Member Forum

Subject: opportunity for imps Please respond?

1.  opportunity for imps Please respond?

Posted 05-09-2017 19:33
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:
1.pay 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  jnantonucci@gmail.com 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

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Jean Antonucci
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2.  RE: opportunity for imps Please respond?

Posted 05-10-2017 12:41
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....




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Scott Macleod
Highlander Family Medicine
Woodstock VA
5404592277
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3.  RE: opportunity for imps Please respond?

Posted 05-10-2017 16:43
Most patients are seen about 3 times a year on avergae
 I would include the "wellness visit"  in that
 At a 99214 that is roughly 100.00 ( 98  here  113 in NJ) and wellness of 139 is it? then throw in depression and adv directive screening( and consider that you must remember it code for it etc,even if it is easy  it takes time The documenting and  the  billing )  it is about 400/yr/patient
You must however code and bill and do mips etc
Now supposing it was 1.00/day /patient but risk adjusted so that using free HowsYour health measurement high burden of disease  patients were 2.00
 If you were capitated and needed no billing time your overhead lowers. I f you are capitiated some of these folks can skip a visit because you can do on the phone or have  med ass't do
 Many people can report BPs  and bs and you could pay a  staff to outreach to  them  and sit  with them to  do HYH  once year You can extend re visit interval time and see them less often
   so
 now, say you had 100 patients 1/3 are low risk  1.00/day ( 365 x 33)= 12,045
 and the others are high risk 2.00 day  ( 66  x  x 730)= 48,180
so that is  60,225 for 100 patients or  602.25/patient average not 400 and without coding and billing and without MIPS reporting measures
 simple fair payment and simple fair useful  quality reporting


Low over head practices can easily take care of these folks for  1 to 2 dollars a day
I have been capitated like this by one plan for many yrs. Up front payment   Check once a month( and there is an incentive plan)
 This is a proposal to   demonstrate simple fair payment for simple useful reporting
 Isn;t that  what we say we want?

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Jean Antonucci
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4.  RE: opportunity for imps Please respond?

Posted 05-11-2017 04:48
Hi Jean,
I would go for $1.50/person/day regardless of acuity of disease burden. One of the pillars of primary care is longitudinal continuity. Assuming my patients age with me, they will develop disease burden sooner or later. If you believe in primary prevention, then pay me to do my job when they have less disease burden and hopefully we can keep it that way for a while. Also, as the relationship strengthens over time, the doc is far less likely to kick the (recently) complex patient to the curb for being too costly. By my calculation, this price would not just help make practicing primary care financially possible even in "dead zones," it should achieve a level of pay equity pretty close to that of some of our colleagues (for recruitment purposes).
I agree with getting rid of all other billing--including the AWV, the CDM codes, and all the add on codes of insanity. Pay us a global fee. Let us figure out the best way to treat our patients.
HYH is fine. Like you said, free and easy to do.
If there is push back regarding MIPS, remember the PRIME registry from the ABFM. It sucks the data from the emr and automatically reports it to CMS. No extra work on the provider's part. It currently works with 108 EMRs (not yet with practice fusion) and is "in negotiations" with many others (including practice fusion). So it is another way to submit data without added burden. Whether much of that data is as worthwhile as the data gathered from HYH is a totally different discussion, but I believe it can be a helpful tool.
John

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John Brady
The Village Doctor
Newport News VA
757-223-0124
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5.  RE: opportunity for imps Please respond?

Posted 05-10-2017 17:21
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.

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Jean Antonucci
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6.  RE: opportunity for imps Please respond?

Posted 05-12-2017 00:19
https://innovation.cms.gov/Files/fact-sheet/cpcplus-fs-rd1.pdf

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.

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Michael S. MD
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7.  RE: opportunity for imps Please respond?

Posted 05-12-2017 04:06
I recently met with a rep for a capitated Medicare plan in our area. They do have some added services for members where they can go to Urgent Care outside of the primary care. When she met with me she told me they pay about $55 PMPM.
Before she brought me the contract she asked how many visits I see my patients for per year - it was typically 3-7. When she came back with the contract, it turned out they put down $40 PMPM for my contract when she had told me others (probably the larger, hospital based groups) get $55. She said that they would re-evaluate in the future after they saw how my first year went.
I probably won't have many patients in this new plan but signed because I have 2 patients that switched to this plan and had not wanted to leave.

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Mamatha Agrawal, MD
Family Doctor CaryNC
Cary, NC
Live in Raleigh, NC
Solo since 2012
Practice Fusion and NueMD
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8.  RE: opportunity for imps Please respond?

Posted 05-13-2017 07:19
Thank you Mamantha Scott and Mike

I did make an error and now have had long talk with Gordon Moore about details
(I do get 1.00 a day myself from a small plan plus incentive not mediciad mike,  Medicaid in Maine   by political action,FOR PCPS THAT ARE  INDEPENDENT  is paid at medicare rates. but anyway...)
--------------------
Current proposal is 2.00/day/patient  and for  people with high burden of disease 3.00/day
Suppose 1000 medicare patients for the sake of simple  math MOst of us have  more like 100-300--- 2/3 are low burden  so 2$ x 365 for 666  is 481,800  and 1/3 very ill  361, 350    so make that 100 patients  48,180 + 36,135= over 83,000 a yr  for 100 of your patients  You can take care of  people for  that !!  If your overhead is low you can do really well  and if you want  increase it  to buy a nurse and increase your panel  which helps the shortage and  help[s you earn more


 IMP should help you lower your overhead and do the imp basics. eg if you have a phone tree that says  please allow three days for a rf,  uh uh  not much of an imp 

 Flu shots and immunizations cost you so are a carve out-- do not count.
There are many people you see never or once a year and others 5-7 average is 2 1/2 to 3 and roughly 500  dollars a yr average( so 100 patietns average 500 a yr is only 50000 AND THAT IS WITH MIPS  crap
Some  docs are good at milking- doing the depression screen and adv  care stuff at wellness visits etc Some of us cannot remember to do all that at that type of visit only and do the codes for that  I am after simple fair sustainable
There are some details to work out but I will not wrangle.  We have to move, here folks.


  One problem is that some  of you are not lowoverhead butt his still should work    1.00 a day  is fabulous for low overhead

 You will need to be an IMP for this- superb access continuity comprehensive care  care corodination

I have  gotten multiple positive responses already but ALMOST NONE from  the imps from thislist servs.

 THe MAine group and the AFFP group seem to get it MAybe no one reads this forum

 What I cannot do is post to AAFP small practice group and if you are on  there I need you to post   for me
I need 5000 patietns minimum and  prob have access to 1000 now



--



     Jean Antonucci MD
     115 Mt Blue Circle
     Farmington ME 04938
ph 207 778 3313   fax 207 778 3544
www.jeanantonucci.com





9.  RE: opportunity for imps Please respond?

Posted 05-13-2017 18:54
Hi all,
I just uploaded text of the final rule for the Advanced APM criteria and CMS's discussion about them in the rulemaking, under
"Advanced APM criteria" in the IMP library.
There are links to the Federal Register source.

My head is spinning from reading this rulemaking stuff.  I believe that a plan submitted through PTAC comes under section 1115A(c) of MACRA, and qualifies under the 'Medical Home' part of the statute, but IANAL.
That would mean the plan would need less risk exposure to have "more than nominal" risk. It doesn't actually make much difference, because the risk in the PCMH program is 3% vs. 8%, of the total paid by Medicare, as a maximum loss.
(Current FFS payment is about $33-40 pmpm. This would increase to $92-97pmpm, plus $3-8 pmpm at risk.)

My reading of the rules is that in order to get out of MIPS, you have to be in an "Advanced APM."
In turn, that requires 
• The AAPM must require >50% of participants to use CEHRT;
• The AAPM must provide for payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS;  (In the discussion files, I've highlighted sections that I believe show how HYH could meet that requirement)
• The AAPM must either require that participating AAPM Entities bear risk for monetary losses of a more than nominal amount under the APM, or
• be a Medical Home Model expanded under section 1115A(c) of the Act. For a discussion of Medical Home Models under this criterion, see section II.F.4.b.(6) of this final rule with comment period. (PCMHs still take risk, but may take less.)
***********************************************************************************************
First, in order to use HYH as a 'quality measure similar to MIPs', it either has to be registered by NQF (hasn't happened,AFAIK) or have been submitted for consideration by NQF, (which I believe Dr Wasson did,) OR it has to be "endorsed by a consensus-based entity" and be evidence-based, reliable and valid. HYH is undoubtedly evidence-based, reliable and valid.  I respectfully suggest that IMP, being a "consensus-based entity," formally "endorse" HYH as a quality measure. The simplest way to do that would be to poll the members of IMP with SurveyMonkey.

 CLICK HERE


to take the survey.  (Of course, if IMP decided they want to restrict this to paid IMP members, you could create a similar poll and put it in a site restricted to such members.) If members endorse it, it can be used.

Second, the AAPM regs allow for some of the risk to be based on cost performance, but requires some to be based on quality measures. For simplicity, I would recommend it all be based on quality.
(Note this doesn't have to be success on those quality measures, just using the quality measures.)

The general standard is 8%; the PCMH risk amount is 3% for 2018.
So the language could say something like, "AAPM entities will also receive (3% if PTAC submission qualifies this AAPM as a PCMH AAPM, or 8% if not) of total reimbursement as risk-based payments, based on performance on HYH."

That percentage would be 3% or 8% of the 12%, of course, ~$3-8 PMPM.
*********************************************************************************************
The reg:

https://www.federalregister.gov/d/2016-25240/p-6781

"(c) Financial risk. To be an Advanced APM, an APM must either meet the financial risk standard under paragraph (d)(1) or (2) of this section and the nominal amount standard under paragraph (d)(3) or (4) of this section or be an expanded Medical Home Model under section 1115A(c) of the Act.

(1) Generally applicable financial risk standard. Except for paragraph (c)(2) of this section, to be an Advanced APM, an APM must, based on whether an APM Entity's actual expenditures for which the APM Entity is responsible under the APM exceed expected expenditures during a specified QP Performance Period, do one or more of the following:

(i) Withhold payment for services to the APM Entity or the APM Entity's eligible clinicians;

(ii) Reduce payment rates to the APM Entity or the APM Entity's eligible clinicians; or

(iii) Require the APM Entity to owe payment(s) to CMS.

(2) Medical Home Model financial risk standard. The following standard applies only for APM Entities that are participating in Medical Home Models, and, starting in the 2018 QP Performance Period, such APM Entities must be owned and operated by an organization with fewer than 50 eligible clinicians whose Medicare billing rights have been reassigned to the TIN(s) of the organization(s) or any of the organization's subsidiary entities. The APM Entity participates in a Medical Home Model that, based on the APM Entity's failure to meet or exceed one or more specified performance standards, which may include expected expenditures, does one or more of the following:

(i) Withholds payment for services to the APM Entity or the APM Entity's eligible clinicians;

(ii) Reduces payment rates to the APM Entity or the APM Entity's eligible clinicians;

(iii) Requires the APM Entity to owe payment(s) to CMS; or

(iv) Causes the APM Entity to lose the right to all or part of an otherwise guaranteed payment or payments.

(3) Generally applicable nominal amount standard. (i) Except as provided in paragraph (c)(4) of this section, the total amount an APM Entity potentially owes CMS or foregoes under an APM must be at least equal to either:

(A) For QP Performance Periods 2017 and 2018, 8 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities; or

(B) 3 percent of the expected expenditures for which an APM Entity is responsible under the APM.



(4) Medical Home Model nominal amount standard. (i) For a Medical Home Model to be an Advanced APM, the total annual amount that an Advanced APM Entity potentially owes CMS or foregoes must be at least the following amounts:

(A) For QP Performance Period 2017, 2.5 percent of the estimated average Start Printed Page 77550total Medicare Parts A and B revenues of participating APM Entities.

(B) For QP Performance Period 2018, 3 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities;

(C) For QP Performance Period 2019, 4 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities.

(D) For QP Performance Period 2020 and later, 5 percent of the estimated average total Medicare Parts A and B revenues of participating APM Entities.

(5) Expected expenditures. For the purposes of this section, expected expenditures is defined as the beneficiary expenditures for which an APM Entity is responsible under an APM. For episode payment models, expected expenditures mean the episode target price.

(6) Capitation. A full capitation arrangement meets this Advanced APM criterion. For purposes of this part, a capitation arrangement means a payment arrangement in which a per capita or otherwise predetermined payment is made under the APM for all items and services for which payment is made through the APM furnished to a population of beneficiaries, and no settlement is performed to reconcile or share losses incurred or savings earned by the APM Entity. Arrangements between CMS and Medicare Advantage Organizations under the Medicare Advantage program (42 U.S.C. 422) are not considered capitation arrangements for purposes of this paragraph."

*************************************************************
CMS seems to conflate 'full capitation' with 'capitation', and doesn't seem to consider primary care capitation except as an approximate payment mechanism, adjustable to match FFS.
However, it also seems one could read para (6) to mean primary care capitation.
I would say it makes sense to put in the 'at risk' part of the payment based on quality w (or using) HYH, just to keep PTAC from getting confused.

So to summarize, the AAPM program would: 
  • Require use of CEHRT by more than half of participants
  • Baseline primary care capitation would be 12% of expected global Medicare payments, risk adjusted.
    • Risk adjust with HHS-HCC (used in the CPC+ program.)  Since primary care risk is about half as skewed as global cost risk (NIHCM data) make
      • half the capitation based on the average cost (so, 6% of the expected average global Medicare payments) and
      • half the capitation based on the HHS-HCC adjusted cost (so, 6% of the risk-adjusted expected global Medicare payments.)
  • Somehow, get the diagnoses to Medicare so they can calculate HCC.
  • if HYH quality measures fail ....... reduce the NEXT year's payments by some amount, (0-3% or 0-8%)
  • Patients would sign up with a practice on a website, or could be attributed based on claims.
One option would be to submit 'claims' on all the enrolling patients, with all their diagnoses, a few months before the start, so CMS can calculate HCC, and use the same claim to enroll the person in this AAPM, to start at some future date.  Medicare could assign some code for this, e.g., 'G-Assign', with a minimal payment to cover the cost of extracting all that information.

I do NOT think you should require practices to be IMPs-that would severely limit the applicability, (and reduce the chance PTAC would approve it) for no compelling reason.
The AAPM could be a single practice(=AAPM 'entity') or a group of practices that decided to do this together, though payments would still be made directly to the practices from Medicare. I see no requirement the AAPM has to be bigger than a single practice.

See the discussion in the AAFP AAPM plan submission.

Sorry this is so long.
Lets brainstorm!

------------------------------
Peter Liepmann MD FAAFP MBA
My mission is to fix US health care www.PCMHpcc.com
Bakersfield CA
5183026006
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10.  RE: opportunity for imps Please respond?

Posted 05-14-2017 16:36
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 www.PCMHpcc.com
Bakersfield CA
5183026006
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11.  RE: opportunity for imps Please respond?

Posted 05-13-2017 10:56
Jean, this is a SPECTACULAR idea!!
If you're open to suggestions for improvements, I'd like to work on this.
You probably saw the AAFP Advanced Alternate Payment Method (AAPM) proposal to PTAC. I posted a link to it a few weeks ago. It has great intro and background info, which you could probably borrow for another AAPM. (I'll ask.) I'll cross post on the small groups MIG.

I think you're selling yourself cheap, especially for the Medicare population.
AAFP proposed 12% of the expected gross costs to go to primary care.  The annual per capita Medicare spending  for folks over 65 is $9972.
$9972 *0.12/12=  $99.72 PMPM.  The current primary care spend, IIRC, is about 5%, so that would be ~$40 PMPM. They need to spend more to get truly comprehensive primary care.  IIRC, 2/3 of Medicare patients have >2 chronic conditions, so would  currently qualify for the ~$42 pmpm FFS CCM fee, which hasn't taken off because CMS decided the deductible/copay had to be applied.  No need for that in a capitated model.


That $99.72 PMPM is the average for primary care.  Primary care spending is highly skewed, though not as skewed as total spending, and can partly be predicted by 'disease count' and various other measures. There's about twice as much skewness for total costs as primary care, (look at slide 4) so we could use the publicly available HHS-HCC (HHS's tool to estimate costs for MA) averaged with the mean cost to make an estimate of primary care costs, risk-adjusted for disease.

I'm pretty sure you'd want this to be an AAPM, which has some very specific requirements.  I'll go check on these and post more later.
But in any case, this is a GREAT idea!!!


------------------------------
Peter Liepmann MD FAAFP MBA
My mission is to fix US health care www.PCMHpcc.com
Bakersfield CA
5183026006
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12.  RE: opportunity for imps Please respond?

Posted 05-14-2017 04:50
Jean, I have 250ish Medicare patients.  I think this is a great idea, it is similar to DPC concept, I take care of patients for a set amount.  I can take the energy of fighting insurance to taking care of patients.  Thank you for working on this!


Maranacook Family Health Care is in!


----------------------------------------------------
Jennifer McConnell, MD
jenn@maranacookhealth.com
Maranacook Family Health Care
169 South Road
Readfield, Maine 04355
phone:(207)620-4449
fax:(207)685-3208
Patient Portal: www.maranacookhealth.com






13.  RE: opportunity for imps Please respond?

Posted 05-15-2017 07:30
Peter wrote in italics:
"My head is spinning  but IANAL"

WHAT IS  IANAL?
.
That would mean the plan would need less risk exposure to have "more than nominal" risk. It doesn't actually make much difference, because the risk in the PCMH program is 3% vs. 8%, of the total paid by Medicare, as a maximum loss.

What PCMH program and risk?? PCMH is a model...
I am thinking that the risk is the capitation amnt With a  stop loss thing that happens for outliers if they need like a whole body transplant Still learning



My reading of the rules is that in order to get out of MIPS, you have to be in an "Advanced APM."
yes

First, in order to use HYH as a 'quality measure similar to MIPs', it either has to be registered by NQF (hasn't happened,AFAIK) or have been submitted for consideration by NQF, (which I believe Dr Wasson did,) OR it has to be "endorsed by a consensus-based entity" and be evidence-based, reliable and valid. HYH is undoubtedly evidence-based, reliable and
 If we include it in our proposal and they support the  proposal I thought we were good.

 

The general standard is 8%; the PCMH risk amount is 3% for 2018.

From where what? I cannot understand this Never heard htis


One option would be to submit 'claims' on all the enrolling patients, with all their diagnoses, a few months before the start, so CMS can calculate HCC, and use the same claim to enroll the person in this AAPM, to start at some future date.  Medicare could assign some code for this, e.g., 'G-Assign', with a minimal payment to cover the cost of extracting all that information.

I think that is sort of what  was suggested t o me so far

I do NOT think you should require practices to be IMPs-that would severely limit the applicability, (and reduce the chance PTAC would approve it) for no compelling reason.
well  IMPs are doing the work that  will support the  project What  do you mean by requiring imps? Imps are supposed to have superb access continutiy care coordiantion and comprehensive care The lowwer the overhead, the  better they will do but that is n ot mine to  talk about  I am looking for a demonstration project to pay us simply and fairly and with   reduced burden reporting that  is the reporting that matters.


------------------------------
Peter Liepmann MD FAAFP MBA
My mission is to fix US health carewww.PCMHpcc.com
Bakersfield CA
5183026006
------------------------------


10.  RE: opportunity for imps Please respond?

Posted 14 hours ago
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 www.PCMHpcc.com
Bakersfield CA
5183026006
------------------------------


11.  RE: opportunity for imps Please respond?

Posted 2 days ago
Jean, this is a SPECTACULAR idea!!
If you're open to suggestions for improvements, I'd like to work on this.
You probably saw the AAFP Advanced Alternate Payment Method (AAPM) proposal to PTAC. I posted a link to it a few weeks ago. It has great intro and background info, which you could probably borrow for another AAPM. (I'll ask.) I'll cross post on the small groups MIG.

I think you're selling yourself cheap, especially for the Medicare population.
AAFP proposed 12% of the expected gross costs to go to primary care.  The annual per capita Medicare spending  for folks over 65 is $9972.
$9972 *0.12/12=  $99.72 PMPM.  The current primary care spend, IIRC, is about 5%, so that would be ~$40 PMPM. They need to spend more to get truly comprehensive primary care.  IIRC, 2/3 of Medicare patients have >2 chronic conditions, so would  currently qualify for the ~$42 pmpm FFS CCM fee, which hasn't taken off because CMS decided the deductible/copay had to be applied.  No need for that in a capitated model.


That $99.72 PMPM is the average for primary care.  Primary care spending is highly skewed, though not as skewed as total spending, and can partly be predicted by 'disease count' and various other measures. There's about twice as much skewness for total costs as primary care, (look at slide 4) so we could use the publicly available HHS-HCC (HHS's tool to estimate costs for MA) averaged with the mean cost to make an estimate of primary care costs, risk-adjusted for disease.

I'm pretty sure you'd want this to be an AAPM, which has some very specific requirements.  I'll go check on these and post more later.
But in any case, this is a GREAT idea!!!


------------------------------
Peter Liepmann MD FAAFP MBA
My mission is to fix US health care www.PCMHpcc.com
Bakersfield CA
5183026006
------------------------------



------------------------------
Jean Antonucci
------------------------------



14.  RE: opportunity for imps Please respond?

Posted 05-15-2017 13:01
WHAT IS  IANAL?

------------------------------
Peter Liepmann MD FAAFP MBA
My mission is to fix US health care www.PCMHpcc.com
Bakersfield CA
5183026006
------------------------------



15.  RE: opportunity for imps Please respond?

Posted 05-16-2017 05:45
IANAL - I am not a lawyer.  ("anal" seems appropriate-JOKE!!)

PCMH is one of the things I want to work on,    This could work with Jean's idea for a model.  If we can change "recognition" model away from NCQA.  They are opening up the model ideas.  It's my next resolution that I need to write soon.

I have not been able to digest everything Peter wrote yet.

------------------------------
Kathleen Saradarian, MD
Branchville, NJ
------------------------------



16.  RE: opportunity for imps Please respond?

Posted 05-16-2017 09:32
thanks Kathy
 IANAL!!:)
Yeah  What Peter understands is scary

I have recruited most of the 5,000 minimum I need( 5000 patients) to   w rite a letter of intent and go ahead with this
  I would like more patients  and docs.

 I am talking to my   advisors on Thursday and Friday to flesh out details  to work on  Hoping I can understand
But if you look at the AAFP proposal although  it is ull of MIPS and percentages, I mean we can do this!!
 2.00/day/patient/month and 3.00 for higher risk patietns
 HYH 60 a year ON the straight medicare folks
 I think we can prove our worth as improving care and reducing costs If so  and the pilot is successful at this  then we have grounds to ask other payers and medicare in a wider   distribution to  offer this paymetn model.
or
at least it will amuse me for a whhile
I think we ask it t o be a two yr project.
Jean

------------------------------
Jean Antonucci
------------------------------



17.  RE: opportunity for imps Please respond?

Posted 05-17-2017 05:45
Jean,
I still think you should ask for more.?? Even so, it will be a cost savings for Medicare by a lot.?? But if they approve less you will never get more.
--  Kathy Saradarian, MD Solo since 2003 Always Private, Small Group since 1990 Practice Partner since 2003 Branchville, NJ





18.  RE: opportunity for imps Please respond?

Posted 05-17-2017 07:00

Jean,
It might be easier to put in proposal what IS included in Capitation, as opposed to what is not.  So less need (incentive) to use all the codes many of us have become adept at using to make a living.
In addition, there is now some incentive to primary care doctors to offer even more comprehensive care and provide some of the services that patients are referred to Urgent Care, Specialists, etc.

Capitation
E/M:  99201-99205,  99211-99215
Preventative codes:  99381-99387,  99391-99397
Weight loss management,
depression screen
MMSE
AWV  /  Welcome to medicare:
Hospital transition:
CCM:
Home Health Care orders:
CPO:
Hospice:
PFTS
EKG:
Waived labs:
Immunization admin
(I am sure there are other codes I have overlooked that are appropriately apart of capitation and some may disagree with.    Others may want to make additions to this list and add the actual codes.)

Anything / everything else is still FFS.  ie: 
GYN / Pap  - this is a difficult one.   Politically probably still better to reimburse for this.
Immunizations
biopsies
laceration repair
minor fracture codes
I and D
meds, injectables
? All other CPT codes that do not start with 9****

NO copay / deductible at primary care.   Incentivizes  patients to start with primary care.   That should save CMS lots of money.









i



------------------------------
Michael S. MD
------------------------------



19.  RE: opportunity for imps Please respond?

Posted 05-30-2017 18:41
Hi Jean,

Let me repeat, this is a terrific idea.  How far have you gotten on writing it up?  I can help on that...
I suggest you/we borrow liberally from the AAFP APM.   I emailed them about this, and they said there was no problem--

"Dear Dr. Liepmann,
I am responding to your email, below, in which you asked if the AAFP proposal to PTAC could be quoted with attribution. I apologize for the delay in my reply.
The AAFP proposal to PTAC is on the PTAC web site. As such, it is a publicly available document at this point. You and others are free to quote it with attribution, just like any other document that is readily available to the public.
I hope that this answer is helpful, despite the delay in my response. Please let me know if you have other questions or if I may be of further assistance. We appreciate your membership in the AAFP!
Kent J. Moore | Senior Strategist for Physician Payment
American Academy of Family Physicians"   
http://www.aafp.org/dam/AAFP/documents/advocacy/payment/apms/PR-PTAC-APC-APM-41417.pdf

FWIW, the AAFP APM puts the primary care capitation at 12% of the expected MCR total, (About $9000 PMPY, so primary care capitation would be ~$90 PMPM)  risk adjusted similar to the CPC+ (though CPC+ payments are much lower. )AAFP used MIPS to quality adjust some part.   You could substitute HYH- (more later.)
They also address issues like attribution, etc., etc.
(Your 'back-of-the-envelope' calculations putting reasonable payments at $1/day put you in competition with professional actuaries who can predict expenses much better than we can.  Current MCR pays something like 4% ($33pmpm) to 6% ($55pmpm.) We should rely on the AAFP expertise regarding a fair payment for primary care.)

You mentioned somewhere "finding 5000 patients"- there's no need for that, and I think you should open it up to any primary care doc with more than ~30 MCR patients- that's about the number needed to manage the risks of adverse selection (especially considering you're going to get paid about 3X what Medicare pays now.)
***************************************************************
So-since AAFP did the homework and made a terrific proposal, take advantage of it.  We can make a new APM submission that exactly duplicates the AAFP APM, and just change a few parts.

Those should be-
  • Pay monthly capitation at 4.8% of average total cost for all patients, plus 7.2% of HCC risk adjusted expected total cost, recalculated on a continuous monthly basis as claims (and new diagnoses) are received.
  • Use HYH for all quality measurement- there needs to be some explanation of how HYH numbers (eg, for cholesterol, HBA1c, etc.,) match very closely w the lab, other measures assess accessibility and communication, and patient confidence is a very good predictor of a number of important outcomes, so essentially, it includes an outcome measure.  (There's justification for using HYH under Comparable Quality Measures in the Final Rule II (F) 4 (b) 2.)  It's been submitted to NQF and won honorable mention.  (Having IMP  'approve' HYH as a quality measure might help too.)
  • Make an additional payment of $2 pmpm conditional on reporting HYH data and being at least one SD above the mean of historical comparison (baseline) clinic practices.  Paid concurrently, and reduced for the next year if quality not acceptable.
  • For practices with over 100 Medicare patients, compare total spending of the population vs. a CMS projection of expected cost for those members.  
  • Make an additional payment of $3 pmpm conditional on achieving savings vs. projected costs. Paid concurrently, and reduced for the next year if total costs not acceptable.  Amount increasing to $4 in 2019, and $5 in 2020 and later, per final rule.
  • Use the same list of "primary care services" as HHS uses in the CPC+ program.
  • Other services paid FFS.
  • Optionally, include outpatient behavioral health services in office, for additional $5 pmpm.
  • Each 'APM Entity' is an Advanced APM.  There is no need to combine multiple practices.
  • Empanel patients as in CPC+ or via a specific non-billed code on a claim. This could be combined with billed codes. Diagnoses for risk calculation would be taken from the empaneling claim.  If there were too many diagnoses to fit on one claim, diagnoses from multiple claims could be combined, as well as billed codes from all providers. E.g., patient has admission for CHF, not with primary doctor- CHF would be added to the patient's diagnoses used for risk calculation. 

**************************************************************************************************
Other comments, documentation:

If  you're doing FULL capitation on a free-ranging MCR population, 5000 is certainly enough to smooth out variations, but you'd still need risk limitation for the very rare, very very high cost patient.https://www.nihcm.org/component/content/article/5-issue-brief/1299-the-concentration-of-health-care-spending-data-brief
I strongly suggest primary care stay away from full capitation-it means we have to ACTIVELY manage other spending, which is a big logistical task.

Primary care costs don't vary as much as total cost, according to NIHCM (see slide 4)
https://www.nihcm.org/component/content/article/11-charts/1529-health-care-one-percent-extreme-concentration-cc
By that measure, the variability of Office-based care is about 60% the variability of the total cost
                        Top 1%        Top 10%   ratio
Total                   $98k           $28 k        3.5
Office-based       $10,700     $5,000      2.15   (about 60%, thus the 7.2 and 4.8% numbers above.)


HHS (in the MACRA rules) didn't specifically mention primary care capitation (blind spot,)   BUT the implication was that just being at risk for supplying all PRIMARY care would not be enough.
An APM would be more acceptable to HHS if primary care had money 'at risk' for both quality and total cost.  The AAFP APM proposal strongly shied away from total cost risk, but my reading of the final rule is that the APM either has to be an expansion of a PCMH from a section 1115 demonstration, OR put money at risk.  It may be that PTAC considers all APM models going through them to be 'Medical Home models expanded under Section 1115A(c)', and if so, it would not be required to put money at risk.  Note however, the way I've written it; this is extra money, ....

In the final MACRA rules, They specify what they require for a "Medical Home Model."  There is a LOT of dancing around what the various laws require, but I think I've found the relevant sections:

"An Advanced APM must, by statute, meet certain requirements, and we are finalizing policies for these requirements within this section. First, the broad category of APMs is defined at section 1833(z)(3)(C) of the Act, which states that an APM is any of the following:
(i) A model under section 1115A (other than a health care innovation award);
(ii) the Shared Savings Program under section 1899;
(iii) a demonstration under section 1866C; or
(iv) a demonstration required by federal law."

(To make a very long story shorter, the broadest umbrella is the "demonstration required by Federal law")
I found such under the Medicare Modernization Act (MMA)  specifically,
Section 646 -- Medicare Health Care Quality Demonstration Program http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID =CMS023618
and
Section 648(a) -- Demonstration Project for Consumer-Directed Chronic Outpatient Services. http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID =CMS1198948  which has no end date.  Both say "the Secretary must..."            Otherwise you need to be in an ACO ("SharedSavings")--blech. Unless CMS considers all the models under PTAC to be under section 1115A(c).

"We are finalizing our proposal that an APM that is considered a demonstration required by Federal law is one that meets the following 3 criteria:
(1) The demonstration must be compulsory under the statute, not just a provision of statute that gives the agency authority, but one that requires the agency to undertake a demonstration;
(2) there must be some "demonstration" thesis that is being evaluated; and
(3) the demonstration must require that there are entities participating in the demonstration under an agreement with CMS or under a statute or regulation.

Second, to be considered an Advanced APM, an APM must meet all three of the following criteria, as required under section 1833(z)(3)(D) of the Act. The criteria are:

  • The APM must require participants to use CEHRT;
  • The APM must provide for payment for covered professional services based on quality measures comparable to those in the quality performance category under MIPS;
  • The APM must either require that participating APM Entities bear risk for monetary losses of a more than nominal amount under the APM, or be a Medical Home Model expanded under section 1115A(c) of the Act. For a discussion of Medical Home Models under this criterion, see section II.F.4.b.(6) of this final rule with comment period."

"

https://www.federalregister.gov/d/2016-25240/p-5049

2) Comparable Quality Measures  II (F) 4 (b) 2

The second criterion for an APM to be an Advanced APM is that it provides for payment for covered professional services based on quality measures comparable to measures under the performance category described in section 1848(q)(2)(B)(i) of the Act, which is the MIPS quality performance category. We interpret this criterion to require the APM to incorporate quality measure results as a factor when determining payment to participants under the terms of the APM....

The statute also established priorities for both the quality domains of measures to be developed and the types of measures to be prioritized in the measure development plan, which are located, respectively, at sections 1848(s)(1)(B) and (D) of the Act. The priority measure types include outcome, patient experience, care coordination, and measures of appropriate use of services such as measures of overuse.

We wanted to ensure that APMs have the latitude to base payment on quality measures that meet the goals of the APM and assess the quality of care provided to the population of patients that the APM participants are serving. It is important to note that many APMs include some common measures that are proposed for inclusion in MIPS. For example, many of the quality measures used in the Shared Savings Program and the Next Generation ACO Model are also proposed for inclusion in MIPS.

However, APMs that focus on patients with specific clinical conditions such as end-stage renal disease (ESRD), or on patients undergoing specific surgical procedures, would have valid reasons for including different quality measures than those that target more general populations. Similarly, some APMs may focus on specialist eligible clinicians for whom there may be only a small number of valid and relevant quality measures. Lastly, we cannot predict the specific care goals and payment designs of future PFPMs and other APMs. Consequently, we did not want to impose measure requirements that would prevent us from including quality measures that may be better suited to the specific aims of new innovative APMs.

We proposed that the quality measures on which the Advanced APM bases payment must include at least one of the following types of measures provided that they have an evidence-based focus, and are reliable, and are valid:

(1) Any of the quality measures included on the proposed annual list of MIPS quality measures;

(2) Quality measures that are endorsed by a consensus-based entity;

(3) Quality measures developed under section 1848(s) of the Act;

(4) Quality measures submitted in response to the MIPS Call for Quality Measures under section 1848(q)(2)(D)(ii) of the Act; or

(5) Any other quality measures that CMS determines to have an evidence-based focus and be reliable and valid.

We believe that quality measures that are endorsed by the National Quality Forum (NQF) would meet these criteria. Because each APM Entity is different, there needs to be the flexibility to determine which measures are most appropriate for use in their respective APM for the purpose of linking those measures to payment under the APM. Measures that could be used in both MIPS and APMs are beneficial to eligible clinicians who may switch from one program to the other, but we also do not want to restrict APMs from including new innovative measures that may not be included in MIPS initially, or until later years of the program."



"(5) Measures for Inclusion    https://www.federalregister.gov/d/2016-25240/p-1927

Under section 1848(q)(2)(D)(v) of the Act, the final annual list of quality measures must include, as applicable, measures from under section 1848(k), (m), and (p)(2) of the Act, including quality measures among:
(1) Measures endorsed by a consensus-based entity;
(2) measures developed under section 1848(s) of the Act; and
(3) measures submitted in response to the "Call for Quality Measures" required under section 1848(q)(2)(D)(ii) of the Act.
Any measure selected for inclusion that is not endorsed by a consensus-based entity must have an evidence-based focus. Further, under section 1848(q)(2)(D)(ix), the process under section 1890A of the Act is considered optional."



------------------------------
Peter Liepmann MD FAAFP MBA
My mission is to fix US health care www.PCMHpcc.com
Bakersfield CA
5183026006
------------------------------



20.  RE: opportunity for imps Please respond?

Posted 05-31-2017 16:19
Thank  you  for doing all that useful homework for me Peter
 For those who want the brief part:  I do plan to submit a proposal for an innovative payment  project that is broadly testable simple and practical,  and easy for small practices The proposal is 2.00 a day with 3.00 a day for high risk patients Risk determined by HYH

Peter  You read and know amazing details
I want to move away from the current complexities However it is useful to hear the comparison to Medicare spending 9000 a yr per beneficiary on average If we get 4% now 30/mo  or about 400 a yr  that  goes along with my  real world capitation figures
 My plan  includes risk by  1 holding practices accountable to  HYH goals(performance risk) but none  of this pay it back stuff  There would be a 15% withhold payable at the end of each yr if goals are met
To avoid having  people just take the money and refer people out  they have to meet performance goals and probably panels would be capped.
This is only about primary care  services not what  you call total  capitiation I cannot take on costs of hospitalization or medds  etc
 

I will have to see what primary care services are in cpc+    Mike thank you for chiming in

People will have to submit  icd 10 codes but no cpt codes I hope


I do not want to  play with HCC codes they are an odd contrived way to make patients look sicker


--



     Jean Antonucci MD
     115 Mt Blue Circle
     Farmington ME 04938
ph 207 778 3313   fax 207 778 3544
www.jeanantonucci.com





21.  RE: opportunity for imps Please respond?

Posted 06-02-2017 20:28
"Ask for May, settle for June."  Likewise with the capitation amount, ask for 12%, settle for 9%.   What I'm worried about  (a little) is if you get really high risk MCR patients who take a LOT of time, $90/mo won't cover it. Six visits a month, every month? Ouch.  That homebound patient with metastatic cancer could take up a lot of your time for a time- several months, anyway.
If you went for a straight $3/day, unadjusted, for all MCR members, AND you had a large enough group- probably several hundred, that would lower the risk of hitting the jackpot. High needs patients would be proportional to the whole population.  The best of the various risk adjusters account for about 60% of risk.

The reason for the somwhat complicated calculations with HCC, is that it protects everyone- you don't have to overpromise, and it's less likely you'd get taken advantage of.  HCC is how MCR estimates the total cost of Medicare enrollees, and it's probably the best methodology we have.  (United Health Care abused it to get higher payments. Surprise!)

A critical factor is whether CMS considers any APM that goes through PTAC to be "a Medical Home plan expanded under 1115A."  If so, you don't have to take financial risk, if not, the way CMS interprets MACRA, it's an absolute requirement.  Whether or not they require financial risk, you don't have to hold back money for quality risk.  You can reduce future payments.  Makes calculations much easier.

I think CPC+ only included E&M codes.  On another thread, you'll see my attempts to find out.  If someon IN a CPC+ are asked, you might get an answer. I think it would make more sense to include more services, but that would make calculations more difficult.
QLiance included a whole BUNCH of stuff, including minor surgeries, splinting & casting nondisplaced fx's, etc.  http://qliance.com/wp-content/uploads/2014/01/Qliance-Booklets_withbleeds.pdf    Pages 10,11

Jean, how are you putting this together, with whom, and what level of detail?Spending is highly skewed
Almost anything other than FFS, at adequate rates, would be an improvement. Ask for more, settle for less.

------------------------------
Peter Liepmann MD FAAFP MBA
My mission is to fix US health care www.PCMHpcc.com
Bakersfield CA
5183026006
------------------------------



22.  RE: opportunity for imps Please respond?

Posted 14 days ago
Could someone please crosspost to AAFP list serv?

 Please see my original post. Much has happened
  I have had conversations with many people
 -we would like to  submit this proposal -a proposed payment model for office based PCP payment - NPS and Docs - based on risk stratification by  using Hows Your Health ;  providers would be  in a project that paid them 2.00/day-  60PMPM -for low and medium risk patients and  3.00 or 90PMPM for high risk patients  Panels would be capped at 1500 patients/provider so you cannot  just add patient  names get rich and do no work;  15% of your  payment would  be withheld until the end of the yr and if you met the benchmarks you get the 15%; if not you might have a reason  and be allowed a second chance you might be kicked out of the project
 That is the basics

 The following now needs to happen
1 I need a professional writer to tie the proposal together( apparently I can't  write)
2  I need to re- create this list of you that were interested.  I had created a list that got me 5000 medicare covered lives Then I was told it was not my  job to  do that Medicare would run the project. NOW I am told I should prove I have docs committed to  do this
I think it can be any payer but starts with medicare
 I am asked to ask people for money to pay the writer and show committment    I am against this    I do not  want to take money  log it as income and be some kind of middleman making docs  that I do not know well send me money as a comittement  to participate in  such a project if it began    There was an independent woman in Reston VA,  there were some of you  I called, .....    I need to find asap interested parties I have no idea whether you would say you were interested only if you take Medicare I think if you are willing to be  in a pilot and  be paid this  way PERIOD  all payers please tell me  Please contact me and tell me your panel size of medicare and total  This is a large chance to infuence how  you might be paid     I need you to be serious    I have no idea how to make you promise to  do it if offered ,nor how to find a writer   I will pay the writer
 Comments please  \
Note many details of the project are to be worked out but the basics are above Very  high cost things to the practice like vaccines and IUDs would stil lbe FFS but very few things will be carved out

Jean

------------------------------
Jean Antonucci
------------------------------



23.  RE: opportunity for imps Please respond?

Posted 14 days ago
I posted AAFP list serve.
Thanks Jean.

I'm in.
We'll talk IMP .

Melissa Weakland, MD
Ballard Neighborhood Doctors
5416 Barnes Ave NW
Seattle, WA 98107
Phone: (206)-297-7678
Fax: (206)-297-5930

.