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Reimbursement Page
from February 2022 O&P Almanac
by AOPA
Secondary Scenarios
Tips for billing correctly when Medicare is the secondary payor
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SOME OF THE MORE confusing billing scenarios are those involving multiple payors. When there is more than one payor, questions arise regarding who needs to be billed first, how much each payor will pay, and what happens if the primary payor fails to pay a claim. Fortunately, when one of the payors involved is Medicare, the answers to those questions can be easily found by examining the Medicare as Secondary Payor (MSP) provisions and regulations.
Several MSP scenarios always render Medicare the secondary payor, meaning that the patient’s other insurance must be billed, and an explanation of benefits acquired, before you may bill Medicare. These situations involve the working aged, workers’ compensation, no-fault and liability insurance, end-stage renal disease (ESRD), and disabled beneficiaries. This month’s Reimbursement Page examines each of these situations and offers insight into how each program operates, as well as how each program affects Medicare’s payment status.
Working Aged
The most common scenario that makes Medicare the secondary payor is the MSP Working Aged program. Individuals involved in this program have become entitled to Medicare benefits, based on age, but have not yet retired. For patients to be considered working aged, they must be at least 65 years old and enrolled in their employer’s group health plan (EGHP); the employer must have at least 20 employees. The EGHP also may cover the patient’s spouse, who would be considered working aged, even if they are currently retired.
For the purpose of the MSP Working Aged provision, a “spouse” is defined as “a person whose marriage is valid in the jurisdiction in which it was performed, including one of the 50 states, the District of Columbia, or a U.S. territory, or a foreign country, so long as that marriage would also be recognized by a U.S. jurisdiction.”
In addition, any time an employer, insurer, third-party administrator, group health plan, etc., has a more inclusive definition of spouse, it may assume primary payment responsibility for the individual in question; and if the individual is reported as a spouse, Medicare will pay accordingly.
Keep in mind that if the patient has a retirement plan through their employer and they are 65 or older, the retirement plan will always be secondary to Medicare. In addition, if the patient chooses not to be covered by the EGHP and wants Medicare as their primary insurer, they cannot also receive benefits from the EGHP; it may only be one or the other.
Workers’ Compensation
Another common scenario involves workers’ compensation claims—claims that are the result of an injury that occurred on the job. Medicare normally will not make payments on a workers’ compensation claim, but there are times when you may send a worker’s compensation claim to Medicare.
If you don’t agree to accept the workers’ compensation payment as your payment in full, and your state allows you to collect your full charge, you may then submit the workers’ compensation claim to Medicare for secondary payment.
No-Fault and Liability Insurance
No-fault and liability insurance programs involve coverage by an insurance company, typically involving some type of accident that does not occur at work.
No-fault insurance, also known as personal injury protection or medical expense coverage, covers expenses due to injuries that occurred on the insured’s property, or in the use of the insured’s vehicle, regardless of who is responsible for the accident.
Liability insurance applies when someone is found to be at fault for causing an injury, and payment is based on the policyholder’s legal liability for injury. The two most common types of liability insurance are auto and malpractice insurance.
End-Stage Renal Disease
If a patient is diagnosed with ESRD, they are entitled to receive Medicare benefits, even if they are under the age of 65. If ESRD is the only reason a patient has Medicare benefits, and they are covered by an EGHP, then Medicare will be secondary to the EGHP.
The ESRD program is a little more complicated than some of the other provisions or scenarios because there are certain situations when Medicare will retain its primary payor status when a patient has ESRD. Medicare will be secondary for ESRD patients for a total of 30 months, which is called the ESRD coordination period. The coordination period begins when the patient first becomes eligible for Medicare benefits. After the coordination period ends, Medicare will become the primary payor.
If the patient is under 65 and is eligible for Medicare benefits solely because of ESRD, the patient also is entitled to all Medicare benefit categories, not just those related to the treatment of the ESRD. However, their entitlement to Medicare benefits will expire 12 months after their last dialysis treatment or 36 months after a successful kidney treatment. So, if you have a patient who has Medicare coverage due to ESRD, you should routinely check their coverage or status, because who is primary and secondary can shift, and they may no longer have Medicare coverage.
Disabled Beneficiaries
Medicare provides benefits and coverage to anyone who has a permanent disability regardless of their age. If someone is receiving Medicare benefits because of a disability, Medicare will usually be primary.
However, it is possible for Medicare to become the secondary payor when certain criteria are met. First, the patient must be under 65, receiving Medicare benefits solely because of a disability, and have other healthcare coverage under a large group health plan (LGHP).
The coverage from the LGHP may be through the patient’s current employment or the current employment of a family member, such as a parent or a spouse. An LGHP is slightly different than an EGHP discussed in relation to the MSP Working Aged provision above. In order for a group health plan to be considered an LGHP, at least 100 people must be employed by the sponsoring company, or in the case of a plan that covers multiple employers, at least one employer in the group must have at least 100 employees.
For example, if Mr. Jones is covered by an LGHP and he has a disabled son who has qualified for Medicare due to his disability, the LGHP would be billed as the primary and Medicare as the secondary for any of the child’s medical expenses— not just those related to the disability.
Medicare and the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have created a questionnaire that your office may use to determine if a patient has insurance primary to Medicare. The questionnaire is lengthy and extremely thorough.
If you don’t want to use the questionnaire, you may instead use it as a guide to create a questionnaire of your own. You also may contact the Benefits Coordination & Recovery Center, the contractor responsible for maintaining and reporting insurance coverage for Medicare patients, at 855/798-2627. If you call, they will only be able to inform you that the patient has an insurer primary to Medicare, but they cannot provide you with any other information; you must obtain all other information from the patient.
Calculating Medicare’s Payment
When dealing with the MSP provisions, one of the biggest questions is: What will Medicare pay? Medicare will never pay more than its allowable, so the most Medicare will pay in an MSP claim is its allowable. The exact amount Medicare will pay is determined using a set of three calculations; Medicare will pay the lesser of the amounts derived from the three calculations: • Calculation 1: Medicare determines the amount they would pay if they were primary, or if they were the only payor. • Calculation 2: Medicare calculates its liability with regard to the primary insurer’s payment. This calculation is done by subtracting the primary insurer’s payment (what it actually pays) from either the Medicare allowable or insurer’s allowable (how much it could pay). • Calculation 3: Subtract the submitted charge minus the payment made by the primary insurer.
These calculations can get confusing. Fortunately, each of the DME MAC websites features aids or calculators to help you determine Medicare’s liability in MSP scenarios.
Set-Aside Arrangements and Conditional Payments
What happens if the primary payor does not or cannot pay you in a timely manner? Will Medicare make a payment or default to the primary payor?
Typically, under the MSP provisions, Medicare will not pay primary for items when payment has been or is expected to be made. However, with liability insurance, no-fault insurance, and workers’ compensation insurance claims—and to some extent claims involving group health plans—you have the ability to seek a conditional payment. Medicare may make a primary payment when there is evidence that the primary payor will not or cannot pay the claim promptly. This payment will only be made on the condition that upon final reimbursement by the primary payor, Medicare will recover their payment, and this will typically be directly from the payor.
If you believe the primary insurer will not pay your claim in a prompt manner, defined as more than 120 days, you may submit the claim to Medicare. However, if it is determined that someone else should have paid first or you eventually receive payment from the primary insurer, you must refund Medicare. Keep in mind that you may not seek primary payment from two insurers at the same time. If you choose to seek a conditional payment from Medicare, you must withdraw any claims you have with the primary insurer and drop any liens or collections you may have placed on the beneficiary.
In some claims involving workers’ compensation, or no-fault or liability insurance, the claim may involve a “set-aside arrangement,” an ongoing responsibility for medicals (ORM). These are defined as “an administrative mechanism used to allocate a portion of a settlement, judgment, or award for future medical and/or future prescription drug expenses.”
In situations when a set-aside arrangement or an ORM has been put in place, you may not bill Medicare until you can provide evidence that the money in the set-aside agreement or ORM has been exhausted and the money was spent on appropriate medical expenses. This may include getting documentation from the patient and/or their attorney, or the insurance company. Once the set-aside amount is exhausted and accurately accounted for, Medicare will pay primary for future Medicare-covered medical and/or prescription drug expenses related to the injury or illness or disease.
Devon Bernard is AOPA’s assistant director of coding and reimbursement services, education, and programming. Reach him at dbernard@AOPAnet.org.
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Bound Beijing
Paralympic athletes prepare for the Winter Games—with a little help from their committed prosthetists
By CHRISTINE UMBRELL
NEED TO KNOW
• Elite-level athletes from across the country will travel to Beijing to compete in the 2022 Winter Paralympic Games, March 4-13. • Athletes with limb loss form close connections with their prosthetists, relying on their expertise with their devices as well as their understanding of their sport and training requirements. • Some prosthetists are athletes themselves, and may display a competitive spirit in seeking to design the most appropriate and efficient prostheses for patients. • Most athletes look to their prosthetists to help them understand the mechanical aspects of their devices—and some go a step further, learning to replace their own sleeves, change valves, and more. • Prosthetists emphasize an individualized approach to patient care and open lines of communication, with both elite athletes and less active prosthesis users, to ensure optimal outcomes.
WHO BETTER TO understand the unique prosthetic needs of a highly active, elite-level athlete than another highly active, elite-level athlete? For Paralympic snowboarder Evan Strong, having his prosthetic needs met by friend and prosthetist Ronnie Dickson, CP, has been a formula for success. Dickson, founder of the Chattanooga, Tennessee, branch of Prosthetic & Orthotic Associates (POA) and winner of several national adaptive climbing competitions, met Strong when they two men were just 19 years old, and formed a friendship that predates their professional relationship.
Strong will compete in the Beijing Winter Games as a member of the U.S. Paralympics Snowboarding National Team, having earned a roster spot after winning two gold medals in the men’s SB-LL2 class in the Austria World Cup late last year. Eight years ago, Strong became the first man to win a Paralympic gold medal in snowboarding when he won the inaugural snowboard-cross event in Sochi. He went on to win a silver medal in 2018 in banked slalom.
Strong turned to snowboarding after losing his left leg below the knee in a motorcycle accident right before his 18th birthday. A former child competitive skateboarder, he was immediately drawn to adaptive athletics postamputation—an interest he shares with Dickson. Dickson’s left leg was amputated above the knee when he was 17, after years of congenital pain. For three years postamputation, Dickson experienced problematic prosthetic pain and discomfort, until he met Stan Patterson, CP, LP, founder of POA, who provided his first well-fitting prosthesis.
Dickson first met Strong when both participated in the 2007 Extremity Games. “I was competing in rock climbing, and [Strong] was competing in rock climbing and skateboarding,” Dickson recalls. “With both of us being right around the same age, we hit it off with a friendship.” The following year, they roomed together at the 2008 Extremity Games.
Paralympic
Snowboarding Events
Evan Strong hopes to compete in both snowboard-cross and banked slalom at the 2022 Winter Paralympics.
Snowboard-cross (also known as snowboarder X, SBX, boarder cross, boarder-X, or BX) is a snowboard competition that first consists of a time-trial; three runs down a course, only one rider at a time with their best run determining their placement for head-to-head brackets. Finals consist of two competitors per heat, fastest rider to the finish advances.
In banked slalom, each athlete gets three runs down the course, with their best run determining the final results based on ascending time. There is only one rider on the course at a time. The course may be a medium pitched slope. It may be preferably a naturally varying terrain, with plenty of bumps and dips, and preferably a U-shape/natural valley.
PHOTOS: Courtesy of Evan Strong Evan Strong (center) took gold at the Austria World Cup late last year.
Two years later, their friendship evolved when Dickson—who continued to compete in adaptive rock-climbing—began his prosthetics residency, under the supervision of Patterson. Dickson saw Strong at the Challenged Athletes Foundation San Diego Triathlon Challenge, and noticed his prosthesis was well-worn and needed some adjustments. Dickson brought Strong to the Southern California branch of POA, were he helped “tidy up” Strong’s prosthesis, with Patterson’s guidance and generosity. “That’s where things went from a friendship to a working relationship, when I started working with Evan on his prosthesis.” Dickson continues to serve as Strong’s prosthetist today.
Strong himself truly appreciates being cared for by another athlete. Dickson “doesn’t just hear what I’m saying; he gets what I’m saying,” Strong explains. “I’ve really been pushing my prosthesis to the extreme. I need a bunch of range of motion to move on my snowboard, but I also need a lot of control. It really becomes a limb,” a concept that Dickson intimately understands. Strong and Dickson first met 15 years ago, when both competed in the 2007 Extremity Games.
Ronnie Dickson, CP, was a national champion in adaptive rock climbing in 2021—in addition to serving as Strong’s prosthetist.
Guillermo “Will” Castillo, captain of the USA Para Bobsled Team, trains at Prosthetic & Orthotic Associates in Orlando, under the supervision of Stan Patterson, CP.
Bobsled Athlete Hopes to
Compete in Future Paralympics
Not all winter sports have been recognized as official sports at the Paralympic Games, so some athletes who compete at high levels must demonstrate their skills at alternate competitions.
Guillermo “Will” Castillo, for example, is captain of the USA Para Bobsled Team, but bobsled is not yet an event in the Paralympic Games. Castillo, who lost his leg above the knee in combat while serving in the U.S. Army, is ranked No. 1 in the United States for seated para bobsled, and No. 7 in the world. Castillo trains almost every day at Prosthetic & Orthotic Associates (POA) in Orlando, overseen by his prosthetist, Stan Patterson, CP. The POA facility features a full gym and trainers who are experienced in running, agility training, and functional movements, allowing Castillo to train and prepare for upcoming competitions.
Castillo remains hopeful that he will one day be able to compete in the Paralympic Games. It was recently announced that bobsled will not be an event in the 2026 Games in Milan and Cortina d’Ampezzo, Italy, but Castillo and others plan to appeal that decision. Going for Gold
Working with elite athletes means “executing at a really high level,” according to Dickson. “As a professional, you put your best foot forward to make somebody the best possible device that you can craft. So there’s a little bit of that challenge, because you know that if your skill level [at designing prostheses] combines with that individual’s skill level [at their chosen sport], it’s going to be a recipe for success.”
Dickson was a national champion in 2021 in adaptive rock climbing, has participated in five U.S. teams, and was awarded a silver medal twice in international competitions. Being an athlete has taught him to work closely with patients and to listen to their ideas when selecting and fitting a prosthesis.
In working with Strong, Dickson seeks to ensure the snowboarder understands all aspects of his prosthesis. Strong uses a Biodapt Versa foot, created by Mike Schultz, paired with “a pretty standard total-surface bearing suction socket,” says Dickson. The prosthesis features an upgraded shock linkage system and heel strike dampener, which provide stability and control for Strong, as well as a barefoot Vibram sole plate. “We have it set up very simply, so it’s all serviceable in the field,” he adds.
Dickson works with Strong to tune his prosthesis and snowboard in his office in Chattanooga, “but then he’s going off to Colorado to train, or Austria to compete, and each one of those racecourses is going to be a little bit different. In some of these situations, his needs are going to change, and I’m not going to be there to be able to help him with that,” says Dickson. “So I have to make sure, as we go through these fittings, that I’m keeping him involved in everything we’re doing together, so that he ultimately has the knowledge necessary to do what he needs to do when the time comes,” for example, replace his own sleeve, change a valve, or adjust toe-in/toe-out.
Dickson tries to help each patient achieve their goals at every clinical encounter. “It comes down to attention to detail. With the athletes, what you learn is that you really need to optimize every bit of percentage of that prosthesis, because they’re going to actually be able to tap into it and use it,” Dickson says. “You get to hone in on that part of your craft.” He approaches all clinical encounters with that mindset. “Even if they’re not going to be able to tap into it 100%, I still want to make sure I paid attention to all those little details, to put my best game forward every time,” he says. “Whenever I put a device out, it’s a reflection of who I am, and I want it to be as excellent as I can make it.”
Being a Team Player
Strong and Dickson share a unique history, but many other prosthetists have formed strong bonds with their athlete-patients. Danielle Baril, MSPO, CPO, says she and Lera Doederlein, a Nordic skiing Paralympic hopeful, “immediately clicked” when Doederlein became her patient.
“I was extremely lucky to meet Lera when she moved to San Diego from Arizona in 2018,” says Baril, clinic manager at Hanger Clinic in San Diego. “She was in need of a new prosthetist, and I was looking to expand my knowledge and skills. I’ve worked with other athletic patients, but none of her Lera Doederlein plays sled hockey for the San Diego Ducks and hopes to compete for Team USA as a skier in Beijing.
caliber. I was inspired by her eagerness to be as active as possible.”
Doederlein, a bilateral above-knee amputee who plays sled hockey for the San Diego Ducks and hopes to compete for Team USA as a skier in Beijing, doesn’t wear her prosthetic legs while competing, but she relies on them to get to practice, when traveling, and throughout her daily activities. When she became Baril’s patient, Doederlein was in ischial containment sockets that worked well, “but with how much pressure she was putting through her ischium during training, she was getting skin breakdown,” recalls Baril. “We took a leap together and changed the design to subischial, which relieved the skin and allowed for more hip range of motion.”
Doederlein uses microprocessor knees, which allow her to have a more energy-efficient gait than with nonmicroprocessor knees, according to Baril. “This means she can use that extra energy she has saved when she’s at the gym training for her next competition.”
When it comes to treating elite-level athletes, “we need to keep additional factors in mind when designing the prosthesis and selecting the componentry, because their activity levels are significantly higher than most of our other patients,” says Baril. “We need to be on the top of our game, in regard to new designs and technology, so they can be at the top of their game.”
Baril enjoys the close relationship she has formed with Doederlein. “Lera has invited me to practice sled hockey with her,” she says. “Once her 2022 Paralympics journey is complete, I’m looking forward to getting out on the ice and observing her in that environment—even though she has promised to ‘check me.’”
Prosthetic Problem-Solving
Fred Schaumburg, CP, has been working with Josh Pauls, captain of the Team USA sled hockey team, for more than a decade. Pauls, who was born without tibia bones and had both legs amputated at 10 months old, is a threetime Paralympic gold medalist, and hopes to win a fourth gold in Beijing.
Schaumburg, a Hanger Clinic national upper-limb specialist based in St. Louis, has played an important part in helping Pauls train for competition. He recalls the first time he worked with Pauls, right after the athlete moved to the St. Louis area for college more than 10 years ago. “He was having issues with the bilateral above-knee prostheses he was wearing at that time,” says Schaumburg. “After some discussion with Josh, we decided to try traditional suction transfemoral sockets instead of the thick cushion gel liner sockets that he was wearing. He was happy the first time he walked with this style of socket, immediately noticing the lack of bulk and improved suspension and prosthetic control the sockets offered.”
While Pauls competes without prostheses—as is the rule for sled hockey—his devices are critical for training off the ice, including in the gym and during everyday activities. Josh Pauls of USA (left) and Billy Bridges of Canada in action during the world para ice hockey championship match between Canada and the United States in Ostrava, Czech Republic, April 27, 2019.
“I see Josh for traditional follow-up appointments to adjust for optimal function and fit, to ensure his legs are operating well for his day-to-day mobility, as well as the training and travel being an athlete of his caliber requires,” Schaumburg says. “I’ve also supplied belts for secondary suspension during Josh’s weight and cardio training.” Schaumburg emphasizes the importance of an individualized approach to care—with both elite athletes and less active prosthesis
Dickson says he competes with himself to provide the most optimal prosthesis for each patient, regardless of age or ability.
Tips for Treating Patient-Athletes
Experienced prosthetists share their advice for best results when working with athletic patients:
“Be a sponge,” says
Ronnie Dickson, CP, founder of the Chattanooga, Tennessee, branch of Prosthetic & Orthotic Associates. “Listen to what the patient’s experience has been—what’s worked well, what hasn’t worked well. And then, as you’re formulating that treatment plan, you can provide some counterpoints to their feedback, and see how, within your skill set and within what that individual wants—where that middle ground is. How can you help this person meet their goals while still utilizing the best things that you have to offer out of your skill set?”
“Be open to new ideas, components,
and designs,” says Danielle Baril, MSPO, CPO, clinic manager at Hanger Clinic in San Diego. “What wouldn’t work for most patients can work for these highly active patients. Don’t be afraid to reach out to other practitioners and seek advice. Our patients rely on our devices to succeed. These patients might have a coach/trainer and a physical therapist; we need to be another supporting figure in this ‘pit crew.’”
says Fred Schaumburg, CP, a Hanger Clinic national upper-limb specialist. “A prosthesis that may work well for general community use often does not perform up to the requirements of high-activity tasks. Teamwork is critical in achieving the optimal outcome. Ask for assistance from other prosthetists, athletic trainers, physical therapists, etc. Don’t forget to include the patient, as he or she is the most valuable team member and is the one who has to use the devices that we make. Highly active patients often have an idea of what they need before they even come in to see their prosthetist. They have researched online what others are utilizing and can form opinions even before coming into our offices. It is important to establish the team mentality early, encouraging different ideas and discussing treatment options openly. Through this open team discussion, the best prosthetic outcomes are often achieved.” users. “Each person has their own unique set of requirements, goals, and challenges,” he says. “A newly amputated diabetic may have frequent volume fluctuations, weaknesses, and range-of-motion restrictions that we need to accommodate for, while a Paralympic athlete generally does not have these restrictions. Rather, an athlete may require enhanced socket flexibility, secondary methods of suspension for security during high stress activities, or environmental considerations. Each patient that we see has their own set of unique challenges that we must meet, regardless of their athletic prowess.”
He also notes the importance of new and emerging technologies. When working with more active patients, Schaumburg has incorporated adjustable socket technology, as well as silicone interfaces and a unique modification to the traditional ischial containment design. These advancements have improved both comfort and function for athletes, according to Schaumburg.
Mutual Wins
For Dickson, Baril, and Schaumburg, working with elite-level athletes has pushed them to sharpen their prosthetic skills while empowering their patients to excel in their sports. Says Dickson, “What’s been so incredible for me is the fact that [Strong and I] met when we were both so young, and here we are now in our mid-30s and have so much amazing life experience under our belts, through adaptive sports. It’s been a lot of fun.”
After all of the preparations, training, and prosthetic fine-tuning, Strong, Doederlein, and Pauls are ready to compete at the highest level in Beijing. “I head into competition with the goal to give my best performance to date, to showcase myself and good snowboarding,” says Strong. “It’s an adventure!”
Christine Umbrell is a contributing writer to O&P Almanac. Reach her at cumbrell@contentcommunicators.com.
U.S. HEALTHCARE IS slowly transitioning away from fee-for-service and toward a value-based model, which offers benefits for patients and providers alike, according to Ceci Connolly, president and CEO of the Alliance of Community Health Plans and former Washington Post reporter. Connolly shared her perspective and offered her thoughts on the challenges, trends, and opportunities facing healthcare providers when she spoke on “Reimagining the Future of O&P: Harnessing the Intersection of Humanity and Technology” during AOPA’s Leadership Conference in January.
During her presentation to O&P executives and business owners, Connolly emphasized the benefits of a partnership model, which brings together clinical teams, health plans, and community patients, “preferably in some sort of value-based arrangement,” so that the financial incentives favor the patient and their health outcomes. “Personalized, targeted medicine for the individual that suits them, that is proven, that is not unnecessary or inappropriate,” should lead to improved patient outcomes and more costeffective healthcare, Connolly said.
Current Challenges Highlight Need for Change
One of the most challenging aspects of the current U.S. healthcare climate is cost, compared to outcomes. Connolly pointed out that even though U.S. per capita healthcare spending exceeds comparable countries, it ranks “No. 1” at chronic disease burden and obesity and has the highest number of hospitalizations from preventable causes, as well as the highest rate of avoidable deaths, compared to similar industrialized nations. She noted that the United States is “great at a lot of things in medicine,” such as cancer detection and treatment as well as development of COVID-19 vaccines, “but when you look at some of these very basic measures across the entire population, like mortality rates, many of our citizens are dying younger now than they were just a few years ago.”
In addition, disparities in coverage of care as well as health inequities are longstanding issues that were “brought out into the forefront” during the COVID-19 pandemic, according to Connolly. She pointed to studies demonstrating that the life expectancy, health, and socioeconomic status of people of color, as well as marginalized communities and individuals in rural areas, are not comparable to the health and well-being of others. “Very little has changed in decades,” she said, adding that these communities often experience a lower quality of care, as well as bias.
Connolly also cited recent studies highlighting how race and socioeconomic status impact the O&P patient population. “Black Americans are four times more likely to experience amputation for any reason than white Americans,” she said. “Latinx Americans are almost two times more likely to experience amputation.”
She also noted that hunger and housing issues are hurdles to improving healthcare. “Social determinants of health, the connections between food or hunger and your health status, your health and wellbeing, are breathtaking,” she said. “If you want to improve the health of a community, just getting people fed can be one of the quickest ways to bump up the health of that population.” She noted that some healthcare companies are starting to study the housing issue, including UPMC, headquartered in Pittsburgh. “They are doing some really cutting-edge work in the area of housing and then incorporating medical services, including behavioral health interventions,” she said. “It’s phenomenal, but … it takes capital. It takes labor, and you kind of are doing it one family at a time. So getting to scale is hard.”
Connolly emphasized the need to curate targeted, actionable data to help address inequities problems. “There are some people that have transportation problems. There are some people that are hungry. You need to know the difference, or you’re going to waste a whole bunch of time and money on something that is not targeting one of the root causes of those disparities,” she said.
She anticipated that the federal government will take a leading role, but suggested that the healthcare sector should be informing “what the federal government is going to say about data collection monitoring, and then in short order, incentives.”
CMS will start to build in quality measures, “maybe even tied to payments,” predicted Connolly. State Medicaid procurement bids are sometimes requiring healthcare providers to use data to show they plan to close gaps within certain populations, and to improve quality in certain populations,
according to Connolly. “It’s not going to be enough in the future to just say, ‘Hey, here’s our quality score for everybody we take care of,’” she said. “In the very near future, this administration is going to work very hard to tie reimbursement dollars to quality for specific populations to see that we are really [helping] everyone in this country, not just some.” “In the very near future, this administration is going to work very hard to tie reimbursement dollars to quality for specific populations to see that we are really [helping] everyone in this country, not just some.”
Fee-for-Service Incentivizes Volume Over Value
The COVID-19 pandemic demonstrated “why fee-for-service medicine is not serving us well as a country,” said Connolly. “It is basically like paying a factory worker per piece. You get paid every time you do a thing; you don’t get paid to have healthy patients, healthy productive communities,” she said, adding that the current system incentivizes volume, not value.
Under the fee-for-service model, too many doctors, nurses, and hospitals are “paid every time they do something, every time they write a prescription, take an X-ray, perform a surgery, put you in a hospital bed, do tests, do more tests, write another prescription,” she said. This fee-for-service model has resulted in “phenomenal waste in the system,” according to Connolly, by means of errors, duplication, and unnecessary care. “Economists will tell you, everybody is doing exactly what you would expect them to do” given the fee-for-service model, Connolly said. “It’s rational behavior, so we need to change the incentives.”
Connolly also noted that looking at the country’s health outcomes demonstrates why “we’re not getting our money’s worth” out of the $3.8 trillion we’re spending on healthcare as a nation each year. “As a whole, our country is not incredibly healthy,” she said.
She lauded those O&P facilities that are already partnering with other healthcare companies in a bundled payment approach and are facilitating a full complement of care, “meeting the patient where they are.” According to Connolly, “That’s really what value needs to be about.”
Rising Senior Population Drives Change
Connolly pointed to Medicare Advantage as a good example of a value-based arrangement. “First and foremost, 42% of our senior population is in Medicare Advantage, and that’s going to very rapidly exceed more than half of the senior population,” she said, explaining that Medicare Advantage is here to stay, and that many seniors are “choosing” the plans. Among minority populations, “50% of African American seniors are in Medicare Advantage, and 60% of Latinx seniors are in Medicare Advantage, as well as the lowest income seniors in the country,” Connolly said. Those who have chosen Medicare Advantage are benefiting from coordinated care for seniors, which results in positive outcomes, including 33% fewer emergency department visits and 23% fewer hospital admissions, according to Connolly.
Medicare Advantage equates to $1,600 less in out-of-pocket costs and premiums compared to original Medicare, according to Connolly, including reduced prescription drug coverage. “Medicare Advantage plans incentivize going to the primary care doctor often” and appointing the primary care provider as the “quarterback” of the healthcare team who coordinates care. She believes Medicare Advantage is here to stay, although “it’s due for a refresh.”
Some O&P professionals are concerned about the Medicare Advantage trend, specifically because many of these plans ask patients to pay large upfront fees and high deductibles. Connolly encouraged O&P facilities to share relevant data that makes the case for reduced out-ofpocket expenses and lower deductibles to both CMS and Medicare Advantage administrators. “If you’re able to demonstrate that by bringing [costs] down, bringing them access to the full complement of care and services that
they need to ultimately be healthier and not have those longer-term costs, then I think that’s a compelling case,” she said.
Future Patients Will Demand ‘Care Anywhere’
Connolly also discussed the need for “portable healthcare products” to accommodate the growing trend among baby boomers who choose to live part of the year in their hometowns and part of the year in warmer climates, like Arizona and Florida. Seniors will want easy information sharing among healthcare providers in different geographic areas, as well as virtual care options. She believes Medicare Advantage must transform to adapt to this trend, “and it’s also going to have to raise its quality measures, because they have tended to focus
on process instead of outcomes—but that’s coming.” While she believes the concept of portable healthcare may be disruptive for many in the industry, it could also be a net positive for patients and healthcare professionals alike.
Implementing “care anywhere” strategies, such as permanent telehealth flexibilities, value-based benefit designs that support telehealth, and “hospital-at-home” programs, could lead to expanded access, improved care coordination, and an improved and more convenient patient experience, Connolly explained. She pointed to the example of an innovative pilot “hospital-at-home” program in Marshfield, Wisconsin; for hundreds of diagnoses, such as some pneumonia cases, patients can choose to be admitted to the hospital for monitoring or to stay home for remote monitoring and home nurse visits. The remote monitoring option offers savings, monitored outcomes, and patient satisfaction.
Connolly hopes that the current administration and Congress will choose to extend flexible telehealth options after the public health emergency is over, “in order for all of us to keep collecting data and be able to show exactly how telehealth has served the population,” she said. While some question the security of new virtual care options, Connolly noted that HIPAA is due for a refresh, and providers will have to watch the transparency regulations and restrict healthcare data access when warranted.
Many Americans Remain Uninsured or Underinsured
Despite the new marketplaces put in place via the Affordable Care Act (ACA), 31 million Americans remain uninsured, which is problematic for patients as well as providers. “Obviously, somebody who is uninsured is not going to have the same access—not only the equipment, but the critical care that you are delivering to individuals,” Connolly said. She is concerned that the uninsured population will grow once the COVID-19 public health emergency ends and some states disenroll some individuals from Medicaid.
She cited studies carried out since the ACA took effect that demonstrate how “having health insurance coverage—just simply having coverage, no matter if it’s good or mediocre, or where it is or which doctors—people that got coverage started to have better health outcomes,” she said. “Things like screening, having a primary care doctor who serves as your hub, maybe it’s prescription drug coverage—any of those elements that come with insurance coverage helped those individuals live healthier lives, and the outcomes and the data are there.”
Higher numbers of insured Americans lead to lower healthcare costs, she added, because fewer people will wait to get care until it becomes an emergency, and emergency department visits will decrease.
Several avenues are available to improve healthcare coverage in the United States, according to Connolly, including permanently extending ACA subsidies; closing the Medicaid gap in nonexpansion states; and providing 12 months of continuous eligibility for the Children’s Health Insurance Program and Medicaid programs. These steps would help provide consistent coverage, lower overall costs, improve patient outcomes through coordinated, preventative care; and improve equity and social determinants of health, according to Connolly.
Partnerships Could Drive Transition to Value-Based Care
Moving from the current healthcare climate to one that emphasizes valuebased care will take some time—but there are steps O&P facilities can take to help move the needle. Connolly encourages O&P stakeholders to engage on the policy level, specifically the CMS Innovation Center (CMMI) and its director, Elizabeth Fowler, PhD, JD, who is interested in value and value-based arrangements. “She has a very open door right now,” said Connolly. “Her goal is to do a much smaller number of pilots and demonstrations but at a much larger scale, involving more players” than in years past.
In addition to engaging with CMMI, Connolly noted that healthcare companies such as O&P facilities should push for value-based care and seek out partnerships with like-minded healthcare companies. “A lot of it is going to have to occur within the industry,” she said, noting that some of the member companies at the Alliance of Community Health Plans are now involved in value-based arrangements. “Some of them are starting to reach that tipping point where it will affect the entire region because they are now more heavily in value-based arrangements,” she said.
“And so, in your communities, I think you want to find those willing partners. You need to be a willing provider as well, and it’s a little bit scary,” she said. “The change is hard, and it will be bumpy and challenging, but it is going to be the future.”
Despite the new marketplaces put in place via the ACA, 31 million Americans remain uninsured … [that] population [could] grow once the COVID-19 public health emergency ends and some states disenroll some individuals from Medicaid.
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