1. Redesigning Healthcare Services to Manage Population Health Lynn Barr- CEO, Caravan Health

2. Part 1: Population Health Defined Part 2: Population Health Components
Part 3: Population Health Revenue Potential
Part 4: Better Care for Your Patients/ Caravan Health Case Study
The healthcare industry is moving from Fee-for-Service to Value-based Payments.
CMS is driving this change through highly-complex programs.
Providers need expert help to qualify, participate, and succeed.

3. Population Health Defined

4. Population Health- Defined
Population health has been defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group". It is an approach to health that aims to improve the health of an entire human population.
In an alternative payment model, such as an ACO, the population is the patients the payor attributes to your organization and providers.
Medicare ACOs= CMS attributed Medicare Beneficiaries- Does not include patients enrolled in Medicare Advantage.

5. Why is Attribution Important
Value-based payment models are tied to defined/attributed populations.
Medicare Shared Savings Program Track 1 ACOs- Shared Savings are tied to performance on quality outcomes and costs for the defined population of attributed patients.
Double-sided risk based Advanced Alternative Payment Models (example-Track 2, Track 3 ACOs) – Shared Savings and Negative payment adjustments are tied to performance on quality outcomes and cost outcomes for the defined population of attributed patients.

6. CMS MSSP Attribution Logic
Beneficiary:
Must have a record of Medicare enrollment and have at least one month of Part A and Part B enrollment and reside in the US
Cannot have any months of private health plan
Must have a primary care service with a qualified physician at the ACO
Assignment Policy Step 1:
The beneficiary has at least one primary care service furnished by a Step 1 provider at the participating ACO. The beneficiary must also have a higher total paid amount of primary care service claims from Step 1 than from any other ACO or non-ACO individual or group TIN.
Assignment Policy Step 2:
This step applies only to beneficiaries who remain unassigned after Step 1 CMS will assign the beneficiary to the participating ACO in this Step if the beneficiary received at least 1 primary care service from a Step 2 ACO physician (specialist) at the participating ACO.  

7. Proposed Rule for ACO Methodology
Step 0: Identify Eligible Beneficiaries
All beneficiaries that had at least one primary care service with a primary care physician in an ACO during the applicable window.
Step 1: Primary Care Assignment
A beneficiary is assigned to an ACO if the allowed charges for primary care services furnished to the beneficiary by PCPs in the ACO are greater than the allowed charges for primary care services furnished by PCPs who are not in the ACO.
Step 2: Specialist Assignment
Beneficiaries who have not had a primary care service rendered by any PCP, either inside the ACO or outside the ACO will be assigned to an ACO if the allowed charges for primary care services furnished to the beneficiary by ACO physicians with certain specialty designations are greater than the allowed charges for primary care services furnished by physicians who are not in the ACO.

8. Expanded Assignment for RHCs/FQHCs
Beginning in performance year 2019, RHC and FQHC ACO participants will no longer be required to submit NPIs or attest for physicians who provide primary care services
Proposed methodology would treat all services reported on an RHC or FQHC institutional claim as a primary care service furnished by a PCP
Would include non-primary care services as well as services furnished by a nurse practitioner, physician assistant, clinical nurse specialist, or other RHC/FQHC practitioner
Impact to Step 0  More beneficiaries may be identified for ACO assignment
Impact to Step 1  More beneficiaries may be assigned to RHC and FQHC participants (more likely to earn a plurality of charges)

9. So What’s New With Pop Health?
Chronic Care Management isn’t new.
Patient Centered Medical Home isn’t new.
Isn’t it just a focus on cost containment?
We already have EMRs that can run reports on patients with chronic diseases and those that are high cost.

10. Yesterday- Claims-based Predictive Models
For years, healthcare insurance companies (payers) have mined claims data for chronic patients and have built predictive models to identify high-risk patients.
While this approach has seen some success, limitations far outweigh merits.
Data used by payers to flag high risk patients is historical claims data — primarily costs, admissions, and diagnoses. Furthermore, regression and time series risk models are typically updated only annually.

11. What’s Wrong With This
Skepticism over claims based predictive models because they have a limited clinical basis, and give no consideration to an individual's current state of health.
There is a complete lack of causation,
-Why is a patient considered high-risk?
-What are the clinical reasons for the score?
-How do we lower the patient's risk score?
-How does the score measure the effectiveness of my care management program?

12. Other Limitations
These models lack a correlation to clinical information.
Claims-based risk scores are created with regression analysis at a population level to predict scores at the patient level.
Not only are today’s calculations unsuitable for determining a patient’s true risk, they provide no insight on how an individual’s score improves or deteriorates after each clinical visit.

13. What’s Different About an Effective Population Health Strategy for Value-based Payment Models
Current thinking and efforts create a disproportionate focus on existing chronic patients.
A better approach is to monitor all patients, healthy and chronic.
Chronic Care Management is only ONE focus.

14. Population Health Components

15. Key Components of a Value-Based, Population Health Model
Common Elements of Value-based Success
Prevention:
Annual Wellness Visits
Chronic Care Management
Advanced Care Planning
Behavioral Counseling
Depression Screening
Mental Health Support
24/7 Access
Coding:
HCC 101
Quality:
Process
Pre-visit Planning
Patient Satisfaction

16. The Pop Health Nurse/Care Coordinator
Coordinates team-based care to provide health services to individuals, through effective partnerships with patients, their caregivers/families, community resources, and their physician. Facilitates a “shared goal model” within and across settings to achieve coordinated high-quality care that is patient- and family-centered.

17. Value of Wellness Services for Patients
One hour per year extends life and reduces disabilities.
Increases compliance with preventive care.
Detects emerging chronic conditions.
Detects functional decline.
Detects changes in family/social support.
Detects depression and substance abuse.
Detects vision and hearing loss.
Appropriate referrals and follow up reduces progression of diseases and improves outcomes.
Generally, no co-pay or deductible.

18. Value of Wellness Visits for Providers
Increases patient compliance with prevention guidelines.
Identifies patients at risk for developing chronic conditions for early intervention and Care Coordination.
Addresses and improves 11 Quality Measures.
Documents all medications to simplify ongoing medication reconciliation.
Documents all co-morbidities annually for risk adjustment.
Increases revenue to support more population health staffing.
Increases attribution of healthy patients to your practice.
Allows practice to provide billable Advanced Care Planning service to patient without copay or deductible if part of wellness visit (modifier-33).
Average billable revenue for 1 hour of nurse supervised services per year = $225

19. Wellness Visits Improve Quality Scores
Measure
2015 Communities Measure Rate
2015 Communities Measure Rate
Measure Rate % Change from 2015 to 2016
Influenza Immunization
48%
71%
48.2%
Screening for Future Fall Risk
42%
60%
43.3%
Screening for High Blood Pressure and Follow-up
62%
82%
30.6%
Screening for Clinical Depression and Follow-up
35%
43%
22.7%
Pneumonia Vaccination Status for Older Adults
58%
68%
17.6%
Documentation of Current Medications in the Medical Record
78%
86%
10.6%
ACE Inhibitor or Angiotensin Receptor Blocker Therapy
77%
83%
6.8%
Colorectal Cancer Screening
55%
59%
6.0%
Hemoglobin A1c Control
79%
5.9%
Tobacco Use: Screening and Cessation Intervention
87%
92%
5.2%
Beta-Blocker Therapy for LVSD
91%
93%
2.9%
Use of Aspirin or Another Antithrombotic for IVD
89%
2.0%
Controlling High Blood Pressure
69%
1.7%

20. Transition of Care Management
Coordination of Care: Continuity between settings, staying informed about anticipated discharge, and engaging patient/family
Acute to
Higher
Level of Care
(Tertiary)
Post-Acute
Care (HH,
SNF,
Rehab)
Home or Domicile
Must Track the Care Need Changes

21. Chronic Care Management
Partnering with patients to improve ability to self-manage their disease
Patient/family centric; trusting relationships; use of health coaching principles and mutual goal setting
Creating Care Plan and monitoring progress toward goal achievement and plan of care adherence
Effective communication with providers and care team around plan of care, access and utilization of services
Care team support partners that assist with linkage to community resource needs

22. New Behavioral Health Services
Behavioral Health Integration
Psychiatric Collaborative Care Model focuses on having a psychiatrist work with a practice to consult on behavioral/mental health management. 
Behavioral Health Integration is care coordination that is solely focused on behavioral and mental health issues, follows all other CCM billing requirements.

23. Population Health Revenue Potential

24. Chronic Care Management Billing
Original CPT Code approved in 2015:
20 minutes non face-to-face encounter/month
Approximately $42.71 per month per patient
X 200 Medicare Patients with 2+ Chronic Conditions
= $8542/month X 12 months = $102,504 annually
2018 PFS Proposed Rule proposes RHCs/FQHCs $61.37 per month using GCCC1, allows general supervision of Care Coordinator

25. New FFS CCM Codes in 2017
CPT 99487 - for complex CCM that requires substantial revision of a care plan, moderate or high complexity medical decision making, and 60 minutes of clinical staff time.
60 Minutes - $94 average reimbursement
CPT 99489 - is a complex CCM add-on code for each additional 30 minutes of clinical staff time.
30 Minutes - $47 average reimbursement
HCPCS G0506 -  is an add-on code to the AWV, IPPE or comprehensive E&M visit for providing a comprehensive assessment and care planning to patients.
One-time - $64 average reimbursement

26. Supervised Nurse-Provided Pop. Health Services
HCPCS
DESCRIPTION
Est. Payment
EST. PREV.
PMPY
99358
Prolong service w/o contact
$113
10%
$11.34
99359
Prolong serv w/o contact add
$55 2%
$1.09
99487
Cmplx chron care w/o pt vsit
$94
20%
$18.73
99489
Cmplx chron care addl 30 min
$47 5%
$2.35
99490
Chron care mgmt srvc 20 min
$43
$102.50
99495
Trans care mgmt 14 day disch
$165
$33.09
99496
Trans care mgmt 7 day disch
$234
$23.40
99497
Advncd care plan 30 min
$83
100%
$82.90
99498
Advncd care plan addl 30 min
$72
$7.25

27. Supervised Nurse-Provided Population Health Services (Cont.)
HCPCS
DESCRIPTION
Est. Payment
EST. PREV.
PMPY
G0502
Init psych care manag, 70min
$143
10%
$14.28
G0504
Init/sub psych care add 30 m
$66 5%
$39.62
G0506
Comp asses care plan ccm svc
$64
20%
$153.32
G0507
Care manage serv minimum 20
$48
$28.64
G0505
Cog/func assessment outpt
$238
$47.66
G0442
Annual alcohol screen 15 min
$18
100%
$18.30
G0444
Depression screen annual
G0402
Initial preventive exam
$169 3%
$5.06
G0438
AWV, initial visit
$174
$5.21
G0439
AWV, subseq visit
$118
90%
$105.94

28. Billing for Behavioral Health Integration
Fee-For-Service
G0507: BHI - $47.73 per month, at least 20 minutes.
Same general requirements as CCM.
RHC
Can only bill All Inclusive Rate (AIR), but can add cost of staff and fees to cost report.
Can bill CCM today if patient qualifies.
2018 PFS Proposed Rule: Bill GCCC1: $61.37 per month, general supervision, minimum 20 minutes.
FQHC
Can only bill for PPS rate.

29. Requirements for Billing
Must be furnished by a Physician, NP, or PA (or under direct supervision)
Must include:
Cognition-focused evaluation with pertinent H&P
Mod to High Complexity Medical Decision Making (E&M criteria)
Functional Assessment (ie ADLs) including decision-making capacity
Standardized Instrument use to stage dementia
Medication Reconciliation and High-risk med review
Evaluation for neuropsychiatric/behavioral symptoms (PHQ-9)
Safety evaluation (including motor vehicle operation, if applicable)
Caregiver Evaluation
Advanced Care Planning
Creation of a Care Plan
Source: Moore & Hays, New Codes, New Payment Opportunities for 2017, Family Practice Management, Jan/Feb 2017 edition

30. Cognitive Assessments
Approximately 10% of patients over 65 and 50% of those over 90 years of age have Dementia.1
With the aging population in America, there just aren’t enough specialists to manage all those with cognitive decline.
Medicare has provided billing support for Cognitive Assessments to be done via primary care providers and their staff
A systematic approach to evaluation and diagnosis of those with cognitive decline can lead to improved outcomes for the patient and their family or caregivers
1 Source-Delman & Daly, Initial Evaluation of the Patient with Suspected Dementia, American Family Physician, 5/1/2005, V71, N9,

31. Cognitive Assessment Billing
Code G0505 Reimbursed by Medicare at $ (2017 average)
Same Date of Service:
Can bill at the time of Annual Wellness Visit or TCM visit
Can NOT be billed with E&M Coding
Can NOT be billed with CCM code G0506 (New CCM add on code)
For CCM provided by physicians, NP & PAs
This does NOT interfere with usual CCM codes (99487 & 99489)
Can NOT be billed at the same visit with Advanced Care Planning
Prolonged services code (99358) may be added if clinician time is recorded: minutes. (& added for each 20 min further)
For more billing requirement detail, refer to CMS guidelines or the source below.
Source: Moore & Hays, New Codes, New Payment Opportunities for 2017, Family Practice Management, Jan/Feb 2017 edition

32. Better Care for YOUR Patients/ Caravan Health Case Study

33. Increased Flu Shots: Reduced ED and Inpatient Admissions
6.000
5.000
4.000
ED/IP rate per 1,000
3.000
2.000
1.000
0.000
40.00
50.00
60.00
70.00
80.00
90.00
100.00
Influenza Vaccine Rate 33

34. Quality Saves Lives

35. Increased Pneumococcal Vaccines: Decreased Pneumonia Admissions90 80 70 60
Pneumonia Vaccination Rate 50 40 30 20 4 6 8 10 12 14 16
Bacterial Pneumonia Admissions Rate Per 1000 Beneficiaries 35

36. Take-aways
Population Health Strategies are Tools for Operating in Value-based Payment Models. Population Health Strategies Can Lead to Revenue Opportunities for Rural Facilities. Population Health Tools Result in Better Patient Care. 36

37. Start the Journey
Now is the time to start planning for a 2019 ACO Start
Participate in a Practice Transformation Network
Sign up for our Managed Care Digest- Access tools, resources and webinars
Attend the Accountable Care Symposium- December 6-7
Phoenix, AZ
| Proprietary & Confidential, Not for Distribution 37

38. www.CaravanHealth.com info@CaravanHealth.com 916.542.4582
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