PHYSICIAN PAYMENT: How AAP Advocacy is Working for You

1. PHYSICIAN PAYMENT: How AAP Advocacy is Working for You April 28-30, 20132013 Legislative ConferenceWashington, D.C.

2. We have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this CME activity.

3. Panel Lynda Young, MD FAAP, COFGA Moderator Anne Edwards, MD FAAP, COSGA Chair Medicaid Payment Advocacy Lou Terranova, MHA, AAP Department of Practice Private Payer Advocacy Amy Gibson, RN, MS, Chief Operating Officer, Patient Centered Primary Care Collaborative (PCPCC) Payment Reform and the Medical Home

4. Context: ACA Implementation • States are implementing the ACA – 2010 was 3 years ago! • States have made some decisions on exchanges for 2014 • States have chosen an essential health benefit (EHB) base-benchmark package • States are debating whether to expand Medicaid • States are implementing the Medicaid primary care payment increase

5. AAP Advocacy on Medicaid Payment • The Medicaid-to-Medicarephysician payment ratio has traditionally been low. In 2011, for (a) all pediatric services and (b) E&M services only, the ration was 70% and 64%. • The Medicaid-to-private payer ratio is at an estimated average of 49% for all pediatric services and 53% for E&M services only, nationally • (AAP Pediatric Medical Cost Model)

6. Pediatricians and Medicaid • Only 53% of physicians (not just pediatricians) are willing to see new Medicaid patients. • New and traditional Medicaid enrollees are in danger of having a Medicaid insurance card that provides no real access to care • AAP study shows 3 percentage point increase in pediatric practice case mix with 22 percentage point increase in Medicaid/CHIP enrollment.

7. ACA’s Medicaid Payment Increase • Primary care physicians, including pediatricians, will receive increased Medicaid payments to 100% of Medicare payment rates for calendar years 2013-2014 • Increased Medicaid rates apply to E/M and vaccine administration codes • Funded by the federal government • Final rule on the payment increase was released in November 2012, including specific state actions needed for implementation • A number of decisions regarding implementation of the payment increase were left to states • States had until March 31, 2013 to submit complete State Plan Amendments (SPAs) to HHS to implement the increase

8. ACA’s Medicaid Payment Increase Have you signed up? www.aap.org/medicaidpaymentincrease

9. State Implementation Issues • States releasing self-attestation forms • Cutoff dates for retroactivity • Cross-walking payment for immunization services • Geographic and site-of-service adjustment • Lump sum payment vs. normal billing • Ensuring non-physician clinicians are enrolled

10. Medicaid Matters: Advocate for increased access to care for them

12. PPA Vision and Opportunities • Advocate for coverage for pediatric services and payment for primary care and specialty pediatricians • Engage payer support of the pediatric medical home model and Bright Futures Guidelines for preventive care • Work with key groups within the Academy on strategies to address new payment models by private payers • Develop education programs and tools to strengthen member's  negotiation & contracting with payers  • Strengthen chapter pediatric councils in engaging carriers on pediatric issues

13. Headlines from AAP News articles on AAP Private Payer Advocacy activities CIGNA to increase vaccine payments AAP helps physicians get paid appropriately for PCV13 vaccine Pediatric councils help secure coverage for developmental screening Humana to pay for the new telephone care CPT codes AAP efforts pay off: UHC to update vaccine fee schedule Aetna, CIGNA & UHC pay for both preventive E/M & problem oriented E/M services Physicians see results after filing disputes against insurers Aetna to pay for claims appended with modifier 25 AAP making impact on UnitedHealthcare pay-for-performance programs

14. New Challenges and Opportunities • ACA Implementation * Coverage and Payment for Preventive Care Services * Grandfather status of plans * Insurance Exchanges • New Payment and Delivery Systems * ACOs, Integrated Delivery Systems * Global fees, shared savings/risk, etc.

15. AAP Private Payer Advocacy (PPA) is a Multi-level approach • National/Regional Dialogue with payers on AAP policy and specific carrier issues; Member Center PPA resources; Assistance to Chapters, Committees, Sections,Councils, and members • Chapters Pediatric Councils meet with payers on regional issues: Hassle Factor Form Reports to identify member concerns • Members Technical assistance by AAP Coding Hotline staff; Appeal Letter Templates; Resources on coding, contracting, appeals, etc. Members can report issues on the AAP Hassle Factor Form on MyAAP, private payer advocacy page

16. Private Payer Advocacy Advisory Committee (PPAAC) PPAAC is a sub-Committee of the AAP Committee on Child Health Financing (COCHF) Charge: Advise the AAP and its leadership on a payment strategy, including specific goals and action steps, to improve pediatrician’s economic and organizational position in the private marketplace and collaborate with other AAP Committees, Sections, Councils, and Task Forces in advancing the payment and benefit coverage issues germane to their constituencies

17. AAP Activities to Sustain Payer Relationships • Meetings with national carriers • Letters to carriers on specific issues • Pediatric representation on carrier physician advisory boards • Review process for WellPoint and UHC clinical policies to incorporate pediatric perspective • Chapter pediatric councils to meet with payers on regional issues

18. AAP Endorsed Principles on Benefit Plan Coverage and Payment The AAP approved a listing of benefit plan coverage and payment principles to serve as an advocacy agenda for discussions with payers.  The principles represent existing AAP policy and strategic plan concepts. Available at: http://www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Documents/Private/PaymentPrinciples.pdf

19. AAP Chapter Pediatric Council • A forum for chapters to meet with payers to discuss issues impacting access, quality, cost, coverage and payment • A means to address payer policies, covered services and administrative practices affecting pediatric services • A collaborative effort to discuss ideas for resolving issues between pediatricians and payers • It is not a means to discuss or negotiate fees, payment, or any collective action by pediatricians

20. Resources for Chapter Pediatric Council Development • Pediatric Council Guidebook (featuring tips and strategies of successful pediatric councils) • Pediatric Council E-mail List • Pediatric Council Web Site on the AAP Member Center • Powerpoint presentation templates and talking points to use with payers • Hassle Factor Form Reports provided quarterly or as needed to chapter pediatric councils

21. Resources for AAP Members • Private Payer Advocacy Web Site on the MyAAPMember Center at http://www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Pages/Private-Payer-Advocacy.aspx • Powerpoint presentation templates and talking points to use with payers • Hassle Factor Form Reports to report payer issues to PPAAC and pediatric councils • Template letters and appeal letters to send to payers • Managed Care contract resources

22. Enhance PPA Communications to Chapters and Members • Monthly PPA updates to AAP Chapters • PPA articles in AAP News, AAP OnCall, Chapter Connections • PPA link on the MyAAPMember Center • Promoting the Value of Pediatrics

23. AAP Hassle Factor Form • AAP Members can report insurance administrative and claims processing concerns. • The information provided will be used to assist the AAP and chapters in identifying trends and facilitating public and private sector advocacy related to health plans. • Members can report issues on the AAP Hassle Factor Form at http://www.aap.org/en-us/professional-resources/practice-support/financing-and-payment/Pages/Hassle-Factor-Form-Concerns-with-Payers.aspx

24. Contact Information National AAP: 800/433-9016 Pediatric councils, coverage/contract issues: Lou Terranova (7633) or at lterranova@aap.org Medicaid: Dan Walter (4086) or dwalter@aap.org) Coding: aapcodinghotline@aap.org Immunizations: Elizabeth Sobczyk (4271) or at esobczyk@aap.org

25. Payment Reform and the Medical Home Amy Gibson, MS, RN Chief Operating Officer, PCPCC

26. Transformation requires…

27. Primary care of the future . . . Data Warehousing & Mining Patient and Provider Portals Family Supports Specialty Care Pharmacy Home Health • Patient/Family • Medical Home • Team-based • Coordinated • Comprehensive • Accessible Long Term Care Acute Care Community Health Schools Palliative Care Health Plans Data Registries & Decision Support EHR Connectivity & Interoperability

28. A Change in Paradigm

29. PCMH and Accountable Care: Two Sides of the Same Coin Accountable Care PCMH Hospitals PCMH Shared Services Care Coordination Care Managers PCMH Specialists PCMH Public Health PCMH Health IT Infrastructure

31. Private Sector Payment Reform • Only 11 percent of payments create incentives for providers to meet quality standards, improve quality, or reduce waste. • 57% are “at -risk” arrangements -- bundled payment, capitation (as well as partial-capitation or condition-specific capitation), and shared-risk payment arrangements. • 35% of non-FFS payments include quality is a factor

32. Transparency: Health Plans • 98% of plans offer/support a cost calculator • 77% of hospital choice tools have integrated cost calculators • 77% of physician choice tools have integrated cost calculators • 86% of plans report benefit design details (copays, cost sharing, and coverage exceptions) • Only 2% of total enrollment use these tools Source: National Scorecard on Payment Reform, 2013

33. What does the data tell us about the PCMH?

34. New PCPCC Publication • Provides nationwide results from 34 recent peer reviewed and industry reports • health care costs • acute care services • quality of care • Provides additional information on 23 case studies outlining specific features of a PCMH

37. Overview of Commercial Health Plan Medical Home Activity AK WA ME MT ND VT NH MN OR NY MA WI CT ID SD RI MI WY NJ PA IA NE OH DE NV IL IN MD WV UT VA CO MO KS CA KY NC TN OK SC AR AZ NM GA AL MS LA TX HI FL Multipayer pilot discussions/activity (30 states) Identified pilot activity (49 states) No identified pilot activity (1 state) Source: Patient Centered Primary Care Collaborative, updated Jan 2012.

38. Examples of Industry Investment

39. Medicaid multipayer activity/involvement (18 states) States making payments for PCMH (27 states) Significant activity for Medicaid/CHIP PCMH advancement (15 states) Overview of Medicaid Medical Home Activity 42 State Medicaid/CHIP Programs Planning/Implementing PCMH27 Making Medical Home Payments, 18 Involved in Multipayer Pilots AK WA ME ND VT MT NH MN OR NY MA WI CT ID RI SD MI WY NJ PA IA OH NE DE IN NV IL MD WV UT VA CO MO KS CA KY NC TN OK SC AR AZ NM GA AL MS HI LA TX FL Source: National Academy for State Health Policy State Scan, October 2012, http://www.nashp.org/med-home-map.

40. Overview of CMS Innovation Center PCMH Initiatives

41. Role of The Collaborative (PCPCC) • Lead from the front • Challenge the status quo • Drive the marketplace • Disseminate timely information • Provide networking & educational opportunities

42. Why the Medical Home Works: A Framework Patient-Centered Feature Definition Sample Strategies Potential Impacts Patients are more likely to seek the right care, in the right place, and at the right time • Dedicated staff help patients navigate system and create care plans • Focus on strong, trusting relationships with physicians & care team, open communication about decisions and health status, compassionate/culturally sensitive care Supports patients and families to manage & organize their care and participate as fully informed partners in health system transformation at the practice, community, &policy levels Comprehensive A team of care providers is wholly accountable for patient’s physical and mental health care needs – includes prevention and wellness, acute care, chronic care Patients are less likely to seek care from the emergency room or hospital, and delay or leave conditions untreated • Care team focuses on ‘whole person’ and population health • Primary care could co-locate with behavioral, oral, vision, OB/GYN, pharmacy, etc • Special attention paid to chronic disease and complex patients Coordinated Ensures care is organized across all elements of broader health care system, including specialty care, hospitals, home health care, community services & supports, & public health Providers are less likely to order duplicate tests, labs, or procedures • Care is documented and communicated effectively across providers and institutions, including patients, primary care, specialists, hospitals, home health, etc. • Communication and connectedness is enhanced by health information technology Better management of chronic diseases and other illness improves health outcomes Accessible Delivers consumer-friendly services with shorter wait-times, extended hours, 24/7 electronic or telephone access, and strong communication through health IT innovations • Implement efficient appointment systems to offer same-day or 24/7 access to care team • Use of e-communications and telemedicine to provide alternatives for face-to-face visits and allow for after hours care Focus on wellness and prevention reduces incidence / severity of chronic disease and illness Committed to quality and safety Demonstrates commitment to quality improvement through use of health IT and other tools to ensure patients and families make informed decisions • EHRs, clinical decision support, medication management to improve treatment & diagnosis. • Establish quality improvement goals; use data to monitor & report about patient populations and outcomes Lower use of ER & avoidable hospital, tests procedures & appropriate use of medicine = $ savings

43. Contact: Amy Gibson, MS, RN Chief Operating Officer agibson@pcpcc.net www.pcpcc.net