1. Robert Sowislo AAHCM Public Policy Committee ©AAHCM Academy Public Policy Academy Public Policy Year in Review and Issues for Your Practice and the Field in Years Ahead

2. No Disclosures ©AAHCM

3. Linda DeCherrie, MD Bruce Kinosian, MD Karl Eric DeJonge, MD Michael Benfield, MD William Mills, MD Rodney Hornbake, MD Thomas Edes, MD Norman Vinn, DO Robert Sowislo, MBA George Taler, MD Steve Landers, MD James Pyles, Esq. Connie Row, Executive Director AAHCM Gary Swartz, Esq.

4.  What does public policy mean for Academy Members – for a house call practice?  How does Academy public policy and advocacy work occur?  Public policy issues and demands now track transition from FFS to Value Based payment/population health management  Current and future issues important to the field ©AAHCM

5. Refers to the laws, the actions of government, the agency funding priorities, and the regulations Impacts your ◦ Practice organization and operation ◦ Practice revenue and success ©AAHCM

6. Service provided by volunteer public policy committee and Academy staff Relationships with alliances, coalitions and multi-specialty groups Augmented through Professional Services relationships ($) ◦ Law/lobbying, data analytics Augmented through organizational relationships ◦ Corporate and professional alliances (AGS, AAHPM, etc.) Supported through practice level and individual voluntary action ◦ Letters/E-mail, calls, visits, political support and letters to editor/journals ©AAHCM

7. Policy area/issueAcademy effort and results Traditional Fee Schedule SGR – supported permanent repeal and signed onto letters, (offered IAH) CCM - advocated for chronic care management code and successful in changes to make it more usable for housecalls (incident to relaxed and business cost increasing requirements generally dropped) ACP – advocating for coverage and payment for advanced care planning effective 2016 – Dr. DeCherrie representing Academy These two services (CCM and ACP) may produce value for Academy members that is greater as a ratio to practice service and revenue than for MDs/NPs and PAs in other practice settings. Professional Fee Schedule Home Health - payment rule and conditions of participation, face to face requirements, templates Medicare Advantage/Advance Call Letter, and other letters regarding managed care Shared Savings Programs (ACOs), CMMI Request for Information Re Advanced Primary Care Models Impact Act Value Base Payment Modifier/risk adjustment for high risk patients Standards Development Telemedicine Academy Comment Letters, and face to face meetings with CMS officials and Congressional staff Restrictive requirements eliminated (PCMH for CCM) The Academy commented on an increased number and range of rule making and requests for comments and information as the impact of home care medicine is recognized and Academy capacity grows. Academy comments have been incorporated into final rules and policy. (Dr. Lauders leading) Waiver recommendations included in ACO development Home continues as location of service for Medicare Advantage assessments, diagnostic code acceptance. Patient attribution rules to include NP / PA, etc. Public Policy Committee response Meeting with MEDPAC. (Dr. Kinosian leading) AAHCM Standards Committee Formed AAHCM developed position paper on telemedicine for HBPC 2014-2015 Services and Outcomes

8. ©AAHCM Policy area/issueAcademy effort and results Independence at HomeAcademy “JEN analysis” of risk adjustment for IAH like population has been accepted within CMS and will inform HCC risk adjustment for Independence at Home. Academy will advocate that results be incorporated across all payment models, measures and the value based payment modifier program. Advocacy toward continuation/expansion. Advocate for accurate evaluation and payment Managed Care and Dual Eligibles The Academy is increasing the depth and breadth of managed care industry relationships. This includes relationships with executives and medical leadership of health plans as well as the representatives/trade associations and regulators of health plans. Regulation, Audits, and Practice Burden The Academy continues to have influence in reducing practice burden and in protecting and expanding opportunities for housecalls. Continued audit intervention. Publications, Media Requests, and Letters to the Editor, etc. Academy members have produced increased number of peer review articles, Academy board and staff have responded to increase level of requests for interviews regarding home care medicine and generated an increased number of letters to the editor

9. Public policy issue of importance to your practice Fee for service volume/code based issues Value based payment and alternative payment models (APMs) issues Patient volume – how is patient relationship established? “Attribution” No requirements, other than medical necessity and PCP relationship (unless preventive/screening) Patient eligibility criteria/ attribution, so; Need to influence the rules for patient assignment to your practice – otherwise threat to patient panel Standards – what standards required to render service as primary care provider? None, other than basic state licensure, and Medicare program enrollment Present in MACRA for APMS and “medical home,” so; Need to influence what will be the standards and who certifies the practices.Measures and outcomesMultiplicity of measures, not population based No outcomes requirements und Present in MACRA for professional fee schedule, APMS and “medical home,” so; Need to influence what will be population appropriate measures and outcomes ©AAHCM

10. Public policy issue of importance to your practice Fee for service volume/code based issues Value based payment and alternative payment models (APMs) issues Services recognized and covered for payment Coverage, payment and RVUs “fought” for on code by code basis, e.g., RVUs for house call E and M codes TCM CCM ACP AWV in home setting Need to participate to negotiate definition of deal, and what is the right bundle/risk/shared savings? and How to keep the budget/deal from shrinking in the future. Payment and measure assessment risk adjusted based on patient condition? No.Yes. Need to influence in order to assure accurate risk adjustment for house call patient population regardless of payment model Accountability – protection against over and underutilization The micromanagement, burden and “hassle factor” Fraud and abuse concerns and Audits and medical record review Will be embedded in evolving models based on outcomes and patient satisfaction. So, need to influence; Who establishes/administers waivers? Who controls patient movement across settings? Who evaluates outcomes and patient satisfaction? “Stark Exceptions” ©AAHCM

11. Patient Enrollment /payment sourceExamples of Academy public policy efforts and influence requirement Where will public policy efforts be required? Medicare fee for serviceNew services considered and covered – e.g., Advance care planning Congress, CMS Medicare AdvantageHome continues as setting and focus for care coordination and care management Eliminate barriers to house call contracting and NP credentialing Risk adjustment Congress, CMS Medicare ACOs/shared savings and bundled payments Beneficiary characteristics Beneficiary attribution Risk adjustment Risk/shared savings, bundled payment “deal” Congress, CMS Dual eligibles and Medicaid Managed CareRole of house calls in population networks Beneficiary enrollment Opt in or out? Payment terms and levels Congress, CMS, and States; Legislative Medicaid/Health Departments Insurance departments Commercial health plansBeneficiary enrollment “Attribution and Engagement” Eliminate barriers to house call contracting Eliminate barriers to NP credentialing Address plans requirement for PCMH Congress, CMS, and States; Legislative Medicaid/Health Departments Insurance departments NAIC, NGA MedicaidBeneficiary enrollment in ACOs, IAH like models adopted by MCOs Straight Medicaid levels of payment need to move to Shared Savings Congress, CMS, and States; Legislative Medicaid/Health Departments ©AAHCM