3/6/2015
Reimbursement:
New Game, New Rules
3/6/2015
Becky Sulik, RDN, LD, CDE
Chair, Academy Nutrition Services Payment Committee
10/15/2014
Changing Times in Health Care
Fear
Uncertainty
3
1
3/6/2015
Crisis – Wei Chi
危机
Danger
Opportunity
4
Objectives
•
•
•
•
What’s happening in health care delivery and payment?
What are the new opportunities?
How might I seize these opportunities?
What resources does the Academy provide?
Bottom line: Help you to win the game
5
Changing Times in Health Care
2
3/6/2015
Comparative Health System Performance
Source: the Commonwealth Fund
7
Exhibit 1. International Comparison of Spending
on Health, 1980–2010
Average spending on health
per capita ($US PPP)
Total health expenditures as
percent of GDP
18
$8,000
US
$7,000
16
SWIZ
NETH
$6,000
14
CAN
12
GER
FR
10
AUS
UK
8
JPN
US
NETH
FR
GER
CAN
SWIZ
UK
JPN
AUS
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
2010
2008
2006
2004
2002
2000
1998
1996
1994
1992
1990
1988
1986
0
1984
2
$0
1982
4
$1,000
1980
$2,000
1980
6
2010
$3,000
2008
$4,000
2006
$5,000
Notes: PPP = purchasing power parity; GDP = gross domestic product.
Source: Commonwealth Fund, based on OECD Health Data 2012.
8
Cost per capita vs healthy life years
Best
Organization for Economic Cooperation and Development data, 2000
9
3
3/6/2015
IHI Triple Aim Initiative
• Improve the health of the population served
• Improve the experience of the individual
• Affordability as measured by the total cost of
care
10
IHI Triple Aim Initiative
• Improve the health of the population served
• Improve the experience of the individual
• Affordability as measured by the total cost
of care
11
Report identifies primary care and PCMH as keys to
improving quality of care and reducing costs
12
4
3/6/2015
Shifting Delivery and Payment Models:
Do You Speak the Language?
•Patient-centered medical home (PCMH)
•Accountable Care Organization (ACO)
•Value-based Purchasing (VBP)
•Pay for Performance (P4P)
•Fee-for-Service (FFS)
•Bundled Payments
• Episode bundles
• Patient bundles (Global Payments)
13
Patient-Centered Medical Home
“A PCMH is not a house, hospital or other building and should not be confused with home-health or
home-care. The PCMH is a model for care provided by physician practices that seeks to strengthen
the physician-patient relationship by replacing episodic care based on illnesses and patient
complaints with coordinated care and a long-term healing relationship. Each patient has an ongoing
relationship with a personal physician who leads a team that takes collective responsibility for
patient care. The physician-led care team is responsible for providing all the patient’s health care
needs and, when needed, arranges for appropriate care with other qualified physicians.”
National Committee for Quality Assurance
14
Widespread adoption in both the
public and private sectors:
• More than 90 commercial
insurance plans
• Employers
• 42 state Medicaid programs
• Federal agencies
• Department of Defense
• Hundreds of safety net clinics
• Thousands of small and large
clinical practices
5
3/6/2015
Accountable Care Organization (ACO)
“An ACO is a high-performing, organized system of care
and financing that can provide the full continuum of care
to a specific population over an event, episode, or a
lifetime while assuming accountability for clinical and
financial outcomes”
Bard and Nugent, Accountable Care Organizations, 2011.
17
Who is in the ACO business?
Source: LP Center for Accountable Care Intelligence, 2/7/14
18
6
3/6/2015
Goals of the ACO
• Efficiency
• Quality
• Effectiveness
• Access
• Patient-centeredness
• Equitability
19
Accountable Care Organizations
Source: Leavitt Partner Center for Accountable Care Intelligence, January 29, 2014
20
Growth of ACOs
Source: Leavitt Partner Center for Accountable Care Intelligence, January 29, 2014
21
7
3/6/2015
Accountable Care Organizations
Source: Leavitt Partner Center for Accountable Care Intelligence, January 29, 2014
22
Why is this Important for the RD and RDN?
The RD and RDN are not listed by
profession for ACOs…however:
• Institutions and providers have monetary
incentives to prevent readmissions
• Including the RD and RDN as part of the
healthcare team can be seen as an
investment to prevent readmission and
improve the health and wellbeing of the
patient
23
Bundled Payments
24
8
3/6/2015
ACO Bundled Payment Example
Bypass surgery for patient with uncontrolled Type 2 DM:
Service
Total = $101,500
Fee-for-Service
Service
Overall budget =
$89,300
ACO Bundled
Payment
(Savings of
$12,200)
Hospital Care
$47,500
Hospital Care
$61,000
Surgeon Fee
$15,000
Physician Fee
$13,000
Fee for
uncontrolled DM
$12,000 (hospital)
$2,000 (physician)
Potential avoidable
costs
$15,300
Readmission for
vein infection
$25,000
If readmission
avoided, hospital
paid additional
$12,800
25
Capitation vs Comprehensive Care Payment
26
27
9
3/6/2015
The Good News…
Focus on Prevention and Primary Care
Rescue Street
28
What does it mean to providers?
• Good & bad
• Constant change & uncertainty
• Redefines “success”
• Potential for radical shifts in
underlying financial incentives
• Not just public payers, but
private/commercial payers as well
3/6/2015
Opportunity Ahead:
Fee-for-Service
Medicare:
• MNT and DSMT
• Annual Wellness Visit
• Intensive Behavioral Therapy
for Obesity
• Waived co-pays and
deductibles
Includes Medical Nutrition
Therapy
• Telehealth
3/6/2015
10
3/6/2015
Opportunity Ahead:
Fee-for-Service
Private Market
• Preventive services
• Waived co-pays and
deductibles for preventive
services
• Healthier Generation
Benefit
3/6/2015
Healthy diet counseling
The USPSTF recommends intensive behavioral dietary counseling for adult
patients with hyperlipidemia and other known risk factors for cardiovascular and
diet-related chronic disease. Intensive counseling can be delivered by primary
care clinicians or by referral to other specialists, such as nutritionists or
dietitians.
Grade B
Obesity screening and counseling: adults
The USPSTF recommends that clinicians screen all adult patients for obesity and offer
intensive counseling and behavioral interventions to promote sustained weight loss for
obese adults.
Grade B
Obesity screening and counseling: children
The USPSTF recommends that clinicians screen children aged 6 years and older for
obesity and offer them or refer them to comprehensive, intensive behavioral interventions
to promote improvement in weight status.
Grade B
32
Opportunities Ahead: Bundled Payments
• Medicare ACOs
• PCMHs
• ACO/PCMH Pilot
Programs
• Private ACOs
http://innovation.cms.gov/initiatives/map/index.html
33
11
3/6/2015
Opportunities Ahead: Bundled Payments
• Who is establishing ACOs in your
community?
• Identify key leaders and decision makers
(Director of Managed Care, Case Manager,
MDs, CNPs, etc.)
• Arrange a meeting to discuss
opportunities
• Provide evidence for the
benefits that an RD or RDN
can bring to ACO target
population
34
Winning the Game
• PMPM payments can help cover the RD or RDN
salary
• How do you positively impact utilization and
cost?
• RDs and RDNs can enhance quality outcomes
bonus payments for systems/practices
• Shift focus of provider relationships
• Produce the best outcomes
35
Winning the Game
Rethink the Value Proposition
• Free up PCP time
• Lower cost provider
• Help the system/PCP earn bonus payments
• Produce the best outcomes to
become the provider/system of
choice
• Reduce readmissions
• Enhance patient/customer
satisfaction
36
12
3/6/2015
Winning the Game
Rethink Your Role
•
•
•
•
•
•
•
•
•
•
•
Collaboration vs. referrals
Contract/employment business models
Care coordinator/case manager
Transitions of care
Population health management
Quality improvement teams (leader)
Self-management training
Group medical appointments
Employee wellness programs
Health coach
Enhanced access
37
Winning the Game
Rethink Your Message
•
•
•
•
•
•
•
•
•
•
•
•
•
Think beyond FFS
Focus on high cost populations
Offer pilot projects
Focus on quality measures
PCMH – use protocols to drive RD and RDN referrals
Target case managers with insurance companies
Enhanced access
Coordinated care
Increased safety
Reduced readmissions
Increased efficiency
Self care management
Patient satisfaction
38
Winning the Game
Build Your Skill Set
•
•
•
•
•
•
•
•
•
•
Learn today’s language of healthcare
New assessment skills (BP, BS, AWV)
Informatics
Outcomes data collection
Motivational interviewing
Team work
Business
Marketing/communications
Leadership
Persistence
39
13
3/6/2015
PCMH: Case Example
Mary Smith, MS, RDN, has been working with several large
physician groups in the Denver, CO area providing MNT and
more recently, the Intensive Behavior Therapy (IBT) for Obesity
Benefit. She recently heard about PCMH demonstration
projects and is interested in trying to get involved with one of
these practices. Although Mary has worked in the fee-forservice arena for several years, she understands some of the
downsides, such as, she does not get paid if a patient does not
show, and receives little or no payment for non-office visit
follow-up contact by phone or HIPAA-certified email
communication.
Case Study Example:
• Mary perused the CMS Innovation Center website and
targets a practice she has had contact with in the past
to approach to provide care management services for
their patients.
• She pulls together her marketing materials from the
Academy’s CPCI toolkit and develops her plan.
• Practice X is a large, multi-physician practice with a
highly complex patient population.
Case Study Example:
Mary proposes bundled care management services that
include:
1) Through the practice’s EHR, develop a list of patients to
proactively contact for preventive care for their
diabetes, hypertension, and hyperlipidemia
2) Engage patients (and families) with type 2 diabetes,
hypertension, hyperlipidemia, or deemed “high user” by
the practice, in developing an individualized care plan.
3) Develop weekly follow-up care plans for each patient.
These will be conducted either by phone or via the
practice’s patient portal at Mary’s home office.
14
3/6/2015
Case Study Example:
4) Provide diabetes group visits: 1-2 group visits each
month (1 hour group visit plus 1 hour prep time)
5) Report on the quality measures for diabetes,
hypertension, and hyperlipidemia for each patient
6) Participate in the bi-monthly practice improvement
team meetings
Case Study Example:
• Mary estimates that she will spend approximately
20 hours each week doing the above activities.
• She develops a contract that reflects her hourly
cost for these “bundled” services and presents it to
the physicians and office manager.
• She also asks for a yearly contract to be
renegotiated at the end of each year
•
For year three, she shares in a percentage of any
“shared savings” that the practice receives.
Case Study Example:
Mary signs the contract with the practice and
begins her work as part of an integrated primary
care team!
15
3/6/2015
Academy Resources
46
Academy Resources
www.eatrightpro.org/resources/practice/
getting-paid
www.eatrightpro.org/resources/practice/
getting-paid-in-the-future
Fall 2013 HOD Meeting Backgrounder
Affiliate Public Policy Panel
Dietetic Practice Groups
47
Academy Resources
www.eatrightpro.org/resources/practice/
getting-paid
www.eatrightpro.org/resources/practice/
getting-paid-in-the-future
16
3/6/2015
Questions?
“Why not go out on a limb?
Isn't that where the fruit is?“
-- Frank Scully, American journalist
50
17