#3400.159 Rev. 10/16

Providing Preventive Health Care, Lifestyle Medicine & Shared Medical Appointments

Dr. Sal

August 27, 2018

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Dr. Sal Lacagnina • System Medical Director of Wellness & Employee Health, Lee Health

• Internal Medicine 1993- 2010

• Board Certified Anti-Aging & Regenerative Medicine 2016 (A4M)

• Board Certified Lifestyle Medicine 2017 (ACLM)

• Passion: Preventive Health care Dr.Sal@LeeHealth.org 239-989-9922

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• The current health care system is a sick care system

• Providers get paid for interacting with patients

• Regardless of the clinical outcome

A number of “no-brainers”

• Providers get paid for each patient visit and

• Patients have a co payment but most of the bill is paid by the insurance company (OR EMPLOYER) regardless of the clinical outcome

• (or even if the patient is non compliant)

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Current Fee for service (FFS) model

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Fee for Service Clinical pros & cons

Pros = the provider gets paid for examining and spending time with the patient Cons = bills are paid regardless of the clinical outcome

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Preventive healthcare pros & cons

• Pros = if providers were paid for providing preventive health care (and if patients were fully compliant & engaged) the benefits are clinical and financial

• Cons = insurance carriers believe there is no ROI (at least in the short term) and therefore at this time reimbursement for preventive health care is problematic

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• As Health Care Providers (HCP’s) we are obligated to help people become and stay healthy

• But the current system pays HCP’s to treat illness and does not pay HCP’s to see people for wellness or “preventive” visits

• Aka. Not paying for the provider and the patient to work together to help the individual stay healthy!

The problem

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Doing the right thing clinically for the patient while at the same time allowing the practice to stay financially viable

So what’s the challenge?

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What is the most useful way to know if a person is healthy?

Question:

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• Evaluating for “risk factors”

• Early diagnosis of chronic disease or cancer

• Identifying chronic illnesses with markers not at goal

• Incentivizing the patient to be fully engaged

Answer: “Screening” for disease

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The current system of preventive health care

Starts too late!

#3400.159 Rev. 10/16

Preventive Medicine Services &

Medicare Preventive Services An Overview of Coding and Billing Guidelines

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Medicare Preventive Services Initial Preventive Physical Examination

IPPE (G0402) • The Initial Preventive Physical Examination (IPPE) is also known

as the “Welcome to Medicare Preventive Visit” (Medicare pays for one IPPE per beneficiary per lifetime for beneficiaries within the first 12 months of the effective date of the beneficiary’s first Medicare Part B coverage period)

• The goals of the IPPE are health promotion, disease prevention, and detection (are you laughing inside?)

Preventive Medicine Services

• New Patient (99381-99387) • Established Patient (99391-99397)

• Purpose is early detection of disease rather than evaluation and

treatment of symptoms or known medical conditions

• Extent and focus of the services will largely depend on the age of the patient

• (Not covered by Medicare) 13

Preventive Medicine Services

• No Chief Complaint (CC) • No History of Present Illness (HPI) • Complete Past, Family, Social, history (PFSH) 3 of 3

elements required • Complete (10+) Review of Systems • 8 organ systems examined • Counseling/anticipatory guidance/risk factor reduction

interventions

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Medicare Preventive Services Initial Preventive Physical Examination

• Review the beneficiary’s medical and social history

• Obtain the following: • Height, weight, body mass index, and blood pressure • Visual acuity screen • Other factors deemed appropriate based on the beneficiary’s medical and

social history and current clinical standards • Perform the following:

• Review the beneficiary’s potential risk factors for depression and other mood disorders

• Review the beneficiary’s functional ability and level of safety • End-of-life planning, on agreement of the beneficiary (really?) • Educate, counsel, and refer based on the previous five components • Educate, counsel, and refer for other preventive services

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Medicare Preventive Services Annual Wellness Visit (G0438)

AWV (G0438) • Annual Wellness Visit to develop a personalized prevention help

plan (Patients are no longer within 12 months after the effective date of their first Medicare Part B coverage period and have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months) – at this time the person is at least 66 years of age!

• This plan is designed to help prevent disease and disability based on patient’s current health and risk factors

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Medicare Preventive Services Annual Wellness Visit (G0438)

• Establish the beneficiary’s medical/family history • Obtain the following measurements:

• Height, weight, body mass index (or waist circumference, if appropriate), and blood pressure

• Other routine measurements as deemed appropriate based on medical and family history

Medicare Preventive Services Annual Wellness Visit (G0438)

Perform the following: • Administer HRA (Health Risk Assessment) – starting at 65 years of age?! • Establish a list of current providers and suppliers • Review the beneficiary’s potential risk factors for depression, including current or past

experiences with depression or other mood disorders • Review the beneficiary’s functional ability and level of safety • Detect any cognitive impairment the beneficiary may have • Establish a written screening schedule for the beneficiary, such as a checklist for the next 5

to 10 years, as appropriate (from 65- 75 year of age!) • Establish a list of risk factors and conditions for which the primary, secondary, or tertiary

interventions are recommended or underway for the beneficiary • Furnish personalized health advice to the beneficiary and appropriate referrals to health

education or preventive counseling services or programs • Furnish, at the discretion of the beneficiary, advance care planning services 18

Medicare Preventive Services Subsequent Annual Wellness Visit (G0439)

• Update the beneficiary’s medical/family history

• Obtain the following measurements:

• Weight (or waist circumference, if appropriate) and blood pressure

• Other routine measurements as deemed appropriate based on medical and family history

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Medicare Preventive Services Subsequent Annual Wellness Visit (G0439)

• Perform the following: • Update HRA • Update the list of current providers and suppliers • Detect any cognitive impairment the beneficiary may have • Update the written screening schedule for the beneficiary • Update the list of risk factors and conditions for which primary,

secondary, or tertiary interventions are recommended or underway for the beneficiary

• Furnish personalized health advice to the beneficiary and a referral, as appropriate, to health education or preventive counseling services or programs

• Furnish, at the discretion of the beneficiary, advance care planning services

Advance Care Planning (ACP) Use the following CPT codes when performing ACP as an optional element of an AWV. • 99497 -Advance care planning including the explanation and discussion of

advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate

• • +99498 -Advance care planning including the explanation and discussion of

advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)

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Why wait until a person turns 65 to start screening for risk factors or disease? By this age most individuals already have risk factors and multiple chronic illnesses!

Again - another problem…

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Questions:

So then what’s the ideal model? And when should prevention start?

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When should prevention start?

• In the adolescent years? • During childhood? • In utero? • Pre pregnancy?

What does the field of Epigenetics prove?

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A quick detour - Epigenetics

• The influence lifestyle behaviors have on gene expression

• Research shows that healthy behaviors can turn on “good genes” and can turn off “bad genes”

• Therefore, heredity is not our destiny!

Individuals come in for an annual “Lifestyle Medicine Consultation”

• The healthcare provider & the individual discuss lifestyle behaviors

• They identify risk factors for chronic disease and cancer and

• And together they develop an action plan to mitigate risk factors and to optimally control current chronic medical problems

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The ideal model for Prevention starts as early as possible when

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Prevention starting • Preconception and then continuing

• In the neonatal period, • During early childhood and adolescence and

• Throughout adult life

• Into the geriatric age

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For the patient and the provider How can we develop a current model of healthcare delivery that allows the individual to be seen for a “check-up” In addition to being able to be seen for acute and chronic medical problems While allowing the healthcare provider to remain financially viable?

How do you develop a win-win?

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• Getting paid based on time – this model allows the provider to spend more time with the patient but the fee schedule is limited; and the schedule cannot be “double booked”

• Getting paid based on outcomes is not part of this model either…

• Although some health care systems are re deploying ACO’s (Accountable Care Organization) and Value-based payment models

Getting paid for what you do

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What about patient responsibility?

• In the fee for service model or when the provider bills based on time the patient has no “Skin in the Game”

• Either clinically or financially

• The patient is not penalized for non-compliance and the current system pays the provider regardless of the clinical outcome

• The problem with value based care (VBC) is the non-compliant patient

• If clinical outcomes are not achieved because the patient is non-compliant

• The healthcare provider gets “dinged” financially and also gets a “black mark” on his/her record

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VBC

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“Managing” chronic illness

• Managing or treating chronic illness

• Is not the same as reversing and curing disease

• The healthcare providers responsibility (and the patient has a large part to play in this) is to help the individual reverse and potentially cure his disease

• But prevention should be the top priority!

• Have multiple risk factors for chronic disease

• And many already have chronic medical problems which are being “managed” inconsistently and incompletely for a variety of reasons

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The reality is that most Americans

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Disease cure

• Is not possible unless we identify the cause of the problem

• The current model is to identify the symptom (i.e. high blood pressure/ Diabetes/ hyperlipidemia) and then reflexively “treat” it

• Aka. Write a Rx, send the person for a procedure or schedule a surgery

• Treatment is not possible unless we identify the reason for the problem!

• Prevention means primary as well as secondary prevention

• We should attempt to not let a person get heart disease

• But we should also help him/her prevent the primary disease from getting worse

• And ideally we should work with the patient to reverse and even attempt to cure the disease

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Treatment

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• In the current fee for service model individuals can receive preventive health care services within a typical visit

• Since most individuals have either risk factors or chronic illnesses which need to be “managed”

• Preventive health care services can be fit into the general visit and billed by diagnosis

• Remember: you can bring the patient back to deal with more problems – everything does not need to be done at one visit!

Billing individuals for a wellness exam

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Shared Medical Appointments (SMA’s) aka. Group Visits • A Shared Medical Appointment represents the delivery of individual,

focused medical care within a group visit

• It is NOT an educations event (although education is provided to the group in the group setting)

• Each individual receives attention focused specifically on their risk factors or chronic medical conditions; and an individual action plan is created

• In addition to providing comprehensive health care

• The “Group Visit” model of health care is also perfect providing preventive health care services

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Billing by diagnosis or risk factor • 50 year old male with mild elevated blood pressure, hyperlipidemia, signs

and / or symptoms of vascular disease

• Can be seen & billed fee for service but at the same time

• Can be referred to a nutritionist, exercise specialist, wellness coach, etc.

• Thereby providing necessary preventive health care services within the individual fee for service model

• The key is to provide the necessary health care services (doing the right thing for the patient)

• The GV is a two hour session with multiple patients (often times 15-20)

• May include the patients significant other

• Designed to deliver individualized medical care within a group setting

• The SMA is a model for the delivery of comprehensive health care (not an education session)

• The Group visit provides chronic disease management and preventive health care services to individuals within a group setting

• (redundant…WRITE IT DOWN!) 39

SMA’s or “Group Visits”

• Financially for the practice • Access to care

• Benefits to the patient (satisfaction, knowledge)

• Clinical outcomes versus traditional delivery

• Physician satisfaction (not having to say the same thing over and over)

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The benefits of a Shared Medical Appointment

Slides from Dr. Sumego

At Harvard they are running about 300 group visits

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• Time • The team • The need to space large enough for 15-20 people • The definite need to be able to spend some individual

time with each participant • Patient understanding of the benefits of the GV • HIPAA • Documentation • What the patient missed when he is away from the group

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Logistics of doing Group Visits

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• If the GV model have been around since 1996 why hasn’t the concept taken off?

• Why have physicians and the HC system not adopted this way of caring for patients?

Questions for Dr. Noffsinger

Group Visits

• Dr. Noffsinger describes a GV as a 1:1 individual visit within a GV

• Cleveland Clinic is currently doing 300 GC’s

• The GV is not focused on education

• The GV is a medical visit focused on the patients health care

• Providers who are the most busy have the most to gain from GV’s

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Group Visits are great

For the treatment, reversal and prevention of HyperLipoDiabesity! High Quality, High value medical care

• Another champion of the Group Visit model

• Delivering high quality health care (in Florida)

• Improving clinical & financial outcomes

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Dr. Saxena

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• Group visits for diabetic patients for 2 years

• Billed Medicare 99213 or 99214

• No questions or concerns from Medicare

• Individual time spent with every participant

• Documentation of each segment of the group and individual time

• Total time for each group 4 hours

• Increased daily productivity by 50%

My experience with GV’s

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• The Group Visit model works well for CDM as well as for the delivery of preventive health care

• Both CDM and preventive health care can be done at the same time

• When it comes to preventive health care the physician often time starts the conversation and then navigates the patient to the person or department which does the actual work

GV’s for chronic disease management (CDM)

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Who is the prevention actually done by? • Does the physician have to do all the prevention?

• Or can some of this care be delivered by another HCP?

• And if so, then how does the other HCP get paid for his/her service?

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Documentation for Group Visits It is most important to spend some private time with each patient and then to document specifically what was done in order to bill appropriately

• If you’re going to change the way you practice and bill for the delivery of health care

• Be sure to tell your administration about this!

• Senior leaders need to understand what you're doing so they can be supportive and champions

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Talking about the change

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• What is the cost for providing care in a GV setting

• And what is the financial ROI?

Cost for doing a GV

The cost for doing a Group Visit

• Depends on the size of the health care team (salary & benefits)

• If compensation has to be paid to other team members

• If a room has to be rented to perform the GV

• For printing materials to hand out to patients

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The ROI for doing a Group Visit

• The ROI becomes positive when considering that a physician (or an advanced provider) can see 15-20 patients in 4 hours

• versus the same number of patients in the 8 hour day

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The other ROI • Clinical – improved metrics

• Patient satisfaction

• Better patient understanding of the educational material

about his/ her illness

• Improved patient compliance with the treatment plan

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Recommendations • Don’t talk about billing for prevention

• Talk about the delivery of health care and doing the right thing for each

patient

• Document the clinical improvements

• Focus on each individual patients needs

• Allow the individuals in the group to educate one another

Documentation for a SMA • Each note should be able to stand alone

• The provider is responsible for delivering the best health care regardless

of the payment structure

• The plan should address each diagnosis and risk factor

• Don’t include generalized statements (about the educational component of the group visit) throughout each patient note

• The focus is on the delivery of individualized health care

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Facilitation of the SMA • If the health care provider is not in the group visit room and a facilitator is

addressing the group

• Documentation & billing should not take this into account

• If the provider is in the room and hears the information provided by the facilitator to the patients then this information can be included in each patients note and can influence the level of the E&M code

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Where do patients receive individual attention? • In a private exam room but the delivery of healthcare for each individual

is done in the group setting

• The physician (or ARNP) discusses each patients medical problems within the group setting

• Each patient signs a confidentiality waiver and agrees to share information within the group setting

• Therefore every patient gets his/ her own action plan ( a generalized treatment plan is NOT part of the group visit)

In the group setting • The provider delivers health maintenance & reviews labs

• Does chronic disease management & addresses individual concerns

• Develops an action plan for each individual

• Educates the entire group at the same time

• Allows the participants to learn from and also teach and support one

another

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Education: a by product of the SMA • But clinically there are significant improvements in outcomes

• Productivity for the physician increases

• Access to care improves

• Patient satisfaction improves

• Physicians are less burned out

• Chronic disease management metrics improve 61

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Important questions to answer If you plan on billing for prevention: • Who is going to help you accomplish this?

• Who is going to be resistant?

• What support do you need from administration?

• What support do you need from your patients?

• All health care providers should be delivering preventive health care

• This starts with a wellness mindset

• It is understood that not all providers can actually deliver the preventive care

• But if the provider starts the conversation and knows who to navigate the

patient to • Then the patient gets what he/ she needs and the preventive health care team

is able to function more effectively

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Who should be billing for prevention?

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In order to bill for prevention: • How do you show value to the insurance co?

• How do you show value to self insured companies in order to stimulate

them to focus on prevention?

• Answer: data!

How to work with Insurance companies

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Billing for prevention – Summary • In a FFS world • In a capitated system or • For cash paying patients

• Billing = Documentation • Documentation of risk factors & chronic medical problems • With medical care being delivered via individual or group visits • With the physician or ARNP as the team leader & navigator • With support from a comprehensive Lifestyle Medicine team

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Thank you!

Dr. Maryann Sumego, Harvard Dr. Ed Noffsinger Lee Health Drs. Garth Davis & Brian Asbill

Thank You