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   RE: opportunity for imps Please respond?
 From: Peter Liepmann
 To: Member Forum
 Posted: 05-14-2017 19:36
 Message: Amen, Michael!!

I also posted this on the AAFP small/solo practice MIG:

I think one other feature we ought to include in this program  is allowing MCR members to opt out on a month's notice, so they're protected against deliberate undertreatment. "Stinting" in the words of CMS:

"We assess all APM designs for possible perverse incentives and the potential for care stinting activities prior to implementation. We agree that we should continually monitor for perverse incentives and behaviors such as care stinting, and we actively perform these assessments now. We believe that both the inclusion of payment based on performance on quality measures in the Advanced APMs and the ongoing monitoring and evaluations conducted on all APMs are mechanisms for identifying whether appropriate care is withheld to save costs."

While problems with 'care stinting' would show up in HYH, there's no harm in further protecting patients, and making this easier for MCR to approve.

Peter Liepmann MD FAAFP MBA
My mission is to fix US health care
Bakersfield CA
Original Message:
Sent: 05-12-2017 03:19
From: Michael Safran
Subject: opportunity for imps Please respond?

This is not simple.  Sorry for the long post.   I believe we are really undervaluing ourselves.  Please look at the CPC Plus program by CMS. The way I read it:
Track 1 pays:
Care management average of $15 pmpm. (ie $ 0.5 pmpd)
It also pays for FFS billing!!  Which I believe is around $600 to $760 per Medicare patient per year.  ($1,65 - $2 pmpd)
Extra $2.5 pmpm potential for performance  (.$083 pmpd)

Track 2 proposal:
$28 PMPM for care management ($ 0.93 pmpd)
reduced E & M code reimbursement
Some additional FFS reimbursement
$4 pmpm performance incentives

Jean  -   I believe the $1 per day you are earning is for Medicaid patients, which of course pays less.

Scott - Why do you feel $2 per day is out of line?   Your question about how are patients attributed to primary MD is a good one.   Although i presume CMS has a way to do it for CPC +,

Some of my thoughts - Those of us in private practice in primary care have become used to earning less income then our colleagues.  To make up for the relatively low reimbursement for cognitive codes vs proceedure codes, we have learned to  use a slew of additional codes, in addition to the typical E and M codes.

$1 a day as Jean calculates earns you $185,000 a year.    Not bad compared to most of our patients and fellow citizens.  But I think a goal of this program should also be to attract medical students to chose primary care and for residents and unhappy doctors in mega groups to consider the option of independent practice.

I propose average $2 to $2.25 per day per patient if we are not doing any FFS billing.    $730 to $820 per year for high quality primary care is not a lot.

Might consider combination of Care management of $ 0.5 pmpd plus FFS billing   or $1 pmpd plus E/M billing.

There should also be some performance / reward criteria or shared savings proposal.

I bill the average Medicare patient: 3 99214 visit per year, 1 AWV,  and maybe two CCM visits.   a "nurse" visit - 99211, Flu shot,
99214 = 115 x 3 = 345
AWV  =    124
CCM x 2 = 45 x 2 = 90
99211 x 1   $21
Flu shot earns approx $30 ?
That comes to $600.  or $1.65 pmpm.     There are also many other codes we often use.   I am not saying I want to use those codes, but I need to, in order to earn a living.  I am not sure which, if any, are covered in CPC Plus.

Is there a way to include a modest copay?   $15-$25 per visit.  Is there a benefit to doing that?

That's enough for now.  Could go on and on.

Michael S. MD
Original Message:
Sent: 05-10-2017 20:21
From: Jean Antonucci
Subject: opportunity for imps Please respond?

AND Scott  thank you
we need to flesh this out  as soon as possible

  With this  plan there are no other reporting measures besides HYH which is free
 the way I see it is
1 right now at 15patients  a day x 4.5 days a week   a doc submits 75 separate pieces of paper to get a paycheck .INclude  the clearing  house and the nuances of bbay sitting transitional care codes  and the occasional rejection if you dare submit a 99215 etc etc

2 the other payors follow cms
 Imagine if you were paid 1-2.00 a day period, without coding and billing  and your measuring tool helped you take care of people as well as risk adjusted them and  measured what matters.

Jean Antonucci
Original Message:
Sent: 05-10-2017 15:41
From: Scott Macleod
Subject: opportunity for imps Please respond?

Interesting idea.
The key is  per day ( including all days not just business week) ( and not expecting every day/anytime physical access) payment for every patient
Most of us have a mix of patients with many insurances.
So if you have 200 pure Medicare
Using  $1/ day = 73,000/yr
Most of this group would be seen about 4/ yr on average
So say you get paid for 70/visit = 56,000/yr
That works out in the positive of about 85/pt per year more.
Which is about 1 extra visit worth per year
And would not include transitional, CCM, wellness money extra you could add on to the regular system and assumes no more than 4 visits a year for these complex patients.
Yes some less paperwork but not much...still doing quality measures, etc..

So at the dollar per day it is a little thin to make much difference.
Right now you are lucky to get a  per pt per month bonus for usual quality/cost /satisfaction criteria in the single digits and that is hard to do
To get 2/pt/day would be somewhat of a miracle without requiring paperwork flow that would be at least 1/day in costs.

Like the idea but not I would be willing to jump in without knowing all the details. Like how are the patients attributed to you, etc....

Scott Macleod
Highlander Family Medicine
Woodstock VA
Original Message:
Sent: 05-09-2017 22:33
From: Jean Antonucci
Subject: opportunity for imps Please respond?

Dear IMP Community,
 For years  IMP has struggled with how we might work together to improve payment or  work on  advocacy  measures despite the fact that we are  spread out across  all the states, with each state having various initiatives around cost/quality/practice transformation efforts/programs  payment etc.We spend time telling stories about "well  what  I  do is" when  the  one listening often  has no power to utilize such stories in their environment.
Tres frustrating

 Our time has come
What we have  been unable to do is now possible
 The law called MACRA established a board or committee called PTAC (Physician Payment Technical Advisory Committee- like SO not any clever acronym but at least it has a vowel so you can  pronounce it:) )- to evaluate new methods to pay docs. Any doc or any  group can make a proposal to this group  The proposals  would be around  the structure of payment and must be  nothing  done  before, be about value over volume and measure  quality  to prove its worth

 Although IMP has been a community that supports practices in practice management, we originated in the idea  of a project that would use innovative measuring and cutting edge tech to pursue practices that were sustainable for the docs and  provide the best care for patients. Those of us that went through the IMP project  cohorts or attended IMP Camps  know the details.

A few  of us have gotten together on the iMP calls and email and agree we should make a proposal
we have a good friend on the committee who  would help us

The basics are: us simply and better
Roughly $1.00( maybe more)/patient/day  (- -  have 1,000 patients?   so-$365,000 into your practice and so say the overhead is 50%, you the doc get  $182,500.) You can take of people for 1.00/day We might risk adjust it but   for this  post we are  keepin gitismple.
2 use HowsYourHealth to measure and risk assess.
 There are details Not for this email

I need a lot of patients to do this I need a lot of docs.
 Please respond to me at if you are  interested inpartcipating
 we need you to take straight ordinary Medicare as payment would apply to them only, we need you to be willing t o use HYH   60 + surveys/yr ( its free)We  may need you to do a little work for the proposal  but I am hoping  a small steering group can  put it together .

We have a good chance this project will be  accepted( which means recommended to DHHS who may put it into action)

If you want  simple pay  better  pay and to get  out of  some of the  administrative measurement junk, please email me
I need this SOON  I need you to  be willing to recruit 1 or 2 or 10 other docs also

Frankly, why wouldn't you?

Jean Antonucci

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