MSMS Reimbursement Advocate Alert

• 86 percent of physicians report PA burdens have increased over the last five years. • The Office of Inspector General found Medicare Advantage Organizations overturned 75 percent of their own denials during 2014-16, overturning approximately 216,000 denials each year. The OIG stated, “The high number of overturned denials raises concerns that some Medicare Advantage beneficiaries and providers were initially denied services and payments that should have been provided.” Evidence suggests that PA and step therapy adversely affect patients… • 37 percent of prescriptions rejected at the pharmacy are abandoned, never to be picked up by patients. • 74 percent of physicians report PA can lead to treatment abandonment. The broad application of PA and step therapy may very well be penny wise and pound foolish… • Studies have shown that while step therapy, for example, decreased drug costs, overall health care costs remained the same or increased. • A review of medical and pharmacy claims of nearly 300,000 Medicaid enrollees found that adherence to medication declined due to formulary restrictions, and total costs increased with formulary restrictions due to increased inpatient and medical costs, as well as, increased pharmacy costs for bipolar disorder. • Prescription PA implementation for medications to treat diabetes, depression, schizophrenia and bipolar disorder has been associated with worsening disease status.

• Requiring prior authorization before covering a drug or patient service. • Requiring patients to try a generic drug if it is equivalent to the brand. • Using step therapy, so long as the protocol is not in conflict with the “best interest” of the patient, as defined in the legislation.

Sources: 1. Bergeson JG, Worley K, Louder A, Ward M, Graham J. Retrospective database analysis of the impact of prior authorization for type 2 diabetes medications on health care costs in a Medicare Advantage prescription drug plan population. J Manag Care Pharm. 2013;19(5):374-384. doi:10.18553/jmcp.2013.19.5.374 2. Seabury SA, Goldman DP, Kalsekar I, Sheehan JJ, Laubmeier K, Lakdawalla DN. Formulary restrictions on atypical antipsychotics: impact on costs for patients with schizophrenia and bipolar disorder in Medicaid. Am J Manag Care. 2014;20(2):e52-e60. 3. 2019 American Medical Association Prior Authorization Physician Survey. https://www. ama-assn.org/system/files/2020-06/prior-authorization-survey-2019.pdf. 4. CoverMyMeds. 2019 ePA national adoption scorecard. https://www.covermymeds. com/main/insights/scorecard/impact/. Accessed November 29, 2019. 5. Office of Inspector General. U.S. Department of Health and Human Services. Some Medicare Part D beneficiaries face avoidable extra steps that can delay or prevent access to prescribed drugs. https://oig.hhs.gov/oei/reports/oei-09-16-00411.pdf. 6. Papanicolas I, Woskie LR, Jha AK. Health care spending in the United States and other high-income countries. JAMA. 2018;319(10):1024-1039. doi:10.1001/jama.2018.1150

MSMS provides periodic updates to members and their offices on new and relevant payer policies. Please find some recent highlights below. For a comprehensive accounting of a health plans announcements, please consult the payer’s official communications.

The CPT code set continues to be modified to respond to the ever-changing health care field. This year is no different. There are 206 new codes, 54 deletions and 69 revisions to the CPT code set. As you know, there were important additions to the CPT code set for new medical testing services due to the public health response to the COVID-19 pandemic. Jill Young will present an overview of changes for 2021 to help prepare you for the new year.

For the last two years, we have been talking about the proposed changes to Evaluation and Management codes and that these changes would become effective January 1, 2021. Understanding those changes is key in making any necessary changes in the office flow. It is also important to consider any potential software changes that may be necessary to ensure correct coding of Evaluation and Management services. The E/M office visit modifications include: • Eliminating history and physical exam as elements for code selection. • Allowing physicians to choose the best patient care by permitting code level selection based on medical decision-making (MDM) or total time. • Promoting payer consistency with more detail added to CPT code descriptors and guidelines. Jill Young will explain these changes and allow time for questions, to help you prepare for 2021.

Gain new perspectives on the following child health issues and review strategies for building trauma-responsive communities of practice in the era of COVID-19 that address:

What is the S.A.M.E. When

• Rising mental and physical health risks for children • Stressors impeding protective factors for children, including caregiver/parent well-being, COVID-19 crisis coping, adult ACEs • Health inequities undermining children’s physical and mental well-being • Research work on COVID-19 impacts on children, families, and health care providers

Creating Circles of Care: Driving Community Impact

1-1:10PM 1:10-1:50PM

1:50-2:30PM

2:30-3PM 3-3:30PM Welcome What is the S.A.M.E. When Everything is Different? Creating Circles of Care: Driving Silent Voices of Chidren Research Panel Q&A

Heather C. Forkey, M.D. Associate Professor of Pediatrics and the Joy McCann Professor for Women in Medicine at the University of Massachusetts Medical School

Jeanette Betancourt, Ed.D. Senior Vice President, U.S. Social Impact, Sesame Workshop

Who should attend: physicians, educators and clinicians including family medicine providers, pediatricians, physician assistants, nurses, psychiatrists, counselors and social workers.

Registration Link: https://bit.ly/33UCMU7

Central Michigan University College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Central Michigan University College of Medicine designates this live activity for a maximum of 2.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the activity and individual assessment of and feedback to the learner, enables the learner to earn up to 2.5 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABP MOC credit.

The Central Michigan University Social Work Program, an accredited social work educational program, is authorized by the Michigan Licensure Law Administrative Rule 338.2965 to award Michigan social work continuing education contact hours. For this program, 2.5 CE’s will be awarded.

CMU, an AA/EO institution, strongly and actively strives to increase diversity and provide equal opportunity for all individuals, irrespective of gender identity or sexual orientation and including but not limited to minorities, females, veterans and individuals with disabilities. MGX, 20050 (10/20)

The time is now as the needs of children and families are compounding during the coronavirus crisis. By concentrating our collective capacities of clinical skills and communities of support, it is possible to confront the challenges and mitigate lifelong health consequences of childhood trauma.

In 2020, physicians have encountered the great need for strategies to address and treat child and family toxic stress due to the collective trauma caused by the coronavirus pandemic. This virtual symposium will provide an opportunity for physicians and care providers (pediatric and family medicine, behavioral health, and education) to learn about approaches for implementing trauma-informed pediatric practice, learn strategies for supporting parents/ caregivers to reduce parental toxic stress which can lead to ACEs in children, and gain insights from researchers actively examining aspects of child/family trauma in hospital emergency and clinical settings responding to dynamics of providing care for COVID-19 illness, mental health, child abuse and isolation.

“Children are inherently vulnerable because they depend on adults to have their most basic needs met. When those adults

Keynote Presentations:

Session 1: 1:10-1:50 PM - Heather Forkey Presentation Title: COVID-19: What is the S.A.M.E. when everything is different?

Learning Objectives:

1. Consider how COVID-19 may be a trauma and an opportunity to build resilience 2. Identify four ways to support caregiver regulation and resilience 3. Formulate a strategy to respond to child symptoms and promote resilience despite the constraints of COVID-19 Session 2: 1:50-2:30 PM – Jeanette Betancourt Presentation Title: Creating Circles of Care: Driving Community Impact by Raising the Silent Voices of Young Children Sesame Street in Communities, activates awareness and strategies to create “Circles of Care” that integrate within community impact models to align trauma-informed practices to mitigate the effects of traumatic experiences. Adverse Childhood Experiences (ACEs) can have long-term negative effects on a child’s brain development and future wellbeing, especially when confronted with repeated traumatic experiences, such as parental addiction or incarceration, unsafe home environments, or the recent consequences of COVID-19. Yet we also know that young children are remarkably resilient, and one of the best ways to counteract the effects of traumatic experiences is by fostering nurturing connections between children and the grownups in their lives, including parents, caregivers, educators, and community service providers. With the help of loveable Muppet friends, Sesame Street in Communities is connecting and empowering these important grownups to build a “Circles of care” to help children – especially the most vulnerable – to grow and learn in ways that will last a lifetime. lack the wherewithal to cope with the immediate, urgent, and multiple adaptive demands a pandemic places on families and when support systems do not exist, falter, or cease, it can result in unmitigated disaster for the very young, according to a recent report examining the Impact of the COVID-19 Pandemic on Early Childhood Care and Education (Early Childhood Education, Nature Public Health Emergency Collection, July 2020).

Providers and teams will gain insights for how to provide and model concrete supports for parents and care givers that can help mitigate adult and child stressors posed by COVID-19 illness, child isolation, and related pediatric risks, through strategies that integrate trauma-informed culturally-specific approaches into services and systems for

children, youth, families.

1. Identify the unique challenges young children face that are perceived as adult-only challenges and provide ways to create an integrated community impact approach to maximize service delivery; 2. Examine how caring adults – from parents to all community service providers– can build a “circles of care” to advocate for the needs of vulnerable children and families, by integrating methods to identify and respond to traumatic experiences; and 3. Review Sesame Street in Communities trauma-informed strategies, resources, and best practices to support mental and behavioral health, especially emphasizing parental addiction, with young children and their families.

Session 3: 2:30-3:00PM – Research Panel: Jocelyn Ang, M.D., Cheryl Geisthardt, Ph.D., Usha Sethuramann, M.D.

Clinical Characteristics and Outcome of Pediatric COVID-19 in a Tertiary Care Children’s Hospital in Detroit 1. Present our experience in children with confirmed COVD-19 illness who were treated at Children’s Hospital of Michigan in Detroit. 2. Describe the clinical presentation, medical intervention, and outcome of these children.

Supporting Children and Families in the Medical Setting During COVID-19: Exploring the Role of Certified Child Life Specialists 1. Describe the role of child life specialists in supporting children and families in the medical setting. 2. Explain the diverse contributions of certified child life specialists to improving quality of pediatric care and promoting positive development in the medical setting during COVID-19.