Archive for category Billing and Reimbursement
Provided by Barbara K. Tomar, ACEP’s Federal Affairs Director
The Medicare Access and CHIP Reauthorization Act (MACRA) Final Regulation was released Oct. 14. This rule – now designated by CMS as the “Quality Payment Program”- describes requirements for physicians to participate in the Merit-based Incentive Payment System (MIPS) and/or the Advanced Alternative Payment Models (Advanced APMs). Both begin January 1, 2017.
Former ACEP President Dr. Mike Gerardi appointed an APM Task Force that is developing some models that we hope will be reviewed and approved by CMS over the next year. Work of the Task Force was overseen this past year by Immediate Past President Dr. Jay Kaplan and current ACEP President Dr. Becky Parker has pledged to continue to support Task Force efforts.
It’s important to note that since few emergency physician groups have ever participated in various CMS bundled payment models/ACOs, etc. in the past, we expect most of the members to participate in MIPS for the next year or so.
We were pleasantly surprised in our early review of the 2,200-page rule, that CMS responded to ACEP’s comments on the timing and scope of some of the new programs.
Merit-based Incentive Payment System (MIPS):
- Reduces timeframe for reporting. Instead of reporting quality measures (much like PQRS) for a full calendar year starting in January, members can report for as little as 90 days of their choosing and avoid the 4% penalty in 2019. (Similar to PQRS, there will be a 2-year lag between data reporting imposition of bonus/penalty.)
- Doctors can report MIPS as individuals or through their groups. However, physicians must elect one or the other for all MIPS categories.
- Quality measures reporting reduced from 9 to 6. Either 6 measures or a specialty measure set can be selected, 1 of which must be an outcome measure; if no outcome measures are available, a high priority measure.
- Reporting thresholds reduced from 90% of patients (or 80% for claims reporting) to 50% in 2017.
- Encourages the use of QCDRs and electronic sources through preferential scoring.
- Increases quality percent of composite performance score: 60 percent of the composite performance score will be based on the quality performance category in 2017, due to the (requested) reduction of the cost performance category weight to zero next year. CMS was going to weight ‘resource use’ at 10% – a nearly impossible measure for EM due to current cost attribution methodology.
- CMS working on patient condition and patient relationship codes to improve future cost attribution. (ACEP’s recent comment letter to CMS noted that none of the patient relationship codes fit EM practice so we will continue to work with CMS to change this).
- (Clinical) Improvement Activities reporting burden reduced. Highly-weighted activities (20 points) reduced from 3 to 2 and medium-weighted activities or some combination of both need to equal 40 points. (Use of QCDR is highly weighted).
- Allows 90-day reporting, also.
- Advancing Care Information (previously known as Meaningful Use) reporting reduced.
- EM has been exempt from reporting on EHR measures and may continue to be in spite of the burden placed by the hospitals.
- Also reduced to 90-day reporting for 2017-2018
Advanced Alternative Payment Models (APM):
- Reduces amount of losses that APMs must bear. CMS used the term “more than nominal risk” in the draft and proposed that qualified APMs pay of to 4% of Medicare spending. The final rule is based on physician/APM revenue which would be at risk for 5% of revenue losses instead.
- Expanded the definition to include practitioners other than physicians so that models can address quality and costs of non-physician services.
Physician-focused payment model Technical Advisory Committee (PTAC):
Note: This brief description of PTAC is included as background as no changes to its role were made in the final rule.
- MACRA created the PTAC (of outside experts) to assist physician groups who are creating APMs, providing a first line review of proposals to determine whether such proposed models meet the criteria established by the Secretary of HHS for PFPMs and offering some technical assistance. Based on its findings, PTAC can make recommendations to CMS as to whether the model should be refined, further studied, tested or implemented, but CMS makes the final decision through its own application process.
By Dennis Beck, MD, FACEP
ACEP is working with a leading registry vendor who currently provides PQRS registry reporting for more than 40 medical societies. The penalty for failure to satisfy the 2014 PQRS requirements equals up to 4% of Medicare payments, approximately $2,500 per provider.
As a member benefit, ACEP is providing ACEP, EMRA & SEMPA members with $100 off the $299 per provider fee. We have negotiated a deeper discount of 10% off ($179) for groups of 10 or more and 15% ($169) for groups of 20 or more. For more information on reporting requirement, go to www.acep.org/qualityregistry. And be sure to return in early September to take advantage of this member benefit.
In 2014 a group of 10 or more eligible professionals may avoid the 2% PQRS penalty as well as the 2% VBM penalty (both applied to 2016 payments) if at least 50% or more of the individual eligible professionals in the group satisfy PQRS reporting requirements in 2014. Even just one Medicare Fee-For-Service claim for the calendar year qualifies a provider (physician or midlevel) as an eligible professional in a group for purposes of the “50% threshold.” However, please note that those eligible professionals in the group, who do not submit PQRS measures, will still be subject to the PQRS payment adjustment of 2%. To avoid the VBM penalty, at least 50% of individual EPs in a group must meet the minimum PQRS reporting requirements (for more information on these requirements visit www.acep.org/quality. So the choice of whether to report as individuals or to report as a group is a decision that is up to your group.
If your group decides to participate in the 2014 PQRS group practice reporting option (GPRO), the group is required to register through the Physician Value-Physician Quality Reporting System (PV-PQRS) Registration System by September 30, 2014. This registration process can take up to two weeks, so start now! Groups will need an Individuals Authorized Access to the CMS Computer Services (IACS) account to access the PV-PQRS Registration System. Registration lets CMS know which groups want to be analyzed at the group level (or TIN-level analysis).
Complete information about IACS and 2014 PQRS GPRO registration is available on the CMS website. Click here for that information.
During registration, the group practice will need to indicate the size of their group at the time they register. For GPRO Group size is based on the number of eligible professionals including PAs and NPs billing under the TIN. Be sure that your group’s Medicare Provider Enrollment, Chain, and Ownership System (PECOS) information is updated for before you begin registration.
Whatever your decision, to report as a group via GPRO registry or to report as individuals, the ACEP PQRS Wizard registry option will be available for you. Although you can upload quality data codes from your practice management, coding, or billing software to the portal through February of 2015, if you want to participate via GPRO your group must complete the PV-PQRS registration process by September 30, 2014. If you plan to report as individuals you can sign up through Dec. 31, 2014.
Dr. Beck is President and CEO of Beacon Medical Services in Aurora, Colorado. He is past chair and current member of the ACEP Reimbursement, Quality and Performance Committees. Dr. Beck is also a member of the ACEP Coding and Nomenclature Committee and chair of the Colorado ACEP Finance Network.
Please register for the next Quality Improvement & Patient Safety (QIPS) “All Section Webinar,” which will feature a presentation from ACEP leaders Dennis Beck, MD, FACEP & Rick Newell, MD, FACEP on the 2014 Updates to the CMS Physician Quality Reporting System (PQRS) and the Physician Value-Based Payment Modifier (VBM) with input from Mike Granovsky, MD, FACEP.
This webinar will take place 11:00 a.m. EDT on Tuesday, April 1.
- Learn about CMS new requirements for the 2014 PQRS incentive and the 2016 payment adjustment and the PQRS measure set as follows. The penalty for failure to report PQRS has increased from 1.5% to 2%, and non-reporters will also be penalized with an additional 2% penalty for the new Value-Based Modifier.
- Learn which measures to report in order to earn the PQRS Incentives CMS requires eligible professionals to report 9 Measures Across 3 NQS Domains via the claims-based or registry reporting mechanisms
- Understand the Measures Applicability Validation (MAV) process, which will allow CMS to determine whether an eligible professional should have reported quality data codes for additional measures.
Please register here or click on the link below and be sure to add the event to your calendar after registering.
Tuesday, April 1 at 11:00 a.m. ET
Dial in Number: 1-877-366-0711
Participant Code: 14253069
ACEP has arranged for its members to receive a 20% discount on the FH Fee Estimator, a new source of independent charge data from private insurance claims. Participants can access emergency medicine charge data for 491 geographic areas nationwide. This tool gives physicians and management a better understanding of the marketplace and allows instant compare charge data to Medicare fees.
The FH Fee Estimator website, www.feeestimator.org, is easy to use for small data requests. But if you need a more sophisticated data set, contact FAIR Health for custom analytics. To get the ACEP 20% discount, enter the promotion code 20ACEP13 at the checkout screen.
FH Fee Estimator is brought to you by the not-for-profit corporation FAIR Health, whose mission is to bring transparency to healthcare costs through comprehensive data products and consumer resources. Created in 2009 to provide an objective source of data, FAIR Health owns and maintains a database of billions of billed medical and dental services. This database serves as the foundation for benchmark products that reflect the prices charged for healthcare services in specific geographic markets across the country.
This database is a great resource for emergency physicians groups to inform development of fee schedules and other practice decision making, says David McKenzie, CAE, ACEP’s director of physician reimbursement. The data is available based on an aggregation of zip codes and can be tailored for the geographic area you serve. Because it is drawn from actual claims data, it is a wonderful source of information on fees charged in your area, he adds.
Should emergency physicians advocate that they be carved-out of payment reform? There may be no easy answer to this question, at least not yet; and in any case, advocating to be an exception to the transition from fee-for-service to pay-for-performance and risk-sharing may be a waste of time and effort. The tide is clearly turning, though not as quickly as payers and government regulators might wish; and it would appear that eventually, every physician and hospital will be subjected to various incentives and disincentives to provide better care for less money, or perhaps less care for less money. Even if the Affordable Care Act is killed by the Supreme Court, along with the provision of this act that mandates “paying more to doctors who provide quality care at lower cost to Medicare, and reducing payments to physicians who run up Medicare’s costs without better results”; this snowball is already rolling. The question for ACEP and emergency physicians is: do we scramble to get out of the way, or hitch a ride?
One of the considerations at issue is the attribution problem. Lots of different providers impact the care of emergency department patients, and what gets done to and for them. Unlike most physicians’ offices, the ED is an open practice. Physicians often send their patients to the ED to get tests and procedures and treatments that the physician could perform, or order, in a lab or outpatient radiology suite, or consultant’s office. One-stop shopping is quick, its easy, and it gets the patient out of the doctor’s office, allowing better turn-around. Consultants call or come to the ED and order all sorts of tests and treatments, and sometimes these orders are attributed to the treating ED physician. When physicians are financially at risk for the cost of caring for their patients, or are simply tracked and compared with each other regarding these costs; attribution is an important issue. Under payment reform, determining how a physician’s decisions impact the cost of care involves many complicated adjustments related to the patient’s health care issues, and the roles of other physicians involved in the patient’s care. According to Dr. Berwick, the former administrator of CMS, this “may be the most difficult measurement challenge in the whole world of value-based purchasing”. These adjustments are even more difficult to make in an open practice like the ED, where the most expensive care is often the result of a multi-provider team effort.
Another consideration relates to the impact of payment reform incentives and risk-sharing on medical decision-making in the context of a medical emergency. In the middle of a heart attack, do you really want your ED physician factoring in how he or she will be judged, or compensated, by how little is spent on your care; or trying to shift critical time dependent decisions to some other provider down the road? Here’s an example: the ED physician can look at your ECG and make the expensive decision to call in the cath lab team in order to reduce the time it takes to get your coronary artery open, saving heart muscle and maybe your life. Or, he can call the cardiologist to come in and make that decision, wasting critical minutes, but putting the cardiologist on the hook for the cost of this decision. Of course, the obvious answer is to make the entire team responsible not only for costs but also outcomes, which is what bundled payments, capitation, ACOs, and integrated health care systems are designed to address. But don’t think for a minute that paying the entire team for performance is going to entirely mitigate the impact of these cost-cutting incentives. Ask seniors how they feel about health care payment reform under Medicare: for the elderly, and most everyone, incentives for physicians to skimp on needed care is frightening.
So far, things like bundled payments and capitation have been focused on scheduled, elective, non-emergency care, because it is easier to predict and monitor the relative contribution of the surgeon, the anesthesiologist, the primary care doc, the pathologist, and so on. In an emergency, care is less predictable, and it’s more difficult to attribute medical decision-making to one or another provider; and frankly, cost-cutting is a bit more risky, and cost-effective care perhaps more difficult to achieve. I suspect, however, that this will not deter the payers, because emergency care is also more expensive. If emergency care providers expect to be able to ride the train of fee-for-service forever, carving themselves out of payment reform, they will likely be disappointed. Either they will be tagged as an expensive commodity that payers will try to work around (using the EMTALA mandate as cover, and non-payment as one of the tactics – as in the Washington State Medicaid non-payment policy), or they will be subsumed into hospital employment or mandated participation in PHOs or ACOs or other risk-sharing ventures that undoubtedly will undervalue emergency physicians’ services and undermine their current paychecks. Unless, that is, these emergency care providers find ways to practice cost-effective care, and participate successfully in shared-savings and other at-risk incentive programs, in a responsible, caring, and efficient manner that ensures good outcomes, saves patients and payers money, and incidentally preserves their own incomes.
This post also appears in The Fickle Finger: www.ficklefinger.net/blog/
Trying to define the market value of someone’s professional services is difficult when those services are typically paid at vastly different rates, depending on the payer, especially when the party paying is usually not the direct recipient of the service. So when an emergency physician provides clinical services to a patient, how are those services valued by different payers, and what does that say about the reasonable market value of those services?
For example, let’s say that you come to the emergency department with an acute asthma attack: you can’t breath well, and your inhaler hasn’t helped to break the attack. A pretty straight-forward case, really: your ER doc does a history and physical exam, orders up some oxygen and a few respiratory therapy treatments, some steroids, perhaps an IV to rehydrate you and get access in case your condition worsens and you need IV meds, and returns to re-evaluate you every 15 minuets to make sure the treatments are working. Two hours later, you are able to go home with a script for three days of Prednisone and a refill for your Ventolin inhaler as the one you have is running low. You get instructions on how to care for yourself at home, when to see your primary care doctor, and what you should do if the wheezing comes on again despite the treatment. Chances are, you will likely get a charge for this service from the physician for 99284 level care for around $320, give or take, if you live, let’s say, in central California.
If you didn’t have insurance, you would be expected to pay the full charge. Unfortunately, many patients can’t afford to pay; or could afford to pay but are just irresponsible, and don’t pay anything. If the patient pays nothing, the emergency physician may be able to recover about $45 from California’s EMS Fund, a tobacco settlement funded program that pays on average about 15% of the emergency physician’s fee.
However, if you were uninsured with a family income at or below 350% of the federal poverty level; or you are insured and have incurred high medical costs (greater than 10% of family income over the prior 12 months) with a family income at or below 350% of federal poverty, and you submitted a request for a discount; you would (by virtue of California law) only have to pay 50% of median billed charges of a nationally recognized database of physician charges, probably around $150.
If you were covered by your County’s new Low Income Health Program (a family of 4 making less than $41,000/year), the county may pay the emergency physician about 30% of the Medicaid rate, or a whopping $21.
If you were covered by California’s Medi-Cal program, one of the lowest paying Medicaid programs in the country: $68.
If you were covered by Medicare: the federal program would pay about $125.
If you had HMO coverage, but had to go to a closer out-of-network ER, your HMO would pay the ER doc between $140 and $250.
If you had PPO coverage, the plan would pay between $175 and $240, minus any co-insurance payment, and you would have to pay the rest up to the $320 charge.
So, for a $320 emergency physician service, the emergency physician might receive anywhere from the full $320 down to $21, and about 10% of the time – nothing. The average emergency physician in California provides about $140,000 a year in unreimbursed care.
Of course, in order to provide these services, the emergency physician has to spend $10 to pay for malpractice insurance, $30 for billing services, and additional costs for other overhead amounting to a total of about $55 for every ED patient treated (even if the payment is $0)
So, what’s the real market value for an emergency physician’s services? I would argue that it is the full amount that the emergency physician charges, as long as these charges aren’t significantly higher than what other emergency physicians in the same area charge, but then I just paid a heating technician $175 for 10 minutes of maintenance on our furnace. Others would argue differently, but their estimate would be based on their particular agenda: protecting those living in poverty, reducing costs for the employer, dealing with government budget deficits, or making higher profits for the insurer. Unfortunately, none of these advocates actually provides emergency care to anyone.
By the way, if you were suffering from a heart attack or serious injury, and the emergency physician (and his team) actually saved your life (it happens hundreds of times every day), the emergency physician’s charge would be around $800 to (rarely) $2000. So, what’s the real market value of YOUR life?
This post also appears on the blog The Fickle Finger www.ficklefinger.net/blog/
In response to a suit by emergency physicians and hospitals in Washington State that led to a judicial injunction against the State’s plan to restrict Medicaid payment for ED visits, the State of Washington’s Health Care Authority has conspired with CMS to require emergency physicians to provide services to Medicaid enrollees for free. Emergency physicians are required by law (EMTALA) to provide medical screening services (and stabilizing care) to anyone who presents to an emergency department, and these physicians are subject to severe fines and penalties if they fail to provide these services.
CMS is well aware of this obligation, yet this agency has notified the State of Washington that the Medicaid program may ‘proceed under its existing authority to pay for only medically necessary Emergency Room visits’ based on a list of so-called ‘non-emergency diagnoses’ submitted on claims to the Medicaid program in that State (and presumably, other states that want to use the same process). Thus, the federal government is requiring emergency physicians to perform a medical screening evaluation (which can be as simple as a brief history and exam, or as complicated as a full and thorough evaluation to rule out subtle but potentially life threatening medical conditions), but is telling federally-funded state Medicaid programs that they need not pay the emergency physician for this service if it turns out the patient does not have a medical emergency, based on this list of final diagnoses. When a government mandates a service from private individuals, and refuses to pay for that service, this is tantamount an unconstitutional and illegal taking of services, and is surely a violation of the physician’s rights.
Curiously, CMS does not allow Medicaid Managed Care Plans in any state to use a list of final diagnoses to preclude payment to emergency physicians or hospitals for these screening and stabilization services. Many states explicitly require payment for medical screening services even when no medical emergency is detected. It is pretty clear that Washington State’s HCA is pushing back hard on emergency care providers for having the gall to use the courts to defy their authority. Resorting to this kind of abusive policy, knowing that it is likely to undermine the financial viability of the safety net and the ability of emergency care providers to meet the needs of all of Washington’s citizens, goes beyond the pale.
The list of so-called non-emergency diagnoses that WA HCA has come up with provides a clear indication of the extent to which this agency will go. This list includes such diagnoses as: hyposmolality (which can cause coma), hemopthalmos (hemorrhage in the eye), foreign body in the hand (often causes infection), multiple contusions (as in getting a beating), pregnancy, etc. Even if every single one of these diagnoses can be managed in a physician’s office, it is important to understand that to get to these diagnoses, it is often necessary to rule out other conditions that may look very similar, but are far more serious, even life-threatening. Performing a cursory medical screening exam in an ED is a prescription for a very expensive EMTALA violation, a hospital’s loss of the right to treat Medicare patients, and a malpractice suit that can end a career. Requiring emergency care providers to perform these evaluations on Medicaid enrollees, and then refusing to compensate them for the effort (and the risk), is just reprehensible.
This post was also published in The Fickle Finger (www.ficklefinger.net/blog/)
Recently, Anthem in Kentucky (and other states), Harvard Pilgrim, and other plans (so I hear), have established policies to reduce by half payment for Evaluation and Management (E&M) services when accompanied by a -25 modifier and billed in combination with some 150 specific (and commonly used) preventative and procedure codes. The -25 modifier is supposed to indicate that these services are ‘separately identifiable’, according to AMA CPT coding rules. The rationale for this 50% reduction is that the plan does not want to pay twice for ‘the overlap of overhead expenses in the RVUs of the code combinations’. Anthem KY also plans to ‘make improvements in (their) primary care fee schedule allowances for office E&M codes’, but it is not clear to me if these improvements are intended to compensate for some or all of these reductions (don’t count on it).
Initially, I was not sure whether this policy would apply to both office based and facility based providers, so I contacted Anthem in KY to see. Though there was some confusion about this at first, the latest response I got from Anthem KY was that “Emergency Room Physicians will NOT be affected by the 50% reduction in payment”. I do not know at this point whether or not this exception also applies to other facility based providers. When I initially saw the policy statement from Anthem, I replied to them that:
I do not believe that ANY portion of the RVUs assigned to the E&M service should be ignored, deleted, modified, or considered duplicative to the RVUs assigned to the additional procedure when separately identifiable services are coded on the same claim. This is what CPT means by ‘separately identifiable': it means ‘distinct from’. The overhead expenses associated with an E&M service are likely to be completely separate and independent of the practice or overhead expenses associated with the procedure: incremental rather than overlapping. For example, the major practice expense for an office-based practitioner associated with the performance of an ultrasound is the cost of the machine and the cost of the training to perform the service. Neither of these are necessarily duplicative of, or overlapping with, the practice expenses associated with the provider’s E&M service.
In the case of facility based providers, like emergency physicians, the practice expense component of the E&M services are likewise separate and distinct from the practice expenses associated with procedural services by these providers, AND IN ADDITION, the practice expense component of the emergency physician’s E&M services represent a very small component of the overall RVUs assigned to the E&M service – certainly far less than 50%.
I indicated that this policy was inappropriate whether or not it was applied to office based or facility based providers. It is my understanding that several plans have initiated or are planning to initiate this same sort of payment policy. The AMA has also responded to this development. The fact that Anthem in KY is apparently not going to apply this strategy to emergency physicians, and perhaps other facility based providers, and the argument above against this practice, is an opening that other providers can use to push back when faced with these payment reductions. The unilateral decision by health plans to re-invent or re-interpret CPT claims coding rules on the fly, using rationales that appear more like rationalizations, begs for adoption of standardized, universally applied coding/payment rules for all payers.
This post also published in The Fickle Finger
State governments have fallen into deep budget deficit holes, as we all know, and state legislators and policy makers are casting about for ways to dig themselves out. Many are climbing over the backs of those least able to fend for themselves in this troubled economy, since the poor have little clout and even less representation, now that the Supreme Court has given corporations and unions carte blanche to finance political campaigns up the political wazoo. Therefor, it should come as no surprise that the budgets of State Medicaid programs all across the nation are taking a big hit, and Medicaid policies intended to protect access to care for the indigent are being bent all out of shape, if not violated outright, in the process. Unfortunately, access to emergency care is getting the lion’s share of the attention in this cost-saving, budget slashing, attack on Medicaid, and this effort is rending holes in the emergency care safety net.
From the East Coast to California, State Medicaid Departments and policy makers have decided to target the ‘unnecessary use of the emergency department’ by Medicaid enrollees as the easiest way to eliminate waste and excessive costs in the Medicaid program, even though there are many far better opportunities to save money and reduce unnecessary expenditures in Medicaid and in health care in general. No doubt, ED care is relatively more expensive than UCCs and clinics and PCP offices for non-urgent medical services, and no doubt, many Medicaid patients could potentially receive this care in other, more appropriate venues, if these venues weren’t already failing miserably when it comes to providing adequate access for unscheduled non-emergency care to Medicaid enrollees. To many people, a cursory look at the efforts to get these non-emergency patients out of the ED might seem not only reasonable, but compelling, in the face of massive State budget shortfalls. Thus, you now see all sorts of policies aimed at limiting access to the ED, some designed to dissuade Medicaid patients from even considering a visit to the ED, others designed to retroactively deny coverage, or payment, for these services, despite the adverse consequences such policies will inevitably have on these patients, their families, and everyone else who might need emergency care. It seems to those of us who understand the implications of such policies the epitome of penny wise, pound stupidity.
California’s Medi-Cal program now intends to impose a $50 copay on ED visits in order to discourage ED use. Texas Medicaid will reduce payment on ER claims by 40% if the final diagnosis is not on their ‘emergency diagnoses list’, and Virginia likewise reduces payment for Level 3 visits using a similar approved list. In Illinois, a very rigid set of criteria are used to deny coverage under the prudent layperson standard, and in Oregon and other states, like Colorado, emergency physicians are paid a $10-20 ‘screening fee’ when the final diagnosis is not on the list of approved medical emergencies. Recently, In Washington State, Medicaid program directors have decided to implement what may be the epitome of bad medical policy by refusing to reimburse providers when the patient uses the ED more than three times in a year for non-emergency problems like hypoglycemic coma or pseudomonal pneumonia or sepsis. The process that WA used to derive this list of unapproved diagnoses, and meet their budget savings target, would be laughable if it weren’t so inane (see this blog )
These policies all have one thing in common; they entail little direct political risk for policy-makers. They rely on the EMTALA obligation of emergency care providers to ensure that patients who seek care from the ED, whether because they are seriously ill or injured or simply because there is no where else they can get any kind of care, will likely not be turned away. It won’t matter if the Medicaid enrollee can’t afford the $50 co-pay, or has to make a fourth visit to the ED in a year for another acute exacerbation of a chronic illness, or fails to pay the ED bill when the State declines to cover the visit, or is relying on the ED for psychiatric care because they can’t get into a treatment program, or makes an ‘imprudent’ decision to use the ED because they are concerned their chest pain might be an MI rather than esophagitis. Nearly all of these patients will be evaluated and treated for their medical emergency and even in most cases for their non-emergency condition, or at least be afforded a referral to an alternative venue once screened. This is not just because of EMTALA, but also because emergency physicians are, in almost every instance, compassionate providers who understand that they are the last, best, and often only hope for many of these patients – the safety net for the safety net.
The States that have adopted these budget-saving strategies also rely on another political reality to justify what otherwise might seem to be a fairly callous approach to the economically disadvantaged: all of these policies effectively dump the financial responsibility for caring for these patients on to the backs of hospitals and emergency care providers. The bet is that voters and taxpayers won’t care if the Medicaid programs in their state take advantage of EMTALA obligated providers in order to ease the burden on state budgets. Despite increasing hospital and ED closures, shortages of emergency physicians, and disappearing ED on-call specialists; the assumption seems to be that emergency care will always be there when needed even if these providers have to work for free. Somehow, EMTALA has suspended the laws of supply and demand.
Medicaid policies designed to reduce payment for ED care also have in common the decision to sidestep the prudent layperson standard that CMS imposed on Medicaid Managed Care organizations under section 1932(b)(2)(B)(ii) of the Social Security Act. Though many states have adopted this standard for Medicaid Fee-for-Service programs, others argue that prudent layperson does not apply to their Medicaid FFS program, and that they are not required to pay for medical screening exams when the final diagnosis does not substantiate an emergency medical condition, even though many of these same states have their own version of an EMTALA mandate on the books. Ultimately, this debate may need to be resolved in courts, where emergency care providers will hopefully be protected from abusive payment practices that effectively result in theft of their services.
The oddest aspect of these state payment policies is that they seem to be founded on the principle that the best way to punish Medicaid patients for using the ED inappropriately for health care services, and change this behavior, is to refuse to pay hospitals and emergency physicians for providing these services. The fact that these policies will adversely impact access to emergency care for everyone, rich and poor, seems to escape just about everyone.
ACOs are coming to a health care market near you. About the only real difference I can see between the ACO model and the ‘managed care model’ is that health plans (or Medicare or Medicaid) will be using incentive payments to promote cost-effective care, rather than (or in addition to) capitation payments as a risk sharing (or risk transferring) strategy. These incentive payments will include aggregate payments negotiated between the ACO and the payers, and incentive payments to individual providers within the ACO that are eligible to receive these incentive bonuses. This may seem like a new approach, but it is really not much different than the ‘risk pools’ that plans once used to incentivize medical groups and IPAs to hold down costs. I guess that everyone assumes that this risk-sharing concept has a better chance to work now that all these sophisticated tools like EMRs and chronic disease management advocates are around to help coordinate care. Some folks might argue that ACO incentives are about promoting effective care, but trust me, the emphasis is likely to be on COST first, and effective, second.
ACOs are not just meant to exist under the Medicare program, so it is likely that many of the payment methodologies and organizational entities (like IPAs, medical groups, PHOs, and integrated health systems like Kaiser) are going to get into the ACO game on the commercial side as well as the government payer side. Consequently, there might be an opportunity here to rewrite, at the federal and especially the state level, the rules under which commercial and government sponsored managed care has been operating for the last few decades. If you have the chance to influence the way ACOs will operate, and the rules they must follow, in your State, or at the federal level, you might consider promoting some of the following suggestions, which are born of many hard lessons learned from the most abusive and inappropriate practices of managed care plans and provider groups around the country (and especially in California, where managed care took root many years ago).
• A managed care model that limits the percent or number of physicians who have equity ownership of the organization is likely to promote both practice and payment policies that preferentially derive benefits for the equity holders rather than for the providers and their patients. Also, it is easier to get physicians ‘on board the bus’ if they all have an equal stake in the success of the organization. ACOs should have broad, and preferably equal, equity participation among all participating physician providers.
• Physician leadership in ACOs should continue to provide clinical services so that they experience the impact of the clinical practice policies they develop and promote.
• When developing payment policies for different physician specialties and roles in the ACO or Foundation model, consideration should be given to whether the physicians are obligated to take on the care of the under- and uninsured as a part of their practice, and these obligations should be considered part of the practice overhead of these physicians, relative to the physicians in the ACO who can and do decline to take on these responsibilities in their practice.
• Foundations and ACOs that are initiated by, or intimately tied to, hospitals have often and particularly used coercive tactics in negotiating contracts with hospital-based providers. Coercive contracting must be countered by strict rules regarding the development of fair market discount and other payment arrangements with hospital based providers, especially those whose ability to decline participation in caring for ACO patients is limited by EMTALA or by virtue of at-risk departmental staffing contracts with hospitals.
• Carve-outs and selective enrollment and dis-enrollment policies must be strictly limited in order to ensure that ACOs and Foundations do not game government sponsored capitation programs.
• Primary care centered ACOs should not be responsible for the payment of the claims of non-contracted non-elective services, as this will encourage these ACOs to inappropriately pay claims rather than manage patient care as a means of reducing costs and increasing profits.
• ACOs that take on claims payment responsibilities for all professional services should be required to contract for non-elective as well as elective specialty care services, so that the ACO does not have to rely on the EMTALA obligation of ED on-call specialists for non-elective and after-hours care.
• ACOs should not be delegated the responsibility by a health plan for paying the commercial claims of non-participating providers: this should be the responsibility of the health plan, with cap deductions or risk pool arrangements to ensure that the ACO does not over-utilize non-par provider services.
• If an ACO becomes financially insolvent, the health plan should be responsible for unpaid commercial ACO-delegated claims, under the concept of negligent delegation.
• ACOs should be accountable to their community, and not just to their assigned patients.
• ACO administrative overhead should be counted against the 85% mandatory health plan medical loss ratio requirements under health reform.
• If an ACO does not have a nurse-advice line or similar mechanism for assisting patients in deciding whether or when to use emergency department services, it should not be allowed to retroactively deny coverage for emergency department services based on the prudent layperson standard.
• Hospitals that participate in, contract with, or develop ACOs should be required to collect data on hospital inpatient and outpatient care services and outcomes that can be accessed and reported by ACO providers in order to meet performance and reporting benchmarks.
Courtesy of a recommendation from a friend, Dr. Joel Stettner, let me also suggest you view the following video, which is very funny, and sadly all too accurate: