Ever since one of the main insurance carriers I was credentialed with decreased their allowable fee almost in half, I have been looking for ways to help get that back for myself and the massage therapy profession.
As contracted providers we cannot get involved with insurance carriers talking fees as the anti-trust fee setting laws around price fixing limit our engagement.
Every week I see more articles talking about Values Based Payment Models where providers are paid by the outcomes they achieve rather than the regular fee-for-service method of payment. I just came upon this from the WA State HealthCare Authority talking about values based care for their medicare plans.
Paying for value is a primary strategy to achieving better health, better care, and lower costs. Meeting this goal will require shifting health care reimbursement strategies away from a system that pays for volume of service to one that rewards quality and outcomes. Our goal is to drive 90 percent of state-financed health care to value-based payment by 2021.
Although massage is not covered on their medicare plans, whatever happens in Medicare usually trickles down to regular plans.
A few years ago I had heard about this from an old aquaintence that I had run into who then worked for UW Medical Center in their Pain and Headache clinics and they were asking about how massage could be integrated into their clinics there. I replied that I didn’t think it would be worth it because the pay rates were so low and the overhead in such facilities must be very high. They replied that they didn’t care and that their overall goal was to get people better faster and they would get paid more from the insurance carriers. They also talked about whether or not students could be used since they are a teaching hospital.
I also heard about these networks when I was involved in another committee for a non-profit non massage related organization and heard that ” Physicians Insurance has created a Clinically Integrated Network, (CIN) in Partnership with Premera and PCN,” called Physician Care Alliance.
In 2013, in order to address the market pressures that influence the long-term viability of independent, physician-owned practices, the Northwest Medical Group Alliance initiated a study to determine the feasibility of creating a physician-led Clinically Integrated Network (CIN). A CIN is “a health network working collaboratively, using proven protocols and measures, to improve patient care, decrease cost and demonstrate value to the market”.
The Alliance determined that The Polyclinic’s Physicians Care Network (PCN) provided the best foundation for the network since it had already built much of the clinical and operational functions, staff, expertise, and experience required for its Medicare Advantage business. The CIN could leverage PCN’s long history of high quality care management and have physicians enhance and customize it for a commercial population.
The person from Premera that was working on this was John Espinola, MD MPH, Executive Vice President, Health Care Services .
I also heard about these various payment models when researching my latest book and the following is an excerpt from Massage Insurance Billing Manual
Shared Savings Program Final Rule December 31, 2018
To learn more, refer to Federal Register December 2018 Final Rule.
On December 31, 2018, the Centers for Medicare & Medicaid Services (CMS) published a final rule that sets a new direction for the Medicare Shared Savings Program (Shared Savings Program). Referred to as “Pathways to Success,” the final rule streamlines and redesigns the participation options available under the Shared Savings Program to encourage Accountable Care Organizations (ACOs) to transition to performance-based risk more gradually and incrementally to increase savings for the Trust Funds. The policies also include changes to address the additional tools and flexibilities for ACOs established by the BBA of 2018, specifically in the areas of new beneficiary incentives, telehealth services, and choice of beneficiary assignment methodology.
While any group should obtain legal advice during the process of integration, the FTC has indicated that clinical integration is acceptable as long as a group comes together with the goal of improving care—and not simply to bargain for better rates.
Once a clinical integration program is established, physicians in a clinically integrated network may negotiate collectively for commercial payer contracts and present them for antitrust review by FTC. These contracts can include Pay-for-Performance components that allow both physicians and hospitals to receive incentive payments for improving the quality of care and efficiencies. Achieving these goals requires enhanced collaboration, which must be demonstrated through compliance with recognized clinical best practices and improved outcomes.
How does this apply to the massage profession? We really don’t know much about clinically integrated networks and whether or not they would help with the issues of low pay and inability to negotiate contracts with insurance carriers or not. We need much more information and a panel of experts to investigate this for the profession.
Accountable Care Networks
“The accountable care organization (ACO) model is a new Medicare option for physicians, hospitals, and other providers to share in cost-savings. ACOs represent a dramatic change in Medicare policy and an opportunity to transform care delivery and provider alignment.
The Medicare Gain-Sharing Program, part of the newly enacted health care reform law, creates the option for health care providers to form ACOs. Through an ACO, providers will take responsibility for the quality and overall care of their Medicare patients. Medicare will then share with ACO providers the savings from improved quality, fewer hospitalizations, and the elimination of unnecessary costs.”
In Medicare’s traditional fee-for-service payment system, doctors and hospitals generally are paid more when they give patients more tests and do more procedures. That drives up costs. ACOs do not do away with fee for service right now, but they create savings incentives. ACOs give bonuses when providers keep costs down and meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. In other words, providers would get paid more for keeping their patients healthy and out of the hospital.
Accountable care networks could open the doors for massage therapists in hospitals and large health care groups. I spoke with the director of the headache clinic and pain management clinic of a large local hospital, who asked me how to get massage into the clinics. Even though health insurance in Washington covers massage therapy, the allowable fees are usually low and would not pay the overhead for having an office in a hospital. The director assured me that wasn’t a concern. The goal was to provide massage to create better outcomes, as the clinics were a part of an ACN. When the patients are happier and have better outcomes from their total care, the hospital is paid more.
Clinically Integrated Networks (CINs)
CINs are individual providers and health systems that collaborate strategically to do three things: 1) improve patient care, 2) decrease the cost of care, and 3) demonstrate their value to the rapidly changing market. according to Becker’s Hospital Review. https://www.beckershospitalreview.com/hospital-physician-relationships/the-7-components-of-a-clinical-integration-network.html
CIN members share a commitment to work to achieve the Institute for Healthcare Improvement’s Triple Aim:
- To improve the patient care experience.
- To improve the health of populations.
- To reduce the cost of health care.
CINs may evolve into ACOs but don’t need to. The ultimate purpose of a CIN is to allow providers to engage in joint contracting. Providers who are not economically integrated (such as independent physicians) may not engage in “single signature” third-party contracting unless they become clinically integrated.
The Department of Justice and the Federal Trade Commission define clinical integration as an active and ongoing program to evaluate and modify practice patterns by CIN participants to create a high degree of interdependence and cooperation among physicians to control costs and ensure quality patient care. Generally, the FTC considers a program or organization to be clinically integrated if it does the following:
- Establishes mechanisms to monitor and control utilization of healthcare services that are designed to control costs and ensure quality of care.
- Selectively chooses CIN physicians who are likely to further these efficiency objectives.
- Utilizes investment of significant capital, both monetary and human, in the necessary infrastructure and capability to realize the claimed efficiencies.
The FTC has specific requirements for forming a CIN. This letter from the FTC explains the requirements in detail. (PDF)
Independent Practice Associations (IPAs) or “super groups”
IPA’s are several or many different practices working together for the purpose of contracting with insurance carriers as a group. They are owned and operated by only physician members and/or partners but each business is a separate business entity that is. IPAs provide the benefits of a larger group, while allowing each of the independent physicians in the group to retain their independence. The IPA does not provide or control physicians’ compensation. My research on IPA’s so far says that they cannot negotiate pay rates but I am wondering if the amount is set according to how well an individual practitioner or clinic performs rather than a set fee. Need much more info.
Stark Law Changes
The Department of Health and Human Services is proposing changes to the Stark Law and Anti-Kickback Statute to allow providers to create these networks. The changes will only apply to providers within these networks and not those looking for loopholes to commit fraud in the referral arena.
So What do we need to do?
These merit-based pay models are not new but no one is looking into them in the massage profession, to my knowledge. The massage profession really needs to have someone with knowledge in health care administration and health care law to see if something like this could help the massage profession with the dwindling allowable fees.
I still am looking for answers and information on what all this means. How do we begin to even look into these networks to see if any of them would help us and help clients more?
- Create a committee within AMTA-WA or WSMTA or both to look into this?
- Create a separate committee not involved with either organization to look into this?
- How much would it cost to look into?
- Who do we need to ask about this?
- What do we need to do?
- Who knows more about this than this?
- Are these networks working for the physicians already in them? (The State of Reform Health Policy conference in Seattle on Jan 7 is asking the same question but the class is sold out. Will there be a replay or can we find out what is said and who is saying it?
- Are acupuncturists and naturopaths looking into this? We could work together if possible or needed.
- Are physical therapists in these networks or chiropractors? Could we learn from them or work with them?
Premera Newsletter last spring also announced this: “To learn more about opportunities to establish a value-based contract with Premera, contact your provider network executive. ” https://www.premera.com/wa/provider/news/high-value-care/payment-models/
For more information on how to bill insurance see my book: Massage Insurance Billing Manual on my other site www.massagepracticebuilder.com