.4 Million Medicare Expenditures 2000: $2.8 Billion 2015: $15.5 Billion 8

9 Top 5 Diagnoses in 2015 Rank ICD-9 Code Diagnosis Number of Hospice Patients Alzheimer s disease 195,469 13% Congestive heart failure, unspecified 114,240 8% Lung Cancer 87,661 6% COPD 80,081 5% Senile degeneration of the brain 46,610 3% %

10 Multiple Diagnoses on Claim Form % of claims with one diagnosis 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 77.2% 72% 67% 49% 37% % of claims with one diagnosis

11 Multiple Diagnoses on Claim Form Year % Submitted with only 1 diagnosis % % 2 diagnoses 63% 3 or more diagnoses 46% 11

12 Monitoring for Hospice Payment Reform Impact 12

13 Pre-Hospice Spending Five Broad Categories of Hospice Patients Alzheimer s, Dementia and Parkinson s CVA/Stroke Cancers Chronic Kidney Disease Heart (CHF and other heart disease) Lung (COPD and pneumonia) All other diagnoses Analysis of pre-hospice spending an initial step in determining whether a case-mix adjustment could be created in the future 13

14 Pre-Hospice Spending Diagnosis Mean Lifetime Length of Stay ALL DIAGNOSES 73.9 Alzheimer s, Dementia and Parkinson s CVA/Stroke 55.6 Cancers 47.3 Chronic Kidney Disease 29.8 Heart (CHF and Other Heart 78.8 Disease) Lung (COPD and Pneumonias 69.4 All Other Diagnoses 78.2

15 Pre-Hospice Spending Analysis $500 $450 $400 $350 $300 $250 $200 $150 $100 $50 $0 180 Days before election 90 days before election 30 days before admission RHC Rate FY2014 $156.06

16 Leakage CMS believes that it would be unusual and exceptional to see services provided outside of hospice Trend analysis on spending outside the Medicare hospice benefit Non-hospice Part A and Part B spending has decreased by 15.4% Beneficiary cost sharing: $122.5 million in FY2014, down from $132.5 in FY2013

17 Medicare Parts A and B Leakage $720,000,000 $700,000,000 $680,000,000 $660,000,000 $640,000,000 $620,000,000 $600,000,000 $580,000,000 $560,000,000 $540,000,000 $710,087,321 Parts A and B Expenditures After Hospice Election $694,130,854 $600,842, "Leakage"

18 Part D Expenditures Outside MHB 2014 patient pay amount: $41, comparison: $50.9 million Why is patient pay important? Beneficiaries now hospice patients paid their co-pay for these drugs Policy questions Should hospice have paid? If yes, then how does the hospice reimburse the patient?

19 Common Palliative Drugs Analgesics Anti-inflammatory non-narcotic Opioids Antianxiety agents Antiemetics Laxatives

20 Cerebral Degeneration Overlapping Drugs - Part D Expenditures - $16,673,285 $1,880,621 $3,229,221 Common Palliative Drugs $11,563,443 Psychotherapeutic and Neurological Agents Antipsychotics/Antimaniac Agents FY2014 Data

21 COPD Part Overlapping Drugs Part D Expenditures $11,194,870 $289,214 $195,780 $1,941,201 Common Palliative Drugs Antiasthmatic and Bronchodilator Agents Respiratory Agents - Misc. $8,768,675 Corticosteroids FY2014 Data

22 CMS Concern Hospices are required to cover drugs for the palliation and management of the terminal prognosis We remain concerned that common palliative and other disease-specific drugs for hospice beneficiaries are being covered and paid for through Part D.

23 Part D Expenditures Outside the MHB Part D Expenditures $360.0 $350.0 $340.0 $330.0 in Millions $320.0 $310.0 $300.0 $290.0 $334.9 $347.2 Part D Expenditures $280.0 $270.0 $291.6 $260.0 CY2012 FY2013 FY2014

24 Live Discharge Rates All reasons for discharge, including revocation Live discharge rates have declined over time Leveling off at ~ 18% Analysis of hospice live discharge rate amount of non-hospice spending average length of stay incidence of cap overpayments

25 CMS Concern Some hospices may be using the Medicare Hospice program inappropriately as a long-term care ( custodial ) benefit rather than an end of life benefit for terminal beneficiaries

26 Live Discharge Rate

27 Concerns with this CMS Data All types of discharges included Patient revocation is a patient right No way for the individual hospice to respond or correct their practices without additional information % of revocations Reasons for hospice-initiated discharge You may want to consider Using PEPPER report for additional analysis 27

28 Skilled Visits in the Last Days of Life On any given day during the last 7 days of a hospice election, nearly 47% of the time the patient has not received a skilled nursing or social worker visit On the day of death nearly 26% of beneficiaries did not receive a skilled nursing or social work visit

29 Incentives for Skilled Visits Service Intensity Add-on RN and social worker visits Up to 4 hours per day combined disciplines Paid at CHC hourly rate New quality measure measuring visits when death is imminent What is CMS telling us?

30 CMS Data Monitoring Monitoring will include: hospice diagnosis reporting length of stay live discharge patterns and their relationship to the provision of services and the aggregate cap non-hospice spending for Parts A, B and D during a hospice election trends of live discharge at or around day 61 of hospice care, and readmissions after a 60 day lapse since live discharge

31 FY2017 Wage Index Update and Rates 31

32 FY2017 Wage Index Update Final marketbasket increase of 2.1% October 1, 2016 implementation

33 FY2017 Final Rates Level of Care FY2016 National Rate Final FY2017 National Rate Routine Home Care 1-60 days $ $ Routine Home Care 61+ days $ $ Service Intensity Add-on Hourly rate $39.37 $40.19 Continuous Home Care Hourly Full 24 hours With Quality Reporting $39.37 $ $40.19 $ Inpatient Respite $ $ General Inpatient $ $734.94

34 FY2017 Rates Without Quality Reporting Level of Care FY2016 Payment Rates FY2017 Final Payment Rates Routine Home Care (days 1-60) $ $ Routine Home care (days 61+) $ $ Service Intensity Add On $39.37 $39.41 Continuous Home Care Hourly Full 24 hours $39.37 $ $39.41 $ Inpatient Respite $ $ General Inpatient $ $720.54

35 CAP Amount and CAP Calculation 35

36 Cap Amount October 1, 2016 and before October 1, 2025 Cap calculation update Same calculation as the hospice payment update percentage Cap amount for 2017: $28, Cap year for 2017: October 1, 2016 to September 30,

37 CAP Self-Report Due Date FY 2015 Hospice Wage Index and Payment Rate Update final rule: Requires providers to complete their aggregate cap determination not sooner than 3 months after the end of the cap year, and not later than 5 months after, and remit any overpayments. Those hospices that fail to timely submit their aggregate cap determinations will have their payments suspended until the determination is completed and received by the Medicare Administrative Contractor (MAC). 37

38 Current and New Quality Measures 38

39 Quality Reporting Summary All current measures continue: CMS will continue with all current HQRP measures. Two new quality measures added: CMS added 2 new quality measures effective April 1, Public display and reporting: All 7 current HIS measures included Hospice CAHPS results included CMS Hospice Compare website Spring/Summer of CY 2017

40 Visits When Death is Imminent Measure 1 Assesses the percentage of patients receiving at least 1 visit from: registered nurses Physicians nurse practitioners or physician assistants in the last 3 days of life Measure addresses case management and clinical care 1 visit in 3 days Measure 2 Assesses the percentage of patients receiving at least 2 visits from: medical social workers, chaplains or spiritual counselors, licensed practical nurses, or hospice aides in the last 7 days of life 2 visits in 7 days

41 Visits When Death is Imminent New Items on HIS Discharge Record: 4 new items added to the HIS Discharge record Will collect necessary data Start date for data collection: April 1, 2017

42 Composite Process Measure All 7 current HQRP measures No new data collection will be required Data for the composite measure will come from existing items from the existing 7 HQRP component measures Measure calculates the % of patients for whom HIS Admission records contain data on all seven current HQRP quality measures Start date: April 1, 2017

43 What Can a Hospice Do Now? For Composite Measure Measures the percentage of patients who have data on all 7 HQRP measures Hospice already has the data on HIS Admissions submissions Check your percentages Develop PIP to analyze the issues and make improvements in processes Prepare for the composite measure NOW! 43

44 Compliance Thresholds for HIS Year January 1, 2016 December 31, 2016 Compliance Threshold 70% of all required HIS records within the 30 day submission timeframe Annual Payment Update Impacted FY 2018 January 1, 2017 December 31, % of all required HIS records within the 30 day submission timeframe FY 2019 January 1, 2018 December 31, % of all required HIS records within the 30 day submission timeframe FY

45 Standardized Patient Assessment Early stages of development new data collection mechanism for use by hospices Hospice patient assessment instrument Provide the quality data necessary for HQRP requirements and the current function of the HIS; and Provide additional clinical data that could inform future payment refinements In line with other post-acute care settings (e.g. OASIS) 45

46 Timeframe and Comments Timeframe for new tool: Early stages of development. Will see in future rulemaking CMS comments: Assessment tool intended to: Address the holistic nature of hospice, incorporating important medical, psychosocial, spiritual, and other aspects of care. Incorporates input from various members of the IDT Accommodates circumstances unique to hospice: Care of the imminently dying Patient/caregivers right to decline service or treatment 46

47 Hospice Compare Spring/Summer 2017! 47

48 Hospice Compare Data Used: HIS and Hospice CAHPS Quarters of data used for determining measures for public reporting Hospice began HIS reporting on July 1, 2014 CMS is using data collected by hospices during Quarter 4 (Q4) CY 2014 and Q1-Q3 CY 2015 Eligible measures: All 7 HIS measures are eligible for public reporting Participation in public reporting CMS analyzed reportability 71-90% of hospices would be able to participate in public reporting depending on the measure 48

49 Hospice CAHPS Questions As part of the Hospice CAHPS Data, Questions included, among others: Hospice rating question Willingness to recommend Will be reported on Hospice Compare 49

50 Data Review Before Public Report Critical Review the HIS and CAHPS data for accuracy before public reporting Provider demographic data: Files now available for review and correction Provider-specific CASPER feedback reports: Review HIS data as it is submitted, watch for opportunities for provider-specific CASPER feedback reports (available in CASPER in December 2016) and finally preview reports through CASPER 50

51 Hospice Data Directory All hospice demographic data has been posted to Medicare data website Agencies/s8t3-rfbg Data includes: Hospice demographic and certification Comes from the CMS automated system First step in preparing for Hospice Compare Hospices should check the website to ensure that all data is correct and up to date Corrections: Provider should contact the CMS Regional Office Coordinator (List is online) CASPER-ASPEN-Contacts/qx7x-wipa 51

52 Preview Reports Preview reports will be available in CASPER before public reporting and will give providers the opportunity to review their quality measure data Hospices have 30 days to review this information, beginning from the date on which they can access the preview report Corrections to the underlying data are NOT permitted at this stage of review 52

53 How Hospice Compare Will Work Consumers will be able to: Search for all Medicare approved hospice providers that serve their city or zip code Quality measures AND CAHPS Hospice Survey results will be available CMS states that no consumer or other user of the Hospice Compare Website will be able to post comments or grievances on the Hospice Compare Website 53

54 Hospice PEPPER Reports 54

55 Use of PEPPER Reports PEPPER Roadmap to help a provider identify potentially vulnerable or improper payments Assist providers in identifying Free comparative report from CMS contractor Go to Click on PEPPER Distribution Get your PEPPER

56 California Retrieval Rate = 30.26% 56

57 Retrieving your PEPPER Report

58 Target Areas 2016 PEPPER Live discharges not terminally ill Live discharges revocations Live discharges LOS days Long length of stay Claims with single diagnosis coded CHC in assisted living facility RHC in assisted living facility RHC in nursing facility RHC in skilled nursing facility Episodes with no CHC or GIP

59 Comparison Groups NGS J6 CGS J15 NGS JK Palmetto JM Nation MAC Jurisdiction State

60 Focus on GIP 60

61 % of days by level of care Level of Care Routine Home Care 97.4% Continuous Home Care 0.4% Inpatient Respite Care 0.3% General Inpatient Care 1.9% Percentage of Total Days

62 GIP Utilization Patient utilization: 77.3% of patients electing hospice did not have a GIP stay during their hospice election Hospices providing GIP 28% of hospices did not bill for a single day of GIP in CY2013 Source: MedPAC analysis of hospice claims, CY2013

63 GIP Utilization National average = 1.9% of days are GIP Do not provide GIP? 66% for-profit Provide GIP? 5-10% = 195 hospices 10% or more = 46 hospices Any GIP Provided? Number of Hospices No 760 Yes 2,758 Hospice claims data from CY 2010-CY 2012 for beneficiaries who were discharged (alive or deceased) in CY 2012

64 Location of GIP % % Hospice Inpt Facility Hospital Skilled Nursing Facility Multi % of Total 5.5% 1.6% Source: CMS CY 2012; FY2015 Hospice Wage Index Final Rule

65 Length of GIP Stay by Location days 6.1 days days 4.7 days All Inpatient Hospice Inpatient Hospital SNF 0 Average Length of Stay in Days Source: CMS CY 2012; FY2015 Hospice Wage Index Final Rule

66 Policy Questions Was the hospice able to provide GIP? Was the hospice cherry picking patients who were less sick? Does the hospice comply with COP requirement for a contract for GIP? Was quality of care compromised?

67 MedPAC Reports on Levels of Care Some hospices did not provide certain levels of hospice care to any patients in 2013 Category No General Inpatient No Continuous Home Care No inpatient respite No GIP or CHC No GIP, CHC, or respite All hospices 28% 58% 25% 19% 12% % of Hospices by total number of patients in 2013 Less than or more Source: MedPAC analysis of Medicare hospice claims data CY2013

68 Office of Inspector General Focus 68

69 OIG 2016 Work Plan Hospice General Inpatient Care Review use of GIP Assess the appropriateness of hospices GIP claims Assess content of election statements for hospice beneficiaries who receive GIP Review hospice medical records to assess appropriateness of level of care NEW! Review beneficiaries plans of care and determine whether they meet key requirements Determine whether Medicare payments for hospice services were made in accordance with Medicare requirements 69

70 Report on Hospice GIP Among the findings published March 31, 2016 the OIG found that hospices billed one-third of GIP stays inappropriately, costing Medicare $268 million in Hospices commonly billed for GIP when the beneficiary did not have uncontrolled pain or unmanaged symptoms Source: OIG Report Hospices Inappropriately Billed Medicare over $250 Million for General Inpatient Care March 31, 2016

71 General Inpatient Data Source: OIG Report Hospices Inappropriately Billed Medicare over $250 Million for General Inpatient Care March 31, 2016

72 Reasons for Inappropriate Billing Reason for inappropriate GIP billing Beneficiary did not have uncontrolled pain or unmanaged symptoms, or the beneficiary received care that could have been provided at home % of inappropriate GIP stays 89% Caregiver issues 15% Source: OIG Report Hospices Inappropriately Billed Medicare over $250 Million for General Inpatient Care March 31, 2016

73 MHB and Part D Concerns OIG reports that Medicare sometimes paid twice for drugs for beneficiaries receiving GIP 110 of 198 of the drugs provided to beneficiaries during the sample of GIP stays were paid by Part D Drugs were used primarily for the relief of pain and symptom control related to the hospice beneficiary's terminal illness Should have been provided by the hospice and covered under the daily rate Source: OIG Report Hospices Inappropriately Billed Medicare over $250 Million for General Inpatient Care March 31, 2016

74 Care Planning in GIP Care Planning Concern Overall hospices did not meet care planning 85% of GIP stays requirements Hospice care plan missing one key element 72% of stays missing either frequency or scope of at least one type of main service in the care plan Care plan not developed by all required 49% of stays members of the team in care planning Pastoral or other counselor not involved 44% of stays in care planning Social worker not involved in care 34% of stays planning Physician not involved in care planning 12% of stays Nurse not involved in care planning 5% of stays Source: OIG Report Hospices Inappropriately Billed Medicare over $250 Million for General Inpatient Care March 31, 2016 Percentage of GIP stays

75 OIG Recommendations Increase its oversight of hospice GIP claims and review Part D payments for drugs for hospice beneficiaries Ensure that a physician is involved in the decision to use GIP Conduct prepayment reviews for lengthy GIP stays Increase surveyor efforts to ensure that hospices meet care planning requirements Establish additional enforcement remedies for poor hospice performance Follow up on inappropriate GIP stays, inappropriate Part D payments, and hospices that provided poorquality care Source: OIG Report Hospices Inappropriately Billed Medicare over $250 Million for General Inpatient Care March 31, 2016

76 What should a hospice do? Level of care eligibility Process and procedure for determining eligibility for the GIP level of care DOCUMENT the reasons that GIP is appropriate for each patient Evaluate continued eligibility for GIP EVERY DAY Physician involvement in GIP decision making Physician orders for a change in level of care? Industry best practice

77 What should a hospice do? Review GIP length of stay regularly Review use of GIP and length of stay regularly, even monthly Conduct internal chart reviews for LOS more than 2-3 days Care planning Review care plan scope and frequency for the GIP stay Confirm that all required members of the IDT participate in GIP plan of care development Part D and hospice Vigilance for medication coverage, especially in contract GIP facilities Keep accurate and detailed pharmacy records to document payment for medications

78 Survey Preparedness 78

79 TOP SURVEY ISSUES 2015

80 2015 Survey Statistics 4,363 active providers 1,398 surveys conducted 32% 2015 # of citations in top 25: 1, # of citations in top 25: 1,267

81 2015 Survey Deficiencies - #1-5 L Tag Survey Deficiency # Providers Cited % of Surveys Cited L0629 Supervision of hospice aides % L0543 Plan of care % L0530 Content of comprehensive assessment % L0545 Content of plan of care % L0547 Content of plan of care %

82 2015 Survey Deficiencies - #6-10 L Tag Survey Deficiency # Providers Cited L0523 Timeframe for completion of assessment % of Surveys Cited % L0647 Level of activity % L0555 Coordination of services % L0552 Review of plan of care % L0625 Hospice aide assignments and duties %

83 Advance Care Planning 83

84 CY2016 MC Physician Fee Schedule January 1, 2016 two CPT codes for advance care planning discussions CPT code 99497: 1 st 30 minutes CPT code: 99498: each additional 30 minutes Provided by: Physicians Other non-physician professionals (NPPs) who bill using the Part B Physician Fee schedule Nurse practitioners Physician assistants Clinical nurse specialists Nurse midwives 84

85 Advance Care Planning Basics Advance Care Planning is designed to help individuals Learn about the health care options that are available for end-of-life care; Determine which types of care best fit their personal wishes; and Share their wishes with family, friends and their physicians. Some patients may need only one advance care planning conversation with their physician or NPP because they have considered their options Many patients may require a series of conversations with their physician or NPP to clearly understand and define their end-of-life wishes 85

86 Reimbursement Details Where? Medical offices, Healthcare facilities, including hospitals Cost Sharing? Beneficiary cost sharing required unless the advance care planning discussion occurs during the annual wellness visit Annual wellness visit discussions For discussions during the annual wellness visit, physicians and other health professionals may: Provide it during the visit Bill Medicare separately for it using the CPT codes Beneficiaries will have no cost sharing liability 86

87 Part A Billing for ACP There is nothing that restricts a Part A hospice claim from including line items and being reimbursed for ACP services performed by attending physicians that work for, or under arrangement with, the hospice (CPT codes 99497, 99498) 87

88 ACP Code Payments CPT code 99497: 1 st 30 minutes Non-facility payment $85.99 Facility payment $79.54 CPT code 99498: each additional 30 minutes Non-facility payment $74.88 Facility payment $

89 ACP Opportunity for Hospices New funding for advance care planning conversations Opportunities for hospice to be a leader in helping physicians learn how to successfully have ACO conversations Broader audience than usual referral sources Broader than end of life Broader than serious illness 89

90 Advance Care Planning : New FAQ CMS posted Frequently Asked Questions on billing Advance Care planning (ACP) services The FAQs are based on policies outlined in the CY 2016 Physician Fee Schedule Final Rule For information on billing ACP services as an optional element of an Annual Wellness Visit see the MLN Matters Article 90

91 HIPAA Security Activity 91

92 $1.55 Million Settlement North Memorial Healthcare of Minnesota has agreed to pay $1,550,000 to settle charges that it potentially violated HIPAA Privacy and Security Rules by failing to enter into a business associate agreement with a major contractor and failing to institute an organization-wide risk analysis to address the risks and vulnerabilities to its patient information. 92

93 $1.55 Million Settlement OCR s investigation indicated that North Memorial failed to have in place a business associate agreement, as required under the HIPAA Privacy and Security Rules, so that its business associate could perform certain payment and health care operation activities on its behalf 93

94 Consequences In addition to the $1.55 million payment, North Memorial is required to: Develop an organization-wide risk analysis and risk management plan, as required under the Security Rule. Train appropriate workforce members on all policies and procedures newly developed or revised pursuant to this corrective action plan 94

95 Phase 2 HIPAA Audit Program The 2016 Phase 2 HIPAA Audit Program Review the policies and procedures adopted and employed by covered entities and their business associates to meet selected standards and implementation specifications of the Privacy, Security and Breach Notification Rules Phase 2 HIPAA Audit Program Info 95

96 Next Round of Audits? They are already underway Communications from OCR will be sent via and may be incorrectly classified as spam If a providers spam filtering and virus protection are automatically enabled, OCR expects you to check your junk or spam folder for s from OCR; OCOCRAudit@hhs.gov 96

97 Who will be Audited? Every covered entity and business associate is eligible for audit OCR is identifying pools of covered entities and business associates that represent a wide range of health care providers, health plans, health care clearinghouses and business associates OCR expects covered entities and business associates to provide the auditors their full cooperation and support OCR will not audit entities with an open complaint investigation or that are currently undergoing a compliance review 97

98 Common Audit Deficiencies Failure to conduct Security Risk Analysis Lack of training Lack of safeguards for mobile or portable devices Failure to implement encryption Lack of secure transmission ( or text) Social Media Need defined policies on employees posting on public sites 98

99 Resources NHPCO s Security Best Practices HIPAA & Security Risk Assessment Guide PCOSecurityBestPracticesRiskAssessment.pdf HHS/OCR Security Risk Assessment Tool RELEASES-SECURITY-RISK-ASSESSMENT-TOOL-TO-HELP- PROVIDERS-WITH-HIPAA-COMPLIANCE.HTML Mobile Device Privacy and Security 99

100 Future Hospice Issues 100

101 Future Planning Efforts FY 2016 and Beyond Additional oversight of hospice care Oversight of certification surveys Hospice-worker licensure requirements Review of select Medicare services ordered by physicians Were payments in accordance with Medicare requirements? 101

102 Palliative Care Issues NEW! Physician home visits reasonableness of services Prolonged services reasonableness of services The necessity of prolonged services are considered to be rare and unusual 102

103 Questions Lisa Abicht-Swensen, M.H.A., LNHA Director of Home Health and Hospice Services Pathway Health

104 This presentation is copyrighted information of Pathway Health. This presentation is not to be sold or reused without written authorization of Pathway Health. 104