The Health Care Environment€¦ · Medicare Mental Health Access Act APA Practice Organization priority legislation Adds psychologists to Medicare’s definition of “physician”,

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Promoting Access to

Psychological Services

in the Evolving

Healthcare Landscape:

the Critical Role of

Advocacy

APAHC

Detroit, MI

March 9, 2017

Katherine C. Nordal, PhD ED for Professional Practice

Promoting and supporting practicing psychologists

Declining reimbursements Increased demands for cost containment Increased cost of doing business (rent, labor,

equipment, insurance, etc.) Increased numbers of providers in the

psychotherapy marketplace Growing regulatory demands (billing, privacy,

confidentiality, patient consent, F-W-A) Lack of negotiation leverage Ever escalating health care costs!

The Health Care Environment

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Increased regulation of price and volume of psychological services by public / private payers

Rapid and large-scale consolidation of health insurance market leading to more payer power: providers have lower reimbursement and less autonomy and consumers have higher premiums

Professional, market and regulatory developments encouraging more collaborative care practices

Emergence of new reimbursement mechanisms to replace fee-for-service: P4P, global payments, episode of care payments, shared savings

Evolving Health Care Landscape

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Evolving Health Care Landscape

Federal and state policies pushing integration:

Quality payment programs with incentives to meet certain quality standards

Health Information Technology (HIT): cost and ability to meet “meaningful use” criteria for incentives

Anti-trust Enforcement Policy: allows integrated provider organizations to negotiate with plans re: payment rates. Groups without integration (financial and clinical) are prohibited from such negotiation.

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New care delivery models/systems: PCMHs, ACOs

New skills and training models for integrated, inter- professional team-based care

Implementation of telehealth, HIT, and electronic health records

Increasing demand for the use of Evidence-based practices and quality metrics

Payment reforms: Value-based payment models; Bundled payments, Shared-savings models

Implications for Professional Practice

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Legislative Advocacy

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Helping Families in Mental Health Crisis

Reform Act of 2016

● Passed with overwhelming margins; became law in December 2016

● Provides for major reforms of federal MH system and funding streams:

• creates a new HHS Assistant Secretary for MH/SU

• strengthens enforcement of federal MH/SUD parity requirements

• clarifies health information privacy protections

• eliminates the Medicaid “same day” exclusion

• promotes greater integration of mental/behavioral health into primary care

• creates or continues federal grant programs

● APA Practice Organization worked with Rep. Tim Murphy (R-PA), a psychologist, and with

Senators Chris Murphy (D-CT) and Bill Cassidy (R-LA), to move the legislation forward


Legislative Advocacy Priorities 2017

Reintroduction and advancing the Medicare Mental Health Access Act, to add psychologists to the Medicare “physician” definition

Protecting key psychological and mental health provisions in the Affordable Care Act, as Congress looks to replace/ repair it

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Medicare Mental Health Access Act

Rep. Kristi Noem(R-SD-At Large)

Rep. Jan Schakowsky (D-IL-09)

Sen. Sherrod Brown(D-OH)

Sen. Susan Collins(R-ME)

● “physician” definition bill

● just reintroduced in Congress by:



● APA Practice Organization priority legislation

● Adds psychologists to Medicare’s definition of “physician”, which already includes dentists,

optometrists, podiatrists and chiropractors

● Removes the unnecessary physician oversight requirements still present in several

Medicare settings, including:

• General hospital outpatient

• Skilled nursing facility

• Partial hospital

• Federally Qualified Health Center

● Psychologists are the only doctoral-level provider not included in Medicare’s “physician”

definition

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● Psychologists also met with members of Congress on this important bill during our “Hill Day”

on Tuesday

● The bill enjoyed bi-partisan support in the last Congress

● Sixteen national organizations support the legislation, including:

• National Rural Health Association

• Brain Injury Association of America

• Paralyzed Veterans of America

• Mental Health America

• Association for Ambulatory Behavioral Healthcare

● American Psychiatric Association is the only group opposing the bill


ACA Repeal and Replace

● President Trump and Republican-led Congress are united in repealing the Affordable Care

Act (ACA)

● ACA has its flaws, but greatly increased access to MH/SUD services:

• applied MH parity to the individual and small group markets

• required plans to include MH/SUD services as essential health benefits

• ended pre-existing condition exclusions and coverage discrimination

• invested in research and training for behavioral healthcare

• expanded Medicaid and Medicaid MH/SUD coverage

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● Congressional leaders are moving forward; now evaluating repeal and replace proposals

● Fluid situation; proposals continue to be revised and modified

● Final legislation likely to remove/rework major provisions of the ACA (ex. eliminating the

essential health benefits requirement and the Medicaid expansion)

● Current plan is to pass repeal legislation by mid-April

● Regulatory actions by new HHS Secretary Tom Price (ACA opponent) will also affect the

details of repeal and replace



● APA Practice Organization and APA working to educate members of Congress on the

importance of the ACA for access to MH/SUD services

● Urged Congress not to repeal the ACA without simultaneously enacting legislation that is

equally protective of MH/SUD services

● Psychologists have sent over 8,500 messages to their members of Congress urging

responsible replacement of the ACA

● On Tuesday, for our annual “Hill Day” in Washington, psychologist state leaders from

around the country met with dozens of lawmakers to stress the importance of MH/SUD

coverage in the ACA

● Efforts to preserve mental/behavioral health in the ACA are intense and on-going. Stay

tuned.

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Psychology PAC Ranking During 114th Congress (2015-2016)

Source: opensecrets.orgAs of 08/31/2015

Psychology’sPAC ranks 44th

among 129 health

professional PACs

$151,946

$156,725

$202,975

$231,578

$2,662,755

$2,114,478

$1,914,399

$1,342,328

$1,205,807

$755,953

$379,769

$508,941

$489,687

$458,573

$437,859

American Psychological Assn Practice Organization

American College of Nurse-Midwives

American Chiropractic Assn

Academy of Nutrition & Dietetics

American Occupational Therapy Assn

National Association of Social Workers

American Speech-Language-Hearing Assn

American Nurses Assn

American Psychiatric Assn

American Podiatric Medical Assn

American Dental Assn

American Medical Assn

American Optometric Assn

American Physical Therapy Assn

American Assn of Nurse Anesthetists


Medicare Access and CHIP

Reauthorization Act of 2015 (MACRA)

● Signed into law in April 2015

● Moves Medicare from a fee-for-service system toward one that requires quality reporting in

service delivery

● MACRA replaced the Sustainable Growth Rate with the Quality Payment Program (QPP)

● MACRA also encourages provider participation in Alternative Payment Models

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● New QPP model: the Merit-based Incentive Payment System (MIPS)

● MIPS combines 3 former programs: Physician Quality Reporting System (PQRS), the

Value-based Payment Modifier, and EHR incentives

● Risk/reward. Providers will receive higher Medicare reimbursement for higher-quality care;

lower reimbursement for lower-quality care.

● Psychologists likely to be added to MIPS in 2019; no impact on payments until 2021

● APA Practice Organization won a “low-volume” exclusion for psychologists




● Quality measures in MIPS are almost identical to PQRS measures

● APA Practice Organization continues to help psychologists with PQRS reporting, through

our Healthmonix registry (PQRSPRO)

● We are also transforming our registry into a Qualified Clinical Data Registry for purposes of

reporting in future years

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Qualified Clinical Data

Registry (QCDR) Initiative

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Centers for Medicare and Medicaid Services

(CMS) Physician Quality Reporting System (PQRS)

In 2015, PQRS shifted to a mandatory reporting system that employs payment adjustments which penalize providers who fail to submit outcomes data on a certain percentage of their patients who are Medicare beneficiaries

To assist members in reporting, the Practice Organization partnered with Healthmonix in 2014 to provide APAPO PQRSPRO, a registry-reporting option for psychologists

Includes approximately 14 measures for psychologists to submit that were developed by a variety of stewards

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What is a QCDR?

“an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes” (AHRQ registry guide, 2014, p. 1)

CMS is encouraging specialty associations to develop their own QCDRs in order to report to MIPS

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Benefits of an APA/Practice Organization-

sponsored QCDR

Define, develop, and/or select the measures that are of the most interest and importance to psychology

Could meet other psychologist data needs, such as licensure/CE requirements, credentialing or board certification requirements, and negotiating with quality-based, differential, and reimbursement payment programs

Provide a real-world view of clinical practice, patient outcomes, safety, and clinical, comparative, and cost-effectiveness

Largest naturalistic, psychotherapy outcomes database

Make de-identified data available to members in clinical science community

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Implementation Plan

September 2016: QCDR proposal approved by CAPP and Board of Directors

APA Practice Organization will work with Healthmonix, an experienced registry vendor, to develop a behavioral health-specific QCDR.

A QCDR Advisory Committee of experts in outcomes measurement will be formed to help guide the development and ongoing maintenance of the QCDR program.

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Legal and Regulatory Advocacy

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Legal and Regulatory Advocacy

TESTING AUDITSPersuaded Anthem to fire Santé Analytics as its auditor and stop abusive audits of psychological and neuropsychological testing.

PARITYSuccessful parity advocacy persuaded Aetna and Regence BCBS to pay more for the 60-minute therapy code (90837) than the 45-minute code (90834).

RISK ADJUSTMENT AUDITS (ACA)Successfully applied our 2014 victory with one major company to all other

companies, leading to almost problem-free risk adjustment audits for membership.

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Insurance & Parity – Insurers

Work with insurers directly before involving state or federal regulators has been effective in several instances:

Aetna was paying 90834 and 90837 at the same rate. We alleged parity violation, and they have since implemented a significant differential.

Anthem and Highmark sent letters to MH professionals who they identified as billing 90837 more than their peers. Psychologists feared that continued use of 90837 would result in audits. We intervened raising parity concerns and each clarified that the letters were simply educational in nature and not intended to dissuade the use of that code. Anthem changed their letter as a result.

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Insurance & Parity – Collaboration with

other stakeholders

Signed letter by Committee on Whole Health to Parity Task Force, in addition to sending our own.

Participate in Scattergood/Parity Track calls on state legislation and on the Parity Registry and provided extensive feedback on the latter

The Pearson-funded parity roundtable

Working with the American Psychiatric Association periodically on reimbursement parity issues

Getting members to submit parity complaints to the federal agencies

Parity Guide created with assistance from Practice Communications

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Federal Parity Issues

Practice Organization comments to White House’s New Parity Task Force: Submitted Aug 31

Focus on Remaining Challenges:

Reimbursement parity and its impact on network adequacy

Inaction on our enforcement complaints, especially when states have primary jurisdiction

Lack of information re comparable limitations on medical side

Results: October 2016 - in several key respects, the task force adopted suggestions or responded to concerns from the Practice Organization on how to advance enforcement of the Mental Health Parity and Addiction Equity Act (MHPAEA).

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Telepsychology

Joint APA/ASPPB/The Trust Task Force developed the APA Guidelines for the Practice of Telepsychology (2013)

APA Practice collaborated in stakeholder meetings in development of ASPPB’s PSYPACT (interstate compact for telepsychology & temporary, in-person practice across state lines)

Coordinating with ASSPB in educating SPTAs and state licensing boards about PSYPACT & supporting advocacy efforts in specific states

Tracking state and federal telehealth policies including insurance mandates

Representation in American Telemedicine Association’s Telemental Health Special Interest Group

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Technology

Input to SAMHSA and other federal agencies on making electronic health records (EHRs) workable and suitable for psychology

Providing support to COPPS (Committee on Professional Practice and Standards) as the Recordkeeping Guidelines are updated to reflect changes in technology and the Social Media Guidelines are developed

Helping psychologists improve their practice through technology

Telepsychology, EHRs, Cloud storage, Mobile Apps, Encryption and Security

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Medicaid Initiative

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Medicaid

Advocating for expansion of psychological services and increased reimbursement in the Medicaid system

Identify key states

(Including DC, NC and NJ)

Collaborate with state psychological associations

Develop strategies and

grassroots advocacy

1 2 3

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Medicaid Initiatives: A Brief History

22% of Americans are Medicaid recipients

Medicaid enrollment will grow by 71% from 2006-2022

Medicaid needs more psychologists.

Barriers to psychological services: limitations on Medicaid reimbursement for independent practice of psychology, Health and Behavior (H&B) Codes, and services provided by doctoral psychology interns.

Working with state psychological associations on these barriers.

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Medicaid Managed Care

Approximately 80% of Medicaid enrollees are served through managed care delivery systems.

States have largely shifted to these types of delivery systems to keep costs low and to deliver value-based care outside of the fee-for-service model.

Managed Care presents unique challenges for our agendaChoice of Providers on PanelsMCO-State Contracts not accessible Interns not “fully licensed”Multiple MCOs operating in same stateWho makes key decisions MCO, state agency, both?

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Research and Strategies for Medicaid

Managed Care

Identify and investigate several states that use Managed

Care for either part or all of their Medicaid services.

Identifying MCOs that have contracted with several

states to provide Medicaid services.

E.G. OPTUM, Molina operating in multiple states

Working with selected state psychological associations

to advocate that MCOs include billing for psychologists

and interns in states where they currently do not cover

those services.

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Medicaid Advocacy

Psychologist Reimbursement

NJPA passed legislation to dramatically increase what were extremely low Medicaid rates

Assisted the Georgia PA with a Medicaid recoupment issue.

Missouri PA received funding through CAPP grants to assist them in their advocacy and legislative process. Legislation passed allowing for the reimbursement of H&B codes in Medicaid.

Other Medicaid Updates

Working with new states on intern reimbursement: NH, AK

New states that have contacted us, providing them initial support: NM, NE

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Medicaid Advocacy

North Carolina – Intern Reimbursement

Work with NC Division of Medical Assistance

Maryland – Intern Reimbursement

Investigating audits of Licensed Psychology Associates

Pursuing intern reimbursement with Maryland Medicaid

DC – Independent Practice and Intern Reimbursement

Collaboration with Children’s Hospital

Patient Centered Medical Homes

Continued Work with Epstein Becker Green

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Legal resources for members

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Legal and Regulatory Resources for

Members

Valuable guidance on legal and regulatory issues raised by members:

• HIPAA and privacy/confidentiality/ security

• Record keeping, including EHRs

• Telepsychology

• Scope of practice, licensing, complaints, subpoenas, testimony

• Duty to warn/protect and abuse reporting

• Abusive insurance/managed care practices

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Responding to Member Questions

Legal staff receives over 1,000 per year on topics such as:

• HIPAA & patient privacy

• Danger and Abuse Situations

Duty to warn/protect, abuse reporting, suicide and patient self-harm, threats to psychologist

• Helping Psychologists Interact with Legal System

Subpoenas, testimony, expert and forensic roles, crime investigations

• Licensure and disciplinary actions

• Recordkeeping and Professional Wills

• Miscellaneous

Psychologists as employees or employers, negative online reviews, closing a practice, etc.

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Other Initiatives

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APA Clinical Practice Guidelines Initiative

October 3: Public call for comments on draft "Clinical Practice Guideline for the Treatment of Posttraumatic Stress Disorder (PTSD) in Adults.“

PTSD Guidelines adopted by APA COR at February 2017 meeting

Draft versions available for comments mid-2017 Depression across the lifespan Obesity in children

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APA: CMS Transforming Clinical Practice

Initiative Grant

Sept. 29 : APA Center for Psychology and Health received federal funding ($2 million over three years)

APA serving as a Support and Alignment Network (SAN) to train psychologists in skills needed to support practices in integrated health care settings

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CMS TCPI grant information

First grant of this type awarded to psychologists

Goal of training 6000 psychologists

Registered APA members receive free training and CEUs

Opportunity to engage in where the industry is heading

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What’s the difference

between APA and the APA

Practice Organization?

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• Promote “psychologists” by advancing the trade of professional psychology

• Engage in unrestricted lobbying, including for reimbursement rates

• Work with political action committee APAPO-PAC

APA: The Practice Organization:

• Promote “psychology”• Advance psychological

knowledge to benefit society• Promote research in psychology• Establish standards of ethics,

conduct, education and achievement

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State Advocacy: Annual Grants from the

Practice Organization – 2007 - 2016

Total legislative grants awarded:

$2, 480,000

Total organizational development grants awarded

$1, 540, 000

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Resources for Practitioners: Member

Communications

Keeping Practitioners Informed

Good Practice magazine

PracticeUpdate e-newsletter

Practice Organization listserv, exclusively for Practice Organization members

Practice Central website: www.apapracticecentral.org

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New Member Resources

Complete Guide to Medicare

7 new Webinars for Practice Organization members re: reimbursement, legal, and marketplace issues during 2017

Reimbursement and ICD webinar with Dr. Antonio E. Puente.

Updating ICD-10-CM resource guide and website section

Collection of Research Roundup columns from PracticeUpdate.

APAPRACTICEORG listserv

“Practice Help Desk” with TPI, available online

Good Practice Fall 2016 – The Money Issue

Innovative Practice Models toolkit on apapracticecentral.org55


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Resources

www.apa.org

www.apa.org/health

www.apa.org/helpcenter

www.apapracticecentral.org

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Questions?

Thank you for your attention. For more information, please contact [email protected] or call 1-800-374-2723

mailto:[email protected]

Documents

The Health Care Environment€¦ · Medicare Mental Health Access Act APA Practice Organization priority legislation Adds psychologists to Medicare’s definition of “physician”,