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Delivering Integrative Healthcare Under Consumer-Driven Health Plans: Using ABC Codes to Improve Care, Claims & Outcomes Second Annual Conference - January 22-24, 2004 Integrative Medicine for Healthcare Organizations Health Forum & InnoVision Communications San Diego, California

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Delivering Integrative Healthcare Under Consumer-Driven Health Plans: Using ABC Codes to Improve Care, Claims & Outcomes

Second Annual Conference - January 22-24, 2004 Integrative Medicine for Healthcare OrganizationsHealth Forum & InnoVision Communications

San Diego, California


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Rationale for ABC Codes

ABC Coding Solutions

A Case Study & Take Home Lessons

Integrative Healthcare in Consumer-Driven Health PlansUse ABC Codes to Improve Care, Claims & Outcomes


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Rationale for ABC Codes

Need for Better Health, Healthcare & Health Policy Decisions

Identify best practices

to ensure more Americans get the right care in the right place at the right time...at a rational cost.

  • Unbiased Measurement!


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Rationale for ABC Codes

Fill Critical Gaps

in the NHII & Older HIPAA Code Sets

4


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CAM office visits = 629 million

PCP office visits =386 million

Source: http://www.medinfo.ufl.edu/cme/grounds/pauly/; Eisenberg,et al, JAMA,Nov11,1998, Vol 280, No 18

Rationale for ABC Codes

Support a Consumer-Driven Healthcare Marketplace


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Rationale for ABC Codes

Characterize, Evaluate & Facilitate Care

Need for Research Tools

to Identify the Most Cost-Effective Approaches to Care

Need for Management Tools to Improve Business Processes in Healthcare

Need for Commerce Tools

to Support Industry Efficiencies

Need for Expanded Standards

to Support Consumer Demand for Integrative Healthcare

Need for Complete Standardsto Support the National Health Information Infrastructure

Need to Resolve U.S. Healthcare Challenges: Access, Quality & Costs


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Rationale for ABC Codes

Establish Open & Unbiased Clinical & Administrative Code Sets

  • Conventional physicians have had government-sanctioned codes owned by the American Medical Association.

  • Until ABC codes were authorized under HIPAA, other practitioners lacked adequate codes.

  • Complete coding is essential for controlling healthcare access, quality & costs.

  • Trade association control supports cartel-like behavior. (An analogy illustrates.)

    • Assume an American Food Association (not a Uniform Code Council) controlled bar codes on all food products.

    • Could the AFA unfairly code international food products?

    • Would fewer international food products reach the grocery store shelves?

    • Could the AFA limit competition & largely dictate pricing & consumption?


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Rationale for ABC Codes

Support Cost-Effective Contracting, UM & Claims Adjudication

  • ABC Codesdescribe alternative medicine, nursing & other integrative healthcare practitioners’ interventions.

  • Relative Value Units(RVUs/RBRVS data)establish the financial value of those interventions.

  • Legal Billing Guidelines(with legal scope of practice information) indicate who can legally provide those interventions & under what circumstances in each state.

  • TheHealthIntel Databasecontains these & other data elements & supports health insurance benefit plan design, managed care & provider contracting, utilization & clinical practice management, claims processing, outcomes research & actuarial analyses. It is the only health-related data set that supports cost-effective adjudication of integrative healthcare claims on a per intervention, per practitioner & per state basis.


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Rationale: Support Cost-Effective Contracting, UM & Claims Adjudication

Financial Value

ABC Code

Hierarchic Description

Legal?

Detailed Description of Intervention

(A Cross Section of the HealthIntel Database)


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Rationale for ABC Codes

Support Credentialing & Network Development


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Some Major Practitioner Types

Modifier

  • 1A Doctor of Chiropractic

  • 1B Licensed Massage Therapist

  • 1C Doctor of Oriental Medicine

  • 1D Registered Midwife

  • 1E Naturopathic Doctor or Physician

  • 1F Clinical Nurse Specialist

  • 1G Certified Nurse Midwife

  • 1H Nurse Practitioner

  • 1J Licensed Practical Nurse

  • 1K Registered Nurse

  • 1L Doctor of Osteopathy

  • 1M Medical Doctor

  • 1N Physician Assistant

Rationale for ABC CodesCharacterize & Document Integrative Healthcare Practices

Source: http://www.medinfo.ufl.edu/cme/grounds/pauly/; Eisenberg,et al, JAMA,Nov11,1998, Vol 280, No 18


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Research

Conducting outcomes studies

Economic, health, quality of life, satisfaction, etc.

Management

Forecasting demand, managing operations & maintaining medical records

(Scheduling patients, optimizing workflow, managing cases, conducting activity-based or standard costing, setting fees/prices, establishing contracts, credentialing, etc.

Commerce

Conducting manualeligibility determinations, prior authorizations, claims submissions, etc

Conducting electroniceligibility determinations, prior authorizations, claims submissions, etc

Rationale for ABC CodesImprove Revenues, Reduce Costs & Enhance Brand Equity


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Rationale for ABC Codes

Improve Healthcare Decisions, Practices & Outcomes

ABC codes were authorized by HHS as a proposed modificationto the HIPAA transaction & code set standards. They are HIPAA-compliant for code set registrants & their trading partners.ABC codes support research, management & commercefor alternative medicine, nursing & other integrative healthcare interventions. ABC codes have the exactinfrastructure functionality & social benefits that the National Foundation for Women Legislators calls for in the 2003 NFWL “Access to Care” Resolution.


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Rationale for ABC Codes

Ensure Integrative Healthcare Claims Are Not Too Expensive to Process

ABC Codes, Relative Values & Legal Billing Guidelines help justify payment decisionswithout expensive utilization reviews.

Without ABC codes, older HIPAA code sets do not provide sufficient information to verify the legality, necessity & cost-effectiveness of integrative healthcare products & services.


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ABC Coding Solutions

Consider Resources for Integrative Healthcare Program Implementation

  • ABC Coding Manual for Integrative Healthcare

  • Practitioner Guides to Billable Interventions Using ABC Codes

  • Relative Values for Integrative Healthcare Using ABC Codes

  • Superbills for Integrative Healthcare

  • HealthIntel Database

  • ABC / CPT / HCPCS II Crosswalk

  • CAM Market Report

  • Consulting Services

  • Beta Testing & Co-Development


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Competing “Quick & Dirty” Approaches & Their Competitive Vulnerabilities

Higher deductibles.A deductible is a total dollar amount that the consumer must pay before the insurer begins making payments for treatments. Under this type of policy, integrative healthcare coverage is offered, but the consumer pays a higher deductible.

Policy riders.A rider is an amendment to an insurance policy that may change coverage in some way (such as increasing or decreasing benefits). A consumer may be able to purchase a rider that adds or expands coverage in the area of integrative healthcare.

Discounted fee-for-service networks.Some insurers work with a group of integrative healthcare practitioners who agree to offer services to group members at a rate lower than that offered to nonmembers. A consumer pays out of pocket for treatment, but at a discounted rate.

Context for the Case StudyCreate Next Generation “High Value” Integrative Healthcare Programs


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The Holy Grail Vulnerabilities: Seamless integration to support data collection & drive best practices.

Use ABC codes in conjunction with the older HIPAA code sets to support integrative healthcare research, management & commerce.

Context for the Case StudyCreate Next Generation “High Value” Integrative Healthcare Programs


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Reduce the total cost of care Vulnerabilities by directing MedicarePlus patients with high cost & integrative healthcare-responsive diagnoses through an integrative healthcare program to avoid costly conventional interventions.

Expand savings by utilizing the MedicarePlus integrative healthcare model as a prototype for other plans & by targeting high cost diagnoses (associated with both conventional & unconventional interventions) to further reduce the total cost of care.

Attract healthier beneficiaries, increase revenues & reduce corresponding medical costs by increasing interest of wellness-oriented populationsin integrative healthcare products & programs.

Promote a unique brand image & enhance overall market share by extending the most cost-effective integrative healthcare solutions into other plans.

Context for the Case StudyImprove Revenues, Cost-Management & the Bottom Line


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Use qualitative research & actuarial data to identify high cost & high incidence diagnoses responsive to integrative healthcare.

Enhance claims adjudication rules engines to accommodate claims that include ABC, CPT, HCPCS II, CDT & NDC.

Establish integrative healthcare practitioner contracting & credentialing initiatives.

Expand integrative healthcare benefits to targeted ICD-9s & beneficiaries.

Compile, analyze & disseminate cost-effectiveness data.

Context for the Case StudyShift Coverage & Reimbursement Policies Incrementally


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Context for the Case Study cost Lead the Integrative Healthcare Market Preemptively

  • Support research, management & commerce for integrative healthcare usingABC codes.

  • Identify practitioner type, using specialcoding modifiers.

  • Establish financial value on a per intervention basis, usingRVUs.

  • Establish legal compliance on a per intervention, per practitioner & per state basis, usingpractitioner guides & legal billing guidelines

  • Support improvements in insurance benefit plan design, managed care & provider contracting, utilization & clinical practice management, claims processing, outcomes research & actuarial analyses on a per intervention, per practitioner & per state basis, using theHealthIntel Database.

  • Help prevent fraud & abuse in integrative healthcare claims.


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Jeffrey S. Sollins, MD cost

Bridges in Medicine (Integrative Healthcare)

Ardent Lovelace Sandia Health System (MedicarePlus/Senior Plan)

ABC Codes & Best Practices

> 5 Years

Pioneering Integrative Medicine Program Within Medicare

Case Study: MedicarePlus & Bridges in MedicineAlign Goals of Patients, Practitioners & Payors


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Case Study: MedicarePlus & Bridges in Medicine cost Address Clinical Delivery, Administration & Financing Concurrently

  • Clinical Delivery

    • Improved patient-practitioner & practitioner-practitioner relationships

    • Improved understanding of optimal treatment pathways (e.g., equally or more effective, less invasive interventions with lower costs)

    • Improved outcomes, esp. for chronic conditions (e.g., fewer side effects)

  • Administration

    • Constructive inter- & intra-organizational interactions

    • Optimal allocation of organizational resources

  • Financing

    • Improved contracts & revenues

    • Improved operating efficiencies

    • Improved bottom line


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Case Study: MedicarePlus & Bridges in Medicine cost Understand We’re at an Early Stage, Dealing with a Global Movement

Morris studies the lower right hand corner of the big picture.


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Case Study: MedicarePlus & Bridges in Medicine cost Consider the Context for Care Before the “Enabling Technology”

It Is All About Health & Healing

  • We are not human beings having a spiritual experience.

    • We are spiritual beings having a human experience.

  • (Pierre Teilhard de Chardin, 1881-1955)


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    Case Study: MedicarePlus & Bridges in Medicine cost Remember Enabling Technologies Don’t Substitute for Good Thinking & Practice

    • Understand the terms holistic, natural, complementary, alternative & integrative medicine.

    • Recognize integrative medicine is not adding a non-conventional modality to conventional Western medicine…mind shift.

    • Learn to build your own bridge.

    • Appreciate strengths & recognize limitations..


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    FIXING cost

    SERVING

    Case Study: MedicarePlus & Bridges in MedicineRemember, In Healthcare, Healthy People are the Product

    HELPING

    * Rachel Naomi Remen, MD


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    Case Study: MedicarePlus & Bridges in Medicine cost Anticipate Significant Shifts from Planned Program Design

    Vision vs. Reality

    • Who Benefits from Bridges in Medicine?

    • What Is the Bridges T.E.A.M.?

    • Why Does Bridges Work?

    • How Is Bridges Evolving?

    • Where Are the Remaining Challenges?


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    Case Study: MedicarePlus & Bridges in Medicine cost Benefit From Lessons Learned

    • Missed diagnoses…KEN atypical angina

    • Delayed definitive treatment…Cw Diverticulitis vs bladder Ca

    • Unrecognized interactions; anticoagulation…Ginko, feverfew, ginger, vitamin E, garlic & Omega 3 fish oil

    • Contraindications…St. John’s Wort, Cyclosporin, SAM-e & Bipolar Disorder

    • Exploitation...Max the cap

      Milt Hammerly, MD, Med. Dir., CAM at Centura Health, Denver, Colo., 1998


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    Provide patients with knowledge & ability to adopt a proactive approach to their total well being.

    Deliver healthcare education for more informed decision making.

    Take a patient-centric approach & use a professional healthcare team.

    Promote open communication between patient & practitioners in a highly supportive environment.

    Assure active participation by the patient in his/her own healthcare.

    Commit to long-term healthcare through a focus on restoring & maintaining good health, wellness education & follow up visits.

    Case Study: MedicarePlus & Bridges in MedicineCreate a Win-Win Situation: Patients


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    Give practitioners a mechanism for integrating a care plan. proactive approach to their total well being.

    Improve patient records.

    ID outcomes of care & develop best practice pathways.

    Prove legality, necessity & cost-effectiveness.

    Use payors’ language & show what’s in it for them.

    Reduce contracting, credentialing, coverage, claims management & reimbursement concerns.

    Focus on the patient.

    Case Study: MedicarePlus & Bridges in MedicineCreate a Win-Win Situation: Practitioners


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    Improve benefit plan design. proactive approach to their total well being.

    Streamline contracting.

    Optimize utilization & care practices.

    Cost-effectively adjudicate integrative healthcare claims.

    Conduct outcomes research.

    Characterize integrative healthcare models, previously not clearly delineated.

    Collect hard data on care-effective & cost-efficient models useful in managing resource intensive conditions.

    Support risk management & other actuarial needs.

    Case Study: MedicarePlus & Bridges in MedicineCreate a Win-Win Situation: Payors


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    Conclusion proactive approach to their total well being.

    Need for Better Health, Healthcare & Health Policy Decisions

    ABC codes, RVUs & legal billing guidelines support research, management & commerce & help stakeholders identify best practices

    to ensure more Americans get the right care in the right place at the right time...at a rational cost.

    • Unbiased Measurement!


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    A Tibetan Monk went to a hot dog stand proactive approach to their total well being.in New York & said, “Make Me One With Everything.”He handed the vendor a $20 bill. The vendor took the $20 but proceeded to turn to the next customer & take his order. After a while, the Monk spoke up & asked for the change. The vendor replied,


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    proactive approach to their total well being.Change Comes From Within”


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    Bridges in Medicine proactive approach to their total well being.

    integrates conventional & complementary medicine, using a multi-dimensional model,

    to create balance & wholeness in individuals, caregivers & health plans& the communities in which they live.

    3924 Carlisle Blvd. NE

    Albuquerque, NM 87107 USA

    Tel: 505-855-5545 Fax: 505-855-5541

    Email: the1beamer@aol.com

    Web Site: www.bridgesinmedicine.com

    Ardent Health Services / Lovelace Sandia Health System is a leading healthcare provider in New Mexico.

    601 Dr. Martin Luther King Jr. Ave. NEAlbuquerque, NM 87102 USATel: 505-727-8000Web Site: www.lovelacesandia.com

    Alternative Link delivers information products & consulting servicesthat help health-promoting organizations & individuals finance, administer & deliver cost-effective care that improves individual & public health, business & industry efficiencies & socioeconomic development.

    6121 Indian School Road NE, Suite 131

    Albuquerque, NM 87110 USA

    Tel: 505-875-0001 Fax: 505-875-0002

    Email: mail@alternativelink.com

    Web Site: www.alternativelink.com