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Health Care Reform and Reimbursement. Laurie Alban Havens, Director, Private Health Plans & Medicaid Advocacy ASHA. Overview. Affordable Care Act Future of Health Care Reimbursement Medicaid Managed Care State Advocacy. ACA Overview.

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health care reform and reimbursement

Health Care Reform and Reimbursement

Laurie Alban Havens, Director, Private Health Plans & Medicaid Advocacy


  • Affordable Care Act
  • Future of Health Care Reimbursement
  • Medicaid Managed Care
  • State Advocacy
aca overview
ACA Overview
  • Patient Protection and Affordable Care Act of 2010 (ACA)
  • Broad focus areas
    • improving health care quality
      • shift towards measuring outcomes and paying for quality care, rather than paying for services and procedures, regardless of outcome
      • Report to Congress: National Strategy for Quality Improvement in Health Care (U.S. Department of Health and Human Services, 2011)
        • Goals: eliminating preventable health care acquired conditions, creating a more coordinated, less fragmented care delivery system, and using patient-reported information, including personal goals and desired outcomes
      • PQRS
aca overview1
ACA Overview
  • Focus areas
    • better coordinating care
      • Increase in HMO–like programs with set limits on the amount of money for episodes of care
      • Bundled payments
      • ACOs
    • reducing fraud and abuse
      • Recovery Audit Contractors (RACs)
      • State Medicaid Fraud Control Units – federal funds for data mining
      • Screening potential Medicare and Medicaid providers and suppliers
aca overview2
ACA Overview
  • Focus areas
    • providing more community-based care
      • address long-term care services to help guarantee that individuals who need such care receive it and should find ways to help make such care available not only in institutions but also in the community (ACA, 2010, §2406(b)1-2)
      • Community first choice option
        • offers incentives through Medicaid to encourage states to provide programs that help seniors stay at home rather than enter an institution
      • Money Follows the Person (MFP) extended for additional 5 years
        • help states develop demonstration projects that allow them to make changes to long-term care strategies and help people avoid institutions altogether or transition from institutions to their community.
  • Essential Health Benefits
  • Exchanges
  • ACOs
  • Bundled payments
  • Preventive services
  • Non discrimination for providers
  • Center for Medicare and Medicaid Innovation (CMMI)
  • Other
essential health benefits
Essential Health Benefits
  • 10 categories that must be included in policies offered in Exchanges and also by Medicaid
rehabilitation and habilitation
Rehabilitation and Habilitation
  • ASHA participated on a statutory working group formed by the NAIC to develop plain language definitions of insurance and medical terms and a standard summary of benefits form
  • Released in proposed rule, to see the documents, go to

  • “Rehabilitation” was one term mandated in the law to be defined in the glossary
  • Final definition
    • "Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt, or disabled. These services may include physical and occupational therapy, speech-language pathology, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings."
  • ASHA recommended that “habilitation” also be defined
  • Final definition
    • "Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn't walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of inpatient and/or outpatient settings."
why this matters
Why This Matters
  • 17% of SLPs in health care provide services to infants and toddlers
  • 13% to preschoolers
  • 11% to school-age children
  • 27% report providing Early Intervention services (defined as those provided under direction of IFSP)
  • Overall, children with autism accounted for 20% of SLPs’ caseloads in 2011, up considerably from 6% in 2009

Source: 2011 ASHA SLP Health Care Survey

why this matters1
Why This Matters
  • “During 2010, did you receive denials from health plans for SLP services for children because the plans claimed that public schools provided those services?”
    • Yes 25%
    • No 49%
    • Don’t know 26%
  • “How did the number of denials in 2010 compare with the number in 2009?”
    • Fewer in 2010 2%
    • No change 19%
    • More in 2010 20%
    • Don’t know 58%

Source: 2011 ASHA SLP Health Care Survey

  • Organized marketplace for the purchase of health insurance
  • May be online, accessible by phone, or a physical site
  • People can compare health insurance plans, enroll in a plan, find out about available subsidies, and obtain customer support
  • Initially offered to individuals and small employers; after 2017, states have the option to expand operation to include larger employers.
exchanges what audiologists and slps need to do
Exchanges – What Audiologists and SLPs Need to Do
  • Find out who is sponsoring/offering exchanges (can be done through health insurance commission for the state)
  • Speak to exchange leadership to get program details
  • Advocate for inclusions of SLP/A in plans
  • Find out provider rates and quality measurements being use to evaluate services.
  • Minnesota – health exchange website

  • Accountable Care Organizations (ACOs) are a method of integrating local group physician practices with other members of the health care system and rewarding them for controlling costs and improving quality.
  • Hospitals, primary care doctors, specialists and possibly even nursing homes and home care agencies would collaborate in an ACO, which would coordinate care and payment for care of participating patients.
  • Some compare the concept to a construction contract, with the ACO having the role of a general contractor and providers that of subcontractors.
  • The theory is that there will be increased communication between providers, leading to better care and less duplication of services, such as laboratory tests, that will reduce overall health care costs.

(Thompson, M. Post-Star; 4-11-2010)


Instead of paying individually for each visit or medical procedure, Medicare or Medicaid would pay a set periodic payment, regardless of the amount of services, to the ACO, which would pass along proportionate payments to participating providers.

  • An ACO may provide rehabilitation services with in-house staff, or contract with rehab provider organizations. An ACO may prefer to contract with a single rehab organization rather than separately with OT, PT, and SLP organizations.
  • Audiology services might be incorporated into rehab contracts, by independent audiology contracts, or through ENT practices that are ACO participants.
  • ASHA submitted comments in response to the proposed ACO regulations issued on April 7, 2011. ASHA urged CMS to require ACOs to:
    • Make speech-language pathology and audiology services accessible to patients. CMS responded that market forces will determine the need for the range of services offered.
    • Allocate an equitable portion of shared savings to speech-language pathologists and audiologists. CMS stated that it does not have legal authority to dictate how shared savings are distributed.
    • Encourage the use of telehealth services provided by audiologists and speech-language pathologists. In response, CMS announced that it is preparing a separate incentive package, not limited to ACOs, which includes telehealth services beyond what is currently reimbursed under fee-for-service Medicare.
bundled payments
Bundled Payments

Under a “bundled” payment model, providers receive a single payment for a defined set of services.

bundled payments1
Bundled Payments
  • Bundled payment models disincentivize the use of those providers whose services increase utilization and cost without adding perceived value.
  • Clinicians will be chosen for the “bundle”
    • Produce results efficiently
    • Perform collaboratively
bundled payments2
Bundled Payments

Bundled Payment InitiativeUnder National Health Reform

CMS seeking applications October 2011 – March 2012

  • Model 1: Acute hospital stay only
  • Model 2: Hospital stay + post-acute care associated with the stay
  • Model 3: Post-acute care only
  • Model 4: Inpatient stay including all physician services, etc.
  • Distinct from National Pilot Program by 1/1/13
bundled payments3
Bundled Payments

Bundled Payment Goals

  • Decrease cost of an acute episode and associated post-acute care
  • Foster quality improvement
  • Stimulate development of new evidence-based knowledge
  • Applicant agrees to 2 to 3% discount of inpatient and other payment rates.
preventive services
Preventive Services
  • Expands coverage for many screenings and other preventive services without copays or deductibles
  • Coverage for the highest rated procedures as determined by the US Preventive Services Task Force
non discrimination
  • Section 2706:
    • Insurers shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law.
    • Reimbursement for such services can be based upon quality and other performance measures
non discrimination1
  • Impact on audiology and SLP?
    • As long providers meet licensure or certification standards, they should be allowed to provide treatment
      • Must abide by other rules
      • Agree to accept reimbursement provider by insurer, if a participating provider
  • The Center for Medicare and Medicaid Innovation
    • Established by the Affordable Care Act
  • Mission: better care and better health at reduced costs through improvement. The Center will accomplish these goals by being a constructive and trustworthy partner in identifying, testing, and spreading new models of care and payment. We seek to provide
    • Better health care: by improving all aspects of patient care, including Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity
    • Better health: by encouraging healthier lifestyles and wider use of preventative care.
    • Reduced costs: by promoting preventative medicine, better record keeping, and improved coordination of health care services, as well as by reducing waste, inefficiency, and miscommunication.
  • Projects that impact audiologists and SLPs
    • Support telehealth through model programs and demonstration projects
    • Oversee bundled payment model where the hospital is paid for inpatient stay and controls a specified duration of post-acute care
    • Develop an alternative to the therapy cap for Congress to consider
aca other
ACA - Other
  • Eliminating lifetime dollar limits as of 9/10; annual dollar limits as of 2014
  • Coverage for pre-existing conditions
hitech act
  • Health Information Technology for Economic and Clinical Health (HITECH) Act
    • Part of the American Recovery and Reinvestment Act of 2009
    • Promotes the adoption and meaningful use of health information technology
      • Incentives for providers to adopt EMRs
      • Monies for training centers to help develop and support IT infrastructure
    • Enhances and strengthens HIPAA regulations
slp use of emrs
SLP Use of EMRs
  • “Do you use an electronic medical record system for documenting clinical activities?”
    • Always 42%
    • Sometimes 22%
    • Never 36%

Source: 2011 ASHA SLP Health Care Survey

future of health care reimbursement
Future of Health Care Reimbursement

Speech-language pathologists and audiologists need to be successful in showing the value of their services.




future of health care reimbursement1
Future of Health Care Reimbursement

Speech-language pathologists and audiologists will be increasingly paid for patient outcomes (value-based purchasing) rather than volume of visits, number of sessions, or number of tests.

future of health care reimbursement2
Future of Health Care Reimbursement
  • Medicare’s current fee-for-service payment systems, which pay on the basis of quantity and consumption of resources, do not support this vision for quality health care.
  • Value-based purchasing (VBP) aligns payment more directly to the quality and efficiency of care provided by rewarding providers for their measured performance across the dimensions of quality.
future of health care reimbursement3
Future of Health Care Reimbursement
  • Over the last 20 years, Congress and presidential administrations have moved Medicare from prospective payment systems to value-based health care purchasing initiatives (paying for results) rather than the number of tests or services, regardless of outcomes.
  • The Patient Protection and Affordable Care Act (ACA) sends a strong signal that QUALITYwill be a central driver of health care reform changes.
future of health care reimbursement4
Future of Health Care Reimbursement

$75 million annually appropriated by the ACA for quality measure development

between 2010 and 2014.

future of health care reimbursement5
Future of Health Care Reimbursement

In an environment that rewards value and quality, attention to outcomes measurement and improvement will be essential to the success of organizations across the health care system.

(Sennett, C., MD, PhD. American Health & Drug Benefits; 2010-2011)

future of health care reimbursement6
Future of Health Care Reimbursement

Milliman’s Health Care Reform Briefing contends that “restructuring the payment system can motivate providers to perform, and payers and patients to pay for, only those procedures consistent with the best evidence and the needs of the patient.”

(Cornett, B. S. ASHA; 8/3/2010)

future of health care reimbursement7
Future of Health Care Reimbursement
  • Opportunities for Quality Outcomes Measurement and Reporting
    • Value-based purchasing creates pressure to perform
    • Performance must be quantifiable
    • Development of metrics to measure all facets of health care performance will be a key element of the reform process and is funded by reform legislation
future of health care reimbursement8
Future of Health Care Reimbursement
  • More robust measures of clinical quality and outcomes will emerge, including:
    • Health outcomes and functional status of patients
    • Management and coordination of care across episodes of care and provider settings
    • Care transitions for patients across the continuum of providers, health care settings, and health plans.
future of health care reimbursement9
Future of Health Care Reimbursement
  • Examples of Quality Outcomes Measurement & Reporting
    • Older systems of quality measurement will be expanded
      • Physician Quality Reporting System (PQRS), formerly the Physician Quality Reporting Initiative (PQRI), introduced by CMS.
    • Likely to become a requirement and quality reporting will no longer be an option.
future of health care reimbursement10
Future of Health Care Reimbursement
  • In 2010, private-practice audiologists and speech-language pathologistsenrolled as Medicare providers began to participate in the Medicare Physician Quality Reporting System (PQRS)
  • PQRS is a voluntary program designed to improve the quality of care to Medicare beneficiaries.
    • Private-practice health care professionals who participate in PQRS by reporting on approved quality measures are eligible for a 0.5% incentive payment from 2012-2014.
future of health care reimbursement11
Future of Health Care Reimbursement
  • The final 2012 Medicare Physician Fee Schedule contains five audiology measures and eight speech-language pathology measures.
  • Starting in 2015, eligible providers who do not satisfactorily report on quality measures will be subject to penalty
future of health care reimbursement12
Future of Health Care Reimbursement

In summary, the Congressional Research Service (CRS) prepared a report (2006) for Congress on pay-for-performance in health care, noting:

“Many health care industry leaders and policy makers have joined the call to pay health care providers different amounts based on variation in the quality of their services as determined through their achievement on quality performance measures.”

future of health care reimbursement13
Future of Health Care Reimbursement

The CRS report opens with this:

Pay-for-Performance in Health Care

If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money.

If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.

— Code of Hammurabi, c. 1750 B.C.

bundled payments under national health reform
Bundled Payments Under National Health Reform
  • CMS seeking applications Oct.2011 – March 2012
    • Model 1: Acute hospital stay only
    • Model 2: Hospital stay + post-acute care associated with the stay
    • Model 3: Post-acute care only
    • Model 4: Inpatient stay including all physician services, etc.
useful links on asha s site
Useful Links on ASHA’s Site
  • For general reimbursement information, go to:

  • For Medicare private practice information, go to:

  • For coding information, go to:

  • For the National Correct Coding Initiative (CCI) edits, go to:

medicaid background
Medicaid Background
  • Enacted in 1965 as part of Title XIX of the Social Security Act
  • Partnership program funded jointly between the States and Federal Government
  • Beneficiaries include low-income families and children, pregnant women, the elderly, people with disabilities
federal role
Federal Role
  • Establishes broad guidelines, minimum standards, and qualifications
  • Oversight of the State Medicaid plans
  • Processes plan amendments and waiver requests
  • Ensures program integrity
state role
State Role
  • Administers the program
  • Determines eligibility standards
  • Determines the type, amount, duration, and scope of services
  • Sets payment rates
medicaid services
Medicaid Services
  • Mandatory
  • Optional
  • Early and Periodic Screening, Diagnosis, and Treatment – EPSDT requires that medically necessary services are provided to children under age 21
  • Although speech-language pathology is optional under Medicaid, under EPSDT, States must provide service to children under 21.
  • Medically necessary services must be provided to individuals under 21, even if the service isn’t available to the rest of the State’s population
growth of medicaid managed care
Growth of Medicaid Managed Care
  • June 2009: 71.7% of Medicaid enrollees receiving care through managed care
  • 2014: an additional 16 million people will become Medicaid eligible
innovative medicaid programs
Innovative Medicaid Programs
  • Delivery system models
    • Medical homes
    • Disease/case management
  • Utilization review
  • Quality Improvement
    • Pay-for-performance
    • Surveys and data collection on plan performance
  • Focus on health information technology
pros managed care
Pros – Managed Care
  • Cost saving
  • Improved quality
  • Covers preventive care
  • Innovative payment, delivery system, and quality improvement models
negatives managed care
Negatives- Managed Care
  • Manages cost, but may not manage care
  • Access – specialists may be further away from home
  • Difficulty in obtaining approval for expenses services such as CT scans and some surgeries
  • Difficulty attracting providers because of lower pay
realities medicaid managed care
Realities – Medicaid Managed Care
  • Significant increases in the Medicaid population by 2014
  • Increased push to enroll in managed care
  • Most states have multiple managed care programs
  • Potential for providers to shop around to find a managed care company that demonstrates the best balance of cost/quality/care
medicaid managed care caveats
Medicaid Managed Care Caveats
  • “When managed care performs well, it substantially outperforms fee-for service,” (from Aetna Medicaid head) “But it doesn’t always perform well.”
  • Some states are just beginning to use Medicaid Managed care, e.g. LA and MS
  • Wide variation among plans
developing an effective advocacy plan
Developing an Effective Advocacy Plan
  • What is Advocacy?

Advocate (n)

  • One that pleads the cause of another
  • One who defends or maintains a cause of proposal

Advocate (v): to plead in favor of

Synonyms: support; promote; uphold; defend;argue for

  • Bargaining for Advantage: Negotiation Strategies for Reasonable People by Prof. G. Richard Shell
  • Advocacy in Action: Negotiation for Increased Medicaid Rates and Coverage

  • ASHA’s Coding, Reimbursement, and Advocacy Modules

persuade make a good cause
Persuade = Make a Good Cause
  • Credibility Increases Influence Influence Increases Your Power to Persuade
  • Knowledge is Power!
    • Prepare
    • Relax – Demeanor sets the tone
    • Build Rapport
    • Ask Questions and Listen to their answers
    • Set up Chain of Agreement
initiating contact
Initiating Contact
  • At your meeting discuss:
    • Credentials held by audiologists and speech language pathologists
    • Medical necessity of services
    • Treatment effectiveness (ASHA’s treatment efficacy summaries)
persuasion negotiation common elements
Persuasion & NegotiationCommon Elements
  • Define the Problem
  • Define the Solution
  • Know Yourself
  • Know Your Audience
  • Be realistic
  • Prepare
minnesota health homes
Minnesota: Health Homes
  • Medicaid State Plan
  • Build on current statewide initiative
  • Care coordination
next steps
Next Steps
  • Advocate and Educate
  • Resources in the Association – STAR – Sarah Hanson
  • Stay informed!
asha contacts
ASHA Contacts