5/14/2018

Sue Cummings, MS, RDBonnie Jortberg, PhD, RDN, CDE

Health Systems and the Primary Care Team

Session Overview

• Changing healthcare landscape• Alignment with Academy Strategic Plan &

CSOWM• Health care delivery initiatives• How does this apply to you?

5/14/2018

Why New Payment Models?

Current fee-for-service model of care: Is not financially sustainable Does not encourage disease prevention Does not translate into better quality of care

Studies have shown that a robust primary care system leads to lower costs and better quality of care

Healthcare Systems

Why care?

• The landscape of healthcare continues to rapidly change

• Ready or not, the traditional model of “fee for service” healthcare delivery will eventually disappear

• We want you to be informed and be prepared to appreciate your value and maximize your success

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The Triple Aim: Care, Health, & Cost

• To improve the U.S. health care system, need pursuit of three aims:• Improve the experience of care• Improve the health of populations• Reduce per capita costs

These concepts have framed primary care transformation efforts

Health Affairs 27, no. 3 (2008): 759-769

Focus Area: Health Care & Health Systems

Alignment with Academy Strategic Plan

5/14/2018

Advocate for health care delivery and payment systems that maximize nutrition services across clinical and community settings

New Specialist Certification:

Board Certified Specialist in Obesity and Weight Management (CSOWM) Interdisciplinary specialist credential

Developed by The Commission on Dietetic Registration-the credentialing agency for the Academy of Nutrition and Dietetics.

…a health professional who possesses

comprehensive knowledge of and expertise in

obesity and weight management. A CSOWM

professional educates, supports, and

empowers patients/clients to understand and

manage their weight and risks associated with

being overweight or obese through nutritional

, physical, psychological, behavioral, medical

and/or surgical interventions.

Health Care Payments are Changing!

Private market: • Alternative Payments increased from 11% (in 2013) to

40% (in 2014)

Medicare:• 85% of FFS payments tied to quality or value by 2016• 50% of payments tied to quality/value through

alternative payments models by 2018

(“Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care,” Burwell, N Engl J Med

2015; 372:897-899 March 5, 2015)

PAYMENT REFORM AND MEDICARE

Health & HumanServices

• Shift 30% of Medicare FFS payments to value through APMs by 2016, 50% by 2018

• Creation of Health Care PaymentLearning & Action Network

• Investment inMulti-payer Efforts

Congress

• Passage of Medicare Access and CHIPReauthorization Act(MACRA)

• Merit-based Incentive Payment System(MIPS)

• AlternativePayment Models(APMs)

https://hcp-lan.org/

Health Systems Module

Practice Management & Reimbursement Module

MIPS, MACRA & APM Resources

5/14/2018

Patient Centered Medical Home

• Began with pediatrics in the 1960’s to coordinate

care of patients with special needs

• In 2007, all primary care organizations developed 7 Joint Principles for the PCMH – currently being used as a framework for the PCMH

• The PCMH is an approach to providing enhanced, comprehensive primary care for children, youth, and adults.

Builds on core primary care principles, but with some key changes

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Patient Centered Medical Homes

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Patient Centered Medical Home

Certification standards set by National Committee for Quality Assurance strong

emphasis on chronic disease management

BCBS of South CarolinaPCMH group had

36% fewer hospital days, 12.4% fewer ER visits and 6.5% reduction in total costs compared with patients in standard system

Currently about 12,000 practices (60,000 physicians) recognized by NCQA as PCMH

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Accountable Care Organizations

Part of the Affordable Care ActTriple Aim:

• improve health of targeted population• improve patient experience• Improve affordability of health care

Group of physicians, hospitals and other suppliers of services that work together to provide coordinated care to a population

Designed to be built around medical homes –must include primary care physicians

Encourages innovations to decrease costs and share savings

Quality measure reporting – accountability

Patient-Centered Medical Neighborhood

Primary Care Innovations & PCMH Map

https://www.pcpcc.org/initiatives/national

Comprehensive Primary Care Initiative(CPC)

An initiative from the Center for Medicare &

Medicaid Innovation (CMMI) and made possible

by the Affordable Care Act (ACA)

• CMMI, part of CMS, supports the development &

testing of innovative health care payment &

delivery service models

The goal of the CPC initiative is to help primary

care practices deliver higher quality, better

coordinated, and more patient-centered care.

Recognizes that a primary care practice is a key point of contact for patients’ health care needs

Overview of CPC

Providers expected to incorporate “5 functions” of primary care

• Care management*• Enhanced access• Planned care for chronic conditions & preventive

care*• Patient engagement & proactive patient

planning*• Care coordination across the medical

neighborhood*

*Denotes RDN

opportunity

Overview of CPCBuilds on existing reform efforts:

• Patient-centered medical home (PCMH)• Accountable Care Organizations (ACOs)• Meaningful Use (MU) standards

Blended compensation model:

• Fee-for-service

• Risk-adjusted care coordination per-member-per-

month (PMPM) payments: to support value-added

non-billable practitioner time*, advanced care team

functionality*, or investments in HIT utilization

• Share in saving eligibility: practice level quality &

utilization metrics *Denotes RDN

opportunity

Comprehensive Primary Care Initiative

• CMS Demonstration in 8 states

• 497 primary care practices, >1

million patients

• Transforming to PCMH with

payment reform

Arkansas: Statewide

Colorado: Statewide

New Jersey: Statewide

New York: Capital District-Hudson Valley Region

Ohio and Kentucky: Cincinnati-Dayton Region

Oklahoma: Greater Tulsa Region

Oregon: Statewide

Care Management Fee (CMF)

Performance-Based Incentive Payment – patient experience, clinical quality measures, & utilization

Medicare Fee Schedule https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus

CPC+: Expanded to 18 Regions

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Why is this Important for the RDN?MNT is linked to improved clinical outcomes and reduced costs related to:

• physician time • medication use and hospital admissions for people with obesity• diabetes and disorders of lipid metabolism, as well as other chronic

diseases

An RDN delivered lifestyle approach to diabetes and obesity improved diverse indicators of health, including:

• Weight• HbA1c• Health-related quality of life, use of prescription medications,

productivity and total health care costs• For every dollar invested in the RD-led lifestyle modification program

there was a return of $14.58

Most recent Academy Evidence Analysis Library analysis found:• Strong evidence to support effectiveness of nutrition

interventions & counseling by an RDN as part of a healthcare team

Why is this Important for the RDN?

The Lewin Group documented an 8.6% reduction in hospital utilization and 16.9% reduction in physician visits associated with MNT for patients with cardiovascular disease.

The group additionally documented a 9.5% reduction in hospital utilization and 23.5% reduction in physician visits when MNT was provided to persons with diabetes mellitus.

Character Development: Opportunity to Expand RDN Roles

• Individual and group MNT, DSMT• Telehealth• Interdisciplinary care teams• Care coordinator/case manager• Transitions of care• Population health management/panel

manager• Quality improvement teams (leader)• PCMH performance measures reports• Self-Management Program Leader• Group medical appointments• Tobacco Cessation Specialist

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Benefits of RDNs for Patients with Obesity: PCP Perspective

• More effective at weight loss & weight maintenance

• Integral for new models of health care delivery and payment:• Pay for Performance: BMI, HgbA1c, BP, LDL

• PCPs feel unprepared to treat persons with obesity:• Inadequate training• Knowledge deficit of obesity treatment• Time• Reimbursement

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Academy’s IBT Toolkit

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Intensive Behavior Therapy for Obesity

Medicare part B benefit for patients with BMI >30kg/m2 since November 29, 2011

Codes: Individual, face to face counseling 15 minutes or Group face to face counseling 30 minutes. Obesity diagnosis coded before service

Frequency: 22 times on 12 month period. *Must lose 3 kg within first 6 months

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Intensive Behavior Therapy for Obesity

Outpatient clinic/hospital setting with eligible PCPs

- family practice, pediatrics, OB-GYN, geriatric, NPs, PAs

RDs must bill “incident to” eligible PCP

Payment: varies by region by averages $25 for each 15 minutes session

Financially much more reasonable to utilize RDs!

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Intensive Behavioral Therapy for Obesity

Benefits:1. More collaboration

with PCPS. 2. Improved access

attrition3. Increased

reimbursement 4. Improved patient

health5. Improved patient

satisfaction

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Challenges:

1. Visit duration2. Visit frequency3. Attrition4. Space

limitations5. PCP referrals

IBT Scenario Discussion

• You are a RDN working in a hospital providing both inpatient and outpatient nutrition services, including WM. You want to start providing IBT – what do you need to do?

• You are in private practice and would like to start providing IBT – what do you need to do?

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What is the Academy doing?

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Academy Resources:

Academy Resources

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Academy Resources

www.eatrightpro.org/resources/practice/getting-paid

Reflection Question:

How do you think you can justify your worth and show your value?

Please text your answer or raise your hand to respond

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Key Take Home Messages

• Reimbursement models are changing!

• Emphasis on services provided within the PCP

office environment

• Moving away from fee-for-service:

Bundled payments and PMPM payments

• Opportunities (and challenges) for RDNs to

become integrated part of primary care!

• RDNs and NDTRs need to learn to speak a

new language

• Don’t wait for them to call you…make the first

move