By Rod Baird
This blog post covers the LTPAC Practice Management highlights from the American Medical Directors Association meeting in Orlando, FL during March 2016. For the first time in my 10+ years of participation, almost all of the pieces of the LTC and PAC puzzles were on display. They included:
- Major facility EHR vendors’ embrace of physician portals, including Meaningful Use
- The emergence of a ‘business’ track
- A viable full risk model for physician-led LTC population management
- Cogent discussions about the importance of physician-led Care Management
- Programs from medical groups with hands-on BPCI experience
- Growing shift from competition towards collaboration
Writing about the annual American Medical Directors Association convention is always a challenge – where to start, and what to discuss? If you are trying to solve a puzzle and don’t know how to start, think about a possible answer and work backwards to where you are. So, I’m going to start describing AMDA 2016 with a thesis statement:
“The individuals we refer to as LTC Patients should be ground zero for our government’s health reform efforts, and their Primary Care Providers are the gateway to that reform.”
— Many of these individuals also spend part of their year with acute problems that lead to a hospitalization. That event places them in a Post-Acute (BPCI or CJR) bundle, but those models are ill-suited for individuals with multiple chronic medical and cognitive problems.
If you accept my thesis, then the AMDA meeting should be the most important meeting of the year; its attendees include the primary care providers for the LTC population. Some large medical groups reject AMDA, saying it’s too focused on Medical Directorship or CME, and less on management, payments, and population management. Neither individuals nor organizations can ignore their DNA – and AMDA began as, and is, a medical education organization. Most attendees come for their annual CME and in support of their CMD (Certified Medical Director) status; the faculty are the thought leaders in clinical care and the QI/QM process for Nursing Facilities.
AMDA 2016 proved that the organization’s nurture can outweigh its nature. While the conference delivered the usual menu of CME/CMD course work, it served up a full day’s track on Payment Reform, and individual programs on ‘hands-on’ practice management.
If you knew where to look, nearly all the key elements of a comprehensive LTPAC population and practice management strategy were available. Sorting through 50+ scheduled session, and up to 200 individual presenters did make it challenging to find those key elements.
The highlights of the four days I attended were:
- Wednesday prior to AMDA is the Vision Group pre-meeting. For the 2nd year in a row, three of the major facility EHR vendors participated in an interactive panel discussion. Those vendors were AmericanHealthTech, MatrixCare, and PointClickCare. Their representatives described product development strategies to electronically engage medical practitioners in shared care of the facility’s patient.
- During the AMDA meeting, PointClickCare announced they have joined forces with my company’s EHR = gEHRiMed™ to deliver a nationwide solution for the post-acute care physicians and care centers they service. That partnership will allow facilities and practitioners to securely exchange patient data to improve direct care. On a practical level, the sharing of data will allow LTPAC Physicians and Nurse Practitioners a relatively easier pathway to achieving Meaningful Use.
- The emergence of a ‘business’ track – On Thursday (3/17), one of the sessions addressed the role of Payment Reform on LTPAC Medicine and LTC in general. Topics covered MIPS, BPCI/CJR, MACRA, ACOs’ assessment of LTPAC, Quality Management/scoring, Facility-Physician collaboration, HIEs and Interoperability.
- The presentations were top notch, with each person covering an aspect of the CMS programs that are changing care delivery. What was missing was a ‘road-map’ for Medical Groups to follow as they make the transition from FFS to full risk payments. That’s understandable because there is no public model for making that transition. Each presenter described the hurdles/pitfalls they saw, and the critical role LTPAC fills in our care spectrum, but there was no path. All of the industry’s focus is on Post-Acute.
- A viable full risk model for physician-led LTC population management. At the end of the day, there was a panel discussion that wove HIT into the program. Five of us gave quick presentations. One of the presenters, Dr. Bill Russell, serves as the Chief Medical Information Officer for an unusual geriatric practice – ChenMed/JenCare. ChenMed is a Full-Risk geriatric medical practice – working in partnership with Medicare Advantage plans. Bill was describing how his team had to invent their own EHR system – to focus on the person, not the accumulation of their problems. The group is not paid FFS, so care isn’t delivered through the paradigm of CPT® codes. I’d recommend anyone working on a road map for their LTPAC practice consider the ChenMed model as a high quality destination. Getting there from FFS medicine is still a problem, but they are a personification of what the destination might look like.
- Cogent discussions about the importance of physician-led Care Management. The one thing everyone giving presentations at AMDA agreed on – that LTPAC patient-centered care required physician leadership of an interdisciplinary team. Beyond that, ideas quickly diverged. Should the Physician (or group) share risk, or serve as a clinician/advocate who can manage care delivery without a direct financial interest in the services’ cost? These issues are truly significant to many of us who dwell inside the current and emerging payment models for LTPAC patient populations; the existing Risk Adjustment tools, and Quality Measures, employed by CMS (Medicare/Medicaid) are defective for the population and lead to perverse incentives. At the same time, MACRA/MIPS is sending a huge signal to Physicians – share risk or suffer a death of 1,000 cuts.
- Programs from medical groups with hands-on BPCI experience. At least three different programs over the course of AMDA 2016 featured physician leaders from IPC/TeamHealth. Prior to the TeamHealth acquisition, IPC launched a Model 2 BPCI program (covered here in August 2015). Dr. Kerry Weiner, IPC’s CMO related their experience during the 1st six months of the program. The single most sobering slide he used in the presentation stated:
“Bottom Line – 15% utilization Improvement to break even”
Regardless of your role in LTPAC care, pay careful attention to IPC/TeamHealth; they are uniquely positioned to see the entire spectrum of bundled payments based on Hospitalizations. They alone fill every niche a medical group can occupy – Acute episode initiator as the admitting MD, hospitalist for someone else’s bundle, PAC attending with or without shared risk.
The organization seems very candid in sharing its experience – pay attention!
- Growing shift from competition towards collaboration: Kerry made another statement which I’ll paraphrase – the days of [IPC’s] rampant acquisitions are over, any LTPAC network expansion will be in carefully targeted markets. However, IPC/TeamHealth was ready to partner with other groups to create ad hoc LTPAC networks in many locations.I cited Kerry’s comments because they are indicative of a newly emerging sense among many attendees — we are all in this together. The sweeping changes in payment reform are going to upset years of careful work –and only by banding together can medical groups, and facilities, create structures that can endure through the waves of change.Late Breaking News – those of us close to LTPAC practice management, coding, and compliance know there is significant debate about the appropriateness of using CPT® 99490 (chronic care management) in LTPAC settings. The debate will continue, but CMS clarified questions about basic coverage in the SNF and NF settings.
- CCM is not covered if Medicare Part A is paying for the patient’s care (SNF or POS 31 stay).
- CCM may be covered if there is NO Part A payment (NF or POS 32 stays).
- CCM is a covered service in Assisted Living, Adult Care, Group Homes, Home (including when Home Health is present).
We plan to discuss the nuances of this code in more detail in upcoming ltcmanagement blogs & the gEHRiMed webinars!
This article was originally published on gEHRiMed and is republished here with permission.