KEYNOTE ADDRESS – TENNESSEE SLEEP SOCIETY 2013

1. KEYNOTE ADDRESS – TENNESSEE SLEEP SOCIETY 2013 Moving Forward In Challenging Times: The Future of Sleep Medicine Amy J. Aronsky, DO, FAASM

2. Objectives • Provide An Update on the Most Current Governmental Issues Impacting Health Care Providers • Understand the Effect of Quality, Cost, Access & Efficiency on New Health Care Models • Discuss Emerging Clinical & Business Trends in Sleep Medicine • Anticipate Future Paradigms of Care Delivery for Sleep Medicine

3. Disclosures • Relative Value Scale Update Committee (RUC) • American Academy of Sleep Medicine (AASM) Primary Advisor • Relativity Assessment Workgroup (RAW) • Current Procedure Terminology (CPT) • AASM Primary Advisor • AASM Board of Directors • Finance Committee • Episode of Care Grouper Project • Centers for Medicare & Medicaid Services (CMS)

4. Growth in Medicare Utilization

5. Medicare Beneficiaries by year

6. Washington Update • 15th Year Under SGR • Recent SGR Patch Prevented 26.5% Cut • Medicare Sustainable Growth Rate (SGR) • CMS method to control spending for physicians • Ensures the yearly increase in Medicare spending per beneficiary does not exceed growth in GDP • “Doc Fix” • CMS fee schedule adjusted to meet targeted SGR • Attempts to Repeal SGR

7. Washington Update – CMS Initiatives • Improved Patient Care • Safety • Quality • Outcomes measurements • Reduce Cost • Reduce unnecessary & unjustified medical cost • Reduce administrative cost through process simplification • Improve Population Health • Improve chronic care management • Improve community health status

8. Washington Update – CMS Initiatives • Affordable Care Act Implemented – 2014 • 32 million people enter health care pool • State Health Care Exchanges • How will the influx affect sleep specialists? • Shift From Traditional Fee-for-Service Models • Special Consideration for “Bundling” of Services • Emphasis on Value vs. Volume

9. Washington Update – CMS Initiatives • Development of New Health Care Delivery Models • Accountable Care Organizations (ACO) • Patient Centered Medical Home (PCMH) • Strethens the patient/provider relationship • Long-term quality care • Systems based approach to quality & safety • Primary care as Principal Provider • Sleep center as Neighbor Provider • DME

10. Washington Update – CMS Initiatives PCMH • Group Health Cooperative of Puget Sound • 29% ↓ in ER visits, 11% ↓ in admissions • Community Care of North Carolina • 40% ↓ in asthma hospitalizations & 16% ↓ ER visits • Health Partners Medical Group Best Care PCMH • 39% ↓ in ER visits, 24% ↓ admissions

11. Washington Update – Physician Based Initiatives • Payment Should Include Quality & Efficiency • Transitions Should Include Physician Choices & Incremental Change • Reward System for Health Savings • Plan Should Encourage Systems of Care, But Preserve Physician Choice • Hardship Exemptions Available

12. Health Care Value = Quality/Cost + Access + Efficiency

14. Quality - PQRS • Physician Quality Reporting System (PQRS) • Any Health Care Provider With An NPI Number Must Participate • 1 Measurement Group Per Provider Per Year • Report Data to CMS • Claims-Based • Electronic Health Record (EHR) • CMS-Approved Registry • In Addition to Other Quality Incentives

15. Quality - PQRS • 2013 - Report 20 Patients Total • 11 traditional Medicare Part B patients • 9 patients with other insurances or • 80% of Total Eligible Medicare B Patients • Group Reporting Option

16. CMS. 2011 Reporting Experience, Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive program , 4/09/2013

17. Quality - PQRS PFS = Physician Fee Schedule

18. Quality - PQRS • Obstructive Sleep Apnea Measurement Group • Severity Assessment • Documented OSA by AHI or RDI • Positive Airway Pressure Therapy Prescribed • If AHI or RDI > 15 • Adherence to Positive Airway Pressure Therapy • Objectively measured adherence to PAP • Assessment of Sleep Symptoms • Assessment of sleep symptoms documented, including presence or absence of snoring & daytime sleepiness • 2 or 3 additional measures for CY 2014 proposed

20. Quality – Physician Compare Website • Reports Location & Specialty Information of Each Physician • Reports Physician Participation in Quality Incentive Programs • CY 2014 & 2015 • Report individual physician performance data • Report group performance data • Report ACO data • www.medicare.gov/physiciancompare

21. Quality – Value Based Modifier • “Pay for Value” • Based Upon PQRS & Cost Measures • Calculate Performance Score • Quality Tiering Compares Group Performance vs. National Mean • Implemented for Groups > 100 – 2015 • Implemented for Individuals – 2017 • 1% Incentive or 1% Penalty • Budget Neutral

22. Quality – Physician Feedback Program • Physician Quality & Resource Use Reports • Comparative Performance Information • Attempt to Improve Quality Care Delivered • 2013 – CMS Provides Group Reports > 25 Providers for Comparison • Reimbursement Reward for Value Rather Than Volume

23. Other Quality Measures • Electronic Health Record (EHR) • Electronic Prescribing Incentive Program (eRx) • Meaningful Use (MU) • Demonstration EHR is being used “meaningfully” • Stages 1 &2 • 14 required core objectives • 5 additional menu objectives • 6 total clinical quality measures

24. Cost – CMS Proposed Rule CY 2014 • Reduced Practice Expense Most Specialties 10% Proposed for CY 2014 • CMS Accepting 60 – 70% of RUC Recommended Values • Practice Expense Cuts for Sleep Medicine Totaling 20% Reduction Over 3 Years

25. 2013 Conversion Factor = $34.0230

27. Access - Telemedicine • E/M Codes Use Telemedicine Modifier • -GT • Via live interaction • -GC • Via asynchronous technology • Same reimbursement as E/M • Expansion of Rural Health Professional Shortage Area • Utilization for Sleep Medicine?

28. Efficiency – New E/M Codes • Transition Care Management CPT Codes - 99495 & 99496 • Communication with the patient or caregiver within 2 business days of discharge (or documentation of 2 unsuccessful attempts) • Via phone, email or in-person • Face-to-face visit required • Medical decision making is at least moderate or high • Medication reconciliation & management documented no later than time of face-to-face visit

29. Efficiency – New E/M Codes • Transition Care Management CPT Codes • Transition Care From • Inpatient hospital setting or ER • Observation status in a hospital • Skilled nursing facility • Rehabilitation hospital • Transition Care To • Home • Domiciliary • Rest home • Assisted living facility

31. Efficiency – New E/M Codes • Complex Care Coordination Services Codes • 99487 • 1st hour clinical staff time spent coordinating patient care per calendar month • Directed by physician or other qualified health care professional • No face-to-face physician or other qualified health care professional visit required • 1.00 wRVU • 99488 • One face-to-face visit per calendar month required • 2.50 wRVU • 99489 • Additional 30 minute increments over initial hour of care coordination • 0.5 wRVU

32. Efficiency – New E/M Codes • Complex Care Coordination Services Codes • Proposed CMS Payment CY 2015 • Patients Have At Least 2 Chronic Conditions That Are Expected to Last At Least 12 Months • The Chronic Conditions Place The Patient At Risk for Death, Acute Exacerbation, Decompensation or Functional Decline • The Patient Must Receive Annual Wellness Visit Within Past 12 Months By Same Health Care Provider

33. Original Sleep Laboratory Emphasis On In-Lab Testing Some Consultations & Occasional Follow-Up Care

34. Sleep Center Comprehensive Care

36. The Future of Sleep Medicine • Shift From Sleep Testing Paradigm to Longitudinal Care • Partnerships with primary care • Satellite offices with other specialties • Emphasis on other co-morbid conditions • Hypertension • Diabetes • DME Affiliation • Improved quality of care • Adherence measurements

37. The Future of Sleep Medicine • Emphasis on Out of Center Sleep Testing • AASM members report fewer than 25% of sleep testing is OCST (2011) • Greater amount of OCST in the east & west • Increased demands for OCST • Prior authorizations required for nearly all commercial payers for in-lab testing • Prior authorizations required for many commercial payers for OCST • Redefining personnel roles • RPSGT/RST • Other personnel • Physician peer-to-peer reviews

38. The Future of Sleep Medicine

39. The Future of Sleep Medicine • Emphasis on Out of Center Sleep Testing • Primary care physicians ordering more OCST • Some insurances require OCST to be interpreted remotely by contracted companies • Data provided to physicians

40. The Future of Sleep Medicine • Role of the Sleep Specialist? • Become an OCST interpreting physician for your center for some commercial payers • Become an OCST interpreting physician for other centers through some commercial payers • Achieve AASM OCST accreditation • Consider an AASM-Approved OCST Provider (AOCST) • “Point: Should Board Certification Be Required for Sleep Test Interpretation? Yes", Chest. 2013; 144(1):9-11 • There will always be a need for sleep professionals

42. The Future of Sleep Medicine • AASM Preauthorization Survey – 2013 • Preliminary Data Trends • Good response from Tennessee AASM members • Aetna’s authorization process is most time-consuming • CIGNA rejects in-lab testing most often • Appeals approved more than 50% of the time • Final Data Report – Mid-October 2013 • www.aasmnet.org

43. The Future of Sleep Medicine • Create of New Sleep Medicine CPT Codes • Split night polysomnography • Adaptive servoventilation titration • Bundled code for PAP management • CSF hypocretin/orexin measurement • New technologies • Define Outcome Measures for Sleep Disorders • AASM workgroups • Application to reimbursement

44. The Future of Sleep Medicine • Discuss Testing With Commercial Payers • Streamline insurance authorization process • Appropriate use of OCST • Achieve Widespread Reimbursement for 98503 • Consider Telemedicine Utilization • Maximize Use of Physician Extenders • Redefine Personnel Roles • RPSGT/RST

45. The Future of Sleep Medicine • Reduction in Number Sleep Medicine Fellowship Training Programs • Reduction in Available NIH Grants • Sleep Medicine Coding is Aggressively Audited by CMS & Commercial Payers

46. Conclusions • Health Care is Rapidly Changing With the Implementation of the Affordable Care Act • There is a Shift From Volume to Value Care • There Are New Opportunities for Sleep Medicine to Reinvent Itself • Sleep Medicine Will Continue to be a Viable Specialty & Health Care Professionals Will Deliver Excellent Care in Challenging Times