Wound Care Reimbursement Things Are A-Changing!
Kathleen D. Schaum, MS President Kathleen D. Schaum & Assoc., Inc. kathleendschaum@bellsouth.net 561-964-2470
Disclosure No relevant financial relationships
Disclaimer Information on reimbursement is provided as a courtesy, but does not constitute a guarantee or warranty that payment will be provided. Wound care professionals are responsible for case-by case assessment, documentation, and justification of medical necessity.
Objectives Summarize wound care reimbursement changes over the past 50 years Explain how the Triple Aim began shifting focus from volume-based care to value-based care Relate the importance of the new Quality Payment Program for physicians Describe successful real-life wound care case management programs
Wound Care Reimbursement 1968-1992
Major Wound Care Providers Received Volume-Based Medicare Payment Hospitals Physician Offices Home Health Agencies (HHA) Nursing Homes
Hospital Volume-Based Payment System Costs Increased Out of Control Diagnosis Related Group (DRG) Payment System
New Sites of Care Developed After Implementation of DRG Payment System Long Term Acute Care Hospitals (LTCHs) Skilled Nursing Facilities (SNFs) Provider-Based Outpatient Wound Care Departments (PBDs) Home Health Agencies (HHAs): providing skilled care
Local Medical Review Policies (LMRPs) Physicians 50 Medicare contractors called Carriers Hospitals, HHAs, and Nursing Homes 50 Medicare contractors called Fiscal Intermediaries Quarterly Paper Policy Update Pages: Only Mailed to People Who Requested Them!
Wound Care Reimbursement 1993-2018
12 Medicare Part A and B Jurisdictions 7 Medicare Administrative Contractors (MACs)
4 Home Health and Hospice Jurisdictions 3 MACs
4 Durable Medical Equipment (DME) Supplier Jurisdictions 2 MACs
Surgical Dressings Not Always Paid When Used by Patients at Home 1993
Pertinent Local Coverage Determinations (LCDs) and Articles Available on Internet Today Cellular and/or Tissue-Based Products (CTPs) for skin wounds Compression Debridement Hyperbaric Oxygen Negative Pressure Wound Therapy ( both DME and Disposable) Surgical Dressings Wound Care
Balanced Budget Act of 1997 Fee-for-Service (FFS) Payment Systems Prospective Payment Systems (PPS) Exception: Medicare Physician Fee Schedule Based on Economic Growth in Country
2000: PPS Implemented LTCHs: LTCH DRGs SNFs: Resource Utilization Groups (RUGs) HHAs: Home Health Resource Groups (HHRGs) PBDs: Ambulatory Payment Classification (APC) Groups
Hospital Diagnosis Related Groups (DRG) Admissions Skilled Nursing Facility Resource Utilization Groups (RUG) Daily Payment Rates for Resources Hospital Based Outpatient Wound Care Provider-Based Department Outpatient Prospective Payment System (OPPS) Visits and Procedures
Physician and Qualified Healthcare Professional (QHP) Physician Fee Schedule (MPFS) Services and Procedures Home Health Agency Home Health Resource Groups (HHRG) 60 Day Episodes of Care for Resources Durable Medical Equipment (DME) Supplier DME Fee Schedule Supplies and Equipment
Unintended Consequences of PPS Patients moved to various sites of care Services and tests duplicated Services, procedures, products selected based on reimbursement Sites of care did not communicate and share patient information Wastage/inconsistent use of products due to lack of care coordination
2010: Institute for Healthcare Improvement Implemented the Triple Aim Image retrieved from: https://www.bing.com/images/search?q=ihi+triple+aim&form=idints
All Sites of Care Now Report Quality to Payers and to the Public
Medicare and Private Payer Incentives for Healthcare Providers and Professionals Work Together Coordinate Patient Care Become Accountable
New Payment and Service Delivery Models Examples: Accountable Care Organizations (ACO) Alternative Payment Model (APM) Bundled Payments for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) Independence at Home Medical Homes
Orders of physicians and QHPs control the majority of health care decisions that drive cost and quality
2017: Quality Payment Program (QPP) for Physicians/QHPs At the end of 2019 the Medicare Physician Fee Schedule (MPFS) annual increases / decreases will cease 2018: 5% maximum increase 2019: 2.5% maximum increase 2020: 0% increase In 2017 QPP began to phase in Merit-Based Incentive Payment System (MIPS) Advanced Alternative Payment Model (APM)
MIPS Performance Scores MIPS Performance Scores 2017 Performance Threshold: 3 points 2018 Performance Threshold: 15 points 2017 2017 Performance Period 2018 2018 Performance Period Quality 6 measures required: one must be an outcome measure No requirements for cross-cutting measures No requirements for national quality domain standards Data submitted via EHR or registry must be reported across all payers 60% 90 days reported for at least 50% of eligible patients 50% 12 months reported for at least 60% of eligible patients
MIPS Performance Scores MIPS Performance Scores 2017 Performance Threshold: 3 points 2018 Performance Threshold: 15 points 2017 2017 Performance Period 2018 2018 Performance Period Advancing Care Information (ACI) Can use either 2014 or 2015 Edition CEHRT 10% bonus if the 2015 Edition CEHRT is used 25% 25% At least 90 days
MIPS Performance Scores MIPS Performance Scores 2017 Performance Threshold: 3 points 2018 Performance Threshold: 15 points 2017 2017 Performance Period 2018 2018 Performance Period Improvement Activities (IAs) 112 activities in the inventory (2 required for small practices; 4 required for all other practices) 15% 15% At least 90 days
MIPS Performance Scores MIPS Performance Scores 2017 Performance Threshold: 3 points 2018 Performance Threshold: 15 points 2017 2017 Performance Period 2018 2018 Performance Period Cost Medicare Spending Per Beneficiary (MSPB) minimum of 35 episodes Total Per-Capita Costs (TPCC) of all Part A and Part B costs minimum of 20 episodes NOTE: CMS will calculate cost measure performance from claims; no action is required from clinicians 0% NA 10% Increases to 30% by 2023 12 months
Advanced Alternative Payment Model (APMs) Performance Scores 2017 2018 Quality 50% 50% Advancing Care Information (ACI) 30% for Medicare Shared Savings Program 30% Improvement Activities 75% for other MIPS APMs 20% for Medicare Shared Savings Program 20% 25% for other MIPS APMs Cost 0% 0%
For QPP, What Should Physicians/QHPs Emphasize? Quality of care and total cost of care based on clinical practice guidelines and published clinical trials and health economic studies Electronic health records to communicate across continuum of care Plans of care based on value rather than volume
Wound Care Examples: QPP Emphasis Evaluation & management rather than procedures Early diagnostics to determine plan of care Vascular procedures to improve blood flow early rather than later Debridement products that patients can use themselves rather than repeated physician debridement Products and procedures based on evidence rather than on reimbursement Focus on total cost of care rather than cost to one site of care
Physicians/QHPs Should Case-Manage Wound Care Across the Continuum of Care Office Home Hospital PBD LTCH HHA SNF
Balance Volume-Based Payment with Value-Based Payment VOLUME VALUE
Have you heard about Care More? Nifty for Fifty
Care More Health Care Delivery Model https://caremore.com/providers/deliverymodel.aspx
Care More Wound Care Case Management Teams Follow Their Patients to Various Sites of Care Physicians Nurse Practitioners Podiatrists Nurses Therapists Pharmacists Dietitians Social Workers Case Managers
Care More s Triple Aim Success Patients are below national average for: Hospital admission rates Hospital average length of stay Bed days Hospital readmission rate Amputation rates
Have You Heard About the ACO That Received a Large Medicare Bonus?
Wound Care Case Management Was One of That ACO s Success Stories Engaged primary care physicians and nurse practitioners Managed wounds from start to finish Achieved excellent wound care outcomes Reduced total cost of care for wound care Received excellent patient satisfaction scores
What Should You Do to Incorporate Value-Based Care into Your Volume-Based Care Models?
Proactively Market Your Wound Care Expertise and Capabilities to Your Organization Identify the leaders of the Triple Aim initiative Meet with the leaders to discuss managing wound care across the continuum of care Create your clinical model and proactively share it with the Triple Aim leaders Revise your business plan and processes as needed
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Will you be chasing, riding, or driving the Triple Aim bus? Triple Aim Clip art provided by Microsoft PowerPoint
Discussion and Questions
Thank you for inviting me to your 4 th Annual Wound Care Conference!