keynote address – tennessee sleep society 2013

Moving Forward In Challenging Times:The Future of Sleep

MedicineAmy J. Aronsky, DO, FAASM

KEYNOTE ADDRESS – TENNESSEE SLEEP SOCIETY

2013

ObjectivesProvide An Update on the Most

Current Governmental Issues Impacting Health Care Providers

Understand the Effect of Quality, Cost, Access & Efficiency on New Health Care Models

Discuss Emerging Clinical & Business Trends in Sleep Medicine

Anticipate Future Paradigms of Care Delivery for Sleep Medicine

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DisclosuresRelative Value Scale Update

Committee (RUC)American Academy of Sleep Medicine

(AASM) Primary AdvisorRelativity Assessment Workgroup (RAW)

Current Procedure Terminology (CPT)AASM Primary Advisor

AASM Board of DirectorsFinance Committee

Episode of Care Grouper ProjectCenters for Medicare & Medicaid

Services (CMS)3

Growth in Medicare Utilization

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Medicare Beneficiaries by year

5

Washington Update15th Year Under SGRRecent SGR Patch Prevented 26.5% CutMedicare Sustainable Growth Rate (SGR)

CMS method to control spending for physicians

Ensures the yearly increase in Medicare spending per beneficiary does not exceed growth in GDP

“Doc Fix”CMS fee schedule adjusted to meet targeted

SGRAttempts to Repeal SGR6

Washington Update – CMS Initiatives

• Improved Patient Care• Safety• Quality• Outcomes measurements

• Reduce Cost• Reduce unnecessary & unjustified

medical cost• Reduce administrative cost through

process simplification• Improve Population Health

• Improve chronic care management • Improve community health status7


Affordable Care Act Implemented – 2014

32 million people enter health care poolState Health Care ExchangesHow will the influx affect sleep specialists?

Shift From Traditional Fee-for-Service Models

Special Consideration for “Bundling” of Services

Emphasis on Value vs. Volume8


Development of New Health Care Delivery ModelsAccountable Care Organizations (ACO)Patient Centered Medical Home (PCMH)

Strethens the patient/provider relationshipLong-term quality careSystems based approach to quality & safetyPrimary care as Principal ProviderSleep center as Neighbor Provider

o DME

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Washington Update – CMS Initiatives PCMH• Group Health Cooperative of Puget Sound• 29% ↓ in ER visits, 11% ↓ in admissions

• Community Care of North Carolina• 40% ↓ in asthma hospitalizations & 16%

↓ ER visits• Health Partners Medical Group Best Care PCMH• 39% ↓ in ER visits, 24% ↓ admissions

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Washington Update – Physician Based

InitiativesPayment Should Include Quality & Efficiency

Transitions Should Include Physician Choices & Incremental Change

Reward System for Health SavingsPlan Should Encourage Systems of Care, But Preserve Physician Choice

Hardship Exemptions Available

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Health Care Value = Quality/Cost +

Access + Efficiency

Quality - PQRSPhysician Quality Reporting System (PQRS)

Any Health Care Provider With An NPI Number Must Participate

1 Measurement Group Per Provider Per Year

Report Data to CMSClaims-BasedElectronic Health Record (EHR) CMS-Approved Registry

In Addition to Other Quality Incentives14

Quality - PQRS2013 - Report 20 Patients Total

11 traditional Medicare Part B patients

9 patients with other insurances or

80% of Total Eligible Medicare B Patients

Group Reporting Option

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CMS. 2011 Reporting Experience, Physician Quality Reporting System and Electronic Prescribing (eRx) Incentive program , 4/09/2013

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Quality - PQRSReporting Year

Positive Incentive

Negative Adjustment

2012 0.5% of all Medicare PFS charges

2013 0.5% of all PFS charges

1.5% negative adjustment on all 2015 PFS

2014 0.5% of all PFS charges

2.0 % negative adjustment on all 2016 PFS charges

2015 & beyond

2.0 % negative adjustment on all 2017 & beyond PFS charges

PFS = Physician Fee Schedule17

Quality - PQRSObstructive Sleep Apnea Measurement

GroupSeverity Assessment

Documented OSA by AHI or RDI Positive Airway Pressure Therapy Prescribed

If AHI or RDI > 15 Adherence to Positive Airway Pressure Therapy

Objectively measured adherence to PAPAssessment of Sleep Symptoms

Assessment of sleep symptoms documented, including presence or absence of snoring & daytime sleepiness

2 or 3 additional measures for CY 2014 proposed18

Quality – Physician Compare Website

Reports Location & Specialty Information of Each Physician

Reports Physician Participation in Quality Incentive Programs

CY 2014 & 2015Report individual physician performance data

Report group performance data Report ACO data

www.medicare.gov/physiciancompare 20

Quality – Value Based Modifier

“Pay for Value”Based Upon PQRS & Cost MeasuresCalculate Performance ScoreQuality Tiering Compares Group

Performance vs. National MeanImplemented for Groups > 100 –

2015Implemented for Individuals – 20171% Incentive or 1% PenaltyBudget Neutral21

Quality – Physician Feedback

ProgramPhysician Quality & Resource Use

ReportsComparative Performance InformationAttempt to Improve Quality Care

Delivered2013 – CMS Provides Group Reports >

25 Providers for Comparison

Reimbursement Reward for Value Rather Than Volume

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Other Quality Measures

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Electronic Health Record (EHR)Electronic Prescribing Incentive

Program (eRx)Meaningful Use (MU)

Demonstration EHR is being used “meaningfully”

Stages 1 &214 required core objectives5 additional menu objectives6 total clinical quality measures

Cost – CMS Proposed Rule CY 2014

Reduced Practice Expense Most Specialties 10% Proposed for CY 2014

CMS Accepting 60 – 70% of RUC Recommended Values

Practice Expense Cuts for Sleep Medicine Totaling 20% Reduction Over 3 Years

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Code Descriptor Work RVU

PE RVU

Total RVU

2013 National Payment

95872 PSG <6 yrs 2.60 27.83 30.72 $1066.62

95873 PSG w/ PAP < 6yrs 2.83 29.63 32.79 $1116.98

95800 Slp stdy unattended 1.05 4.26 5.36 $182.70


95803 Actigraphy 0.90 3.53 4.48 $152.42

95805 MSLT/MWT 1.20 11.34 12.62 $429.37


95807 Slp stdy attend 1.28 13.26 14.69 $499.80

95808 PSG any age 1-3 param

1.74 17.32 19.23 $654.26

95810 PSG > 6yrs 4+ param 2.50 16.27 18.98 $646.10

95811 PSG w/ PAP > 6yrs 4+ param

2.60 17.08 19.91 $677.74

2013 Conversion Factor = $34.0230

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Code Descriptor % Proposed Total RVU Change CY 2014

95872 PSG <6 yrs -12%

95873 PSG w/ PAP < 6yrs -10%

95800 Slp stdy unattended -7%


95803 Actigraphy -25%

95805 MSLT/MWT -7%


95807 Slp stdy attend -11%

95808 PSG any age 1-3 param -8%

95810 PSG > 6yrs 4+ param -10%

95811 PSG w/ PAP > 6yrs 4+ param -10%

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Access - TelemedicineE/M Codes Use Telemedicine

Modifier-GT

Via live interaction-GC

Via asynchronous technologySame reimbursement as E/M

Expansion of Rural Health Professional Shortage Area

Utilization for Sleep Medicine?27

Efficiency – New E/M Codes

Transition Care Management CPT Codes - 99495 & 99496Communication with the patient or caregiver

within 2 business days of discharge (or documentation of 2 unsuccessful attempts)Via phone, email or in-person

Face-to-face visit requiredMedical decision making is at least moderate

or highMedication reconciliation & management

documented no later than time of face-to-face visit28


Transition Care Management CPT CodesTransition Care From

Inpatient hospital setting or ERObservation status in a hospitalSkilled nursing facility Rehabilitation hospital

Transition Care ToHomeDomiciliaryRest homeAssisted living facility29


Complex Care Coordination Services Codes99487

1st hour clinical staff time spent coordinating patient care per calendar month

Directed by physician or other qualified health care professional

No face-to-face physician or other qualified health care professional visit required

1.00 wRVU 99488

One face-to-face visit per calendar month required

2.50 wRVU99489

Additional 30 minute increments over initial hour of care coordination

0.5 wRVU31


Complex Care Coordination Services CodesProposed CMS Payment CY 2015Patients Have At Least 2 Chronic

Conditions That Are Expected to Last At Least 12 Months

The Chronic Conditions Place The Patient At Risk for Death, Acute Exacerbation, Decompensation or Functional Decline

The Patient Must Receive Annual Wellness Visit Within Past 12 Months By Same Health Care Provider32

Original Sleep Laboratory

Emphasis On In-Lab Testing

Some Consultations &

Occasional Follow-Up Care

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Sleep Center Comprehensive Care

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The Future of Sleep Medicine

Shift From Sleep Testing Paradigm to Longitudinal CarePartnerships with primary care Satellite offices with other specialtiesEmphasis on other co-morbid

conditionsHypertensionDiabetes

DME AffiliationImproved quality of careAdherence measurements

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Emphasis on Out of Center Sleep TestingAASM members report fewer than 25% of

sleep testing is OCST (2011)Greater amount of OCST in the east &

westIncreased demands for OCST

Prior authorizations required for nearly all commercial payers for in-lab testing

Prior authorizations required for many commercial payers for OCST

Redefining personnel rolesRPSGT/RSTOther personnelPhysician peer-to-peer reviews

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Emphasis on Out of Center Sleep TestingPrimary care physicians ordering more

OCST

Some insurances require OCST to be interpreted remotely by contracted companiesData provided to physicians

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Role of the Sleep Specialist?Become an OCST interpreting physician

for your center for some commercial payers

Become an OCST interpreting physician for other centers through some commercial payers

Achieve AASM OCST accreditationConsider an AASM-Approved OCST

Provider (AOCST)“Point: Should Board Certification Be Required for Sleep Test Interpretation? Yes", Chest. 2013; 144(1):9-11

There will always be a need for sleep professionals


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AASM Preauthorization Survey – 2013Preliminary Data Trends

Good response from Tennessee AASM membersAetna’s authorization process is most time-

consumingCIGNA rejects in-lab testing most oftenAppeals approved more than 50% of the time

Final Data Report – Mid-October 2013www.aasmnet.org


Create of New Sleep Medicine CPT CodesSplit night polysomnographyAdaptive servoventilation titrationBundled code for PAP managementCSF hypocretin/orexin measurementNew technologies

Define Outcome Measures for Sleep DisordersAASM workgroupsApplication to reimbursement43


Discuss Testing With Commercial PayersStreamline insurance authorization processAppropriate use of OCST

Achieve Widespread Reimbursement for 98503

Consider Telemedicine UtilizationMaximize Use of Physician ExtendersRedefine Personnel Roles

RPSGT/RST

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Reduction in Number Sleep Medicine Fellowship Training Programs

Reduction in Available NIH Grants

Sleep Medicine Coding is Aggressively Audited by CMS & Commercial Payers

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ConclusionsHealth Care is Rapidly Changing With the

Implementation of the Affordable Care ActThere is a Shift From Volume to Value

CareThere Are New Opportunities for Sleep

Medicine to Reinvent ItselfSleep Medicine Will Continue to be a

Viable Specialty & Health Care Professionals Will Deliver Excellent Care in Challenging Times

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keynote address – tennessee sleep society 2013

Documents

carrier sgr

cms data

carrier file126

annual sgr code

final sgr web document

federal register

recent cms sgr web document

vs cms