“New Rules…New Game” Relating Public Policy Changes to Program Evolution in Cardiac & Pulmonary Rehab Jim Rosneck RN, MS

Presentation Objectives Describe Medicare Account Contractors (MACs) Describe AACVPR Health & Public Policy Committee Functions Report on current AACVPR national & local public policy initiatives Discuss programming opportunities given the new rules Describe national lobbying strategies and 2012 DOTH activities

CMS MAC-15 Update “What is a MAC”? CMS Medicare Account Contractor (MAC)  ‘Integrate & centralize information and create efficient processes for delivery of comprehensive care to Medicare beneficiaries’. Goals: Full and open competitions to replace existing system of Fiscal Intermediary (FI) contractors Increased efficiencies Consistent approach to medical coverage across the service area Competition among current MACs to encourage quality cost efficient service to health providers. Focus on financial management to achieve more accurate claims payments and greater consistency in payment decisions.

Section 911, Medicare Prescription Drug, Improvement and Modernization Act of 2003 15 MAC Geographic Regions J-15 CIGNA “CGS” The eventual plan is consolidation of the current 15 MACs to 10 in “Several Years” J-15 & J-8 (Wisconsin & Minnesota…NGS) to be consolidated.

CIGNA Government Services (CGS) Functions CMS will ensure its MAC contracts focus on three critical areas: Customer service Operational excellence Financial management. Medicare coverage and billing requirements, and the receipt, processing, and payment of Medicare fee-for service core claims processing operations for both Part A and Part B. . Interpret national coverage determination “NCD” language and intent in the development of MAC-LCD’s Maintain a staff of experts knowledgeable of all aspects of the fee-for-service program

AACVPR MAC J-15 Committee Dalynn Badenhop, OH Mike Bichsel, OH Elaine Bohman, OH Sherri Bradley, KY Peggy Cox, KY Tammy Garwick, OH Jim Rosneck, OH Rich Sukeena, OH Stephanie Tucker, KY (Physician Liaison: Rich Josephson, OH)

AACVPR J-15 Committee Functions Maintain Communication Insure that CGS  Cardiac & Pulmonary Rehab local coverage determination (LCD) represents the letter and intent of the recent national coverage determination. Coordinate activities with AACVPR national H&PP committee members & leadership. Communicate issues effectively with OACVPR & KACVPR leadership to insure that member and nonmember programs are aware of H&PP issues.

MAC J-15 Current History CGS “Cutover” from NGS (Fiscal Intermediary) management October 17, 2011 LCD Postings at least by September 1st 2011 October 2012 CGS decision to adhere to the National Coverage Determination NCD for Pulmonary & Cardiac rehab rules & coverage interpretation. Comment period characterized by participation of an advisory committee and/or state & local provider organizations.

MAC J-15 “CGS Strategy” “Watchful Waiting” Announcement of CGS LCD writing group J-15… action committee will directly contact CGS medical directtor Gary Oakes MD. Educate Petition for adherence to Medicare NCD statute Involve AACVPR national officers PRN

Current PR LCD? 10

NCD: Components of Pulmonary Rehab Physician prescribed exercise: Patient centered Some aerobic training included in each session Education Tailored to individual needs Tailored to behavioral change Brief smoking cessation Nutrition Proper medication use & adherence Psychosocial Assessment Include assessment of home support Objective measure of progress (Pre & Post Testing) 11

NCD: Components of Pulmonary Rehab Outcomes assessment: Baseline assessment & patient centered goals Individual progress via objective measurements. Pretesting - Goal Setting – Post testing Individualized Treatment Plan Diagnosis Type, amount, frequency and duration of the items and services Patient centered goals Established reviewed and signed by a physician Reviewed & signed by the medical director 12

NCD: Components of Pulmonary Rehab - Diagnosis COPD Moderate, severe and very severe COPD (GOLD guidelines) Billing code = G0424 Non-COPD All other previously recognized diagnoses Billing code = G0239 “Group Exercise” Billing code = G0238 “Individual Exercise q15min” Billing code = G0237 “Individual Education q15min” LCD will eventually determine the status of Non-COPD diagnosis Require the “59” modifier NHLBI/WHO Global Initiative for chronic Obstructive Pulmonary Disease “GOLD” 13 13

Pulmonary Program Evolution Necessity of ECG monitoring? Aerobic exercise requirement (PR/session - CR/day) Two daily sessions 36 sessions / 36 weeks (PR limited 72 lifetime) Sessions in excess of 36 No restrictions re: program crossover Educational & Psychosocial requirements GOLD standard = increased PR patient eligibility Program individualization per patient focused needs Knowledge translated to behavioral change Require the “KX” modifier If you dead everything wrong with you. If you CAD you high risk. In fact the earlier the manifestation of risk the higher your overall risk. Preservation of myocardial contractility EF = low risk 14 14

NGS & CGS Cardiac Rehab Coverage Physician directed & *supervised Components include: exercise prescription risk factor modification psychosocial assessment outcome assessment Individual treatment plan diagnosis individual goals type, amount, frequency and duration of items and services provided. Reviewed and signed by “a physician” every 30 days Non-physician practitioner (NPP) may order the Cardiac Rehabilitation if it is within his/her scope of state practice under licensure *DOTH 2012 issue

Pulmonary Rehab Coverage Scenarios T. B. A.

Cardiac Rehab Performance Measures

NGS vs. CGS Cardiac Rehab Coverage NGS: heart valve surgery, PTCA or stenting and stable angina must begin a program within “6mths” CGS: accepted diagnosis can begin a program within 12mths of procedure or diagnosis NGS: clause re: angina assessment via angiographic changes during GXT. CGS: angina diagnosis is determined by the referring physician

Medical justification for extended participation “Once a patient has reached the exit criteria (i.e. 36 sessions), further CR will not be considered reasonable and necessary.” Proof of ischemia or dysrhythmia per GXT Achievement of 7< METs “a stable level of exercise tolerance” (AHA Class I or normal FWC) 6< minutes on a Bruce Protocol (or equivalent) Significant ischemia or dysrhythmia > 6 minutes GXT Heart Transplant < 90% predicted VO2 peak ….unless 6 minutes on a Bruce protocol: Men = 5.7 METs, Women = 6.4 METs ( without demonstrating significant ischemia or dysrhythmia after completion of six minutes of a Bruce protocol, or equivalent, 7 1/2 min: Men & women 6 1/2 min = 7 METs CGS: Medical necessity proactively documented by the referring / supervising physician

1st Talking Point: NPP Supervision of CAH - C&P Programs Issue: Critical Access Hospitals (CAH) programs in jeopardy due to physician supervision language in current statute. (Imposes strict requirements, describing the direct physician supervision standard for PR, CR services) “Technical Correction” to existing 2008 legislation codifying Cardiac & Pulmonary rehab. Bi-partisan co-sponsors No additional $ involved. Prevents use of Medicare services by constituents served by CAHs. CBO = Cost is Zero; Everyone agrees CMS included that the physician on-site requirement for CAHs is onerous.

2nd Talking Point: Cost Reporting 2009 CMS commissioned Research Triangle Institute (RTI) to investigate HOPPS rate setting processes. RTI data indicated a reimbursement of > $100/session (Current CR = $69.50…PR = $37.43) RTI found the CMS processes mapping cost-to-charge relationships in C&P programs was flawed and easily corrected. CMS chose to not heed this advise. HOPPS final rule page 101:CMS-1504-FC 101 (2011 rule changes this process & allows for the use of the “non-standard” methodology) CRUCIAL all programs should contact their reimbursement depts. to insure they use this method of reporting costs to CMS. HOPPS = Hospital Outpatient Prospective Payment System

3rd Talking Point: Excessive Medicare “Advantage” Co-pays Medicare “Advantage” = Pulmonary & Cardiac Rehab “Disadvantage” !!! Medicare pays a fixed amount every month to the companies offering Medicare Advantage Plans. Mandated to follow rules set by Medicare. Each Medicare Advantage Plan however has the freedom to require per-session co-pays greatly in excess of the typical 20% ($7.49) per session fee. High co-payments = denial of services AKA “MA’ 7 Part c

Thank you…questions