APM

The New Era of Population Health: Key Trends for Physicians in 2017

Jas Grewal

While there are many definitions of population health or the “health outcomes of a group of people”, the terms place emphasis on the determinants of health and the interventions to elevate overall health status. Population health is often used interchangeably with public health to describe the activities conducted by governmental public health agencies, community and national organizations to improve the health of a community.

 

Promoting health and preventing disease are key components of population health, both at the societal level and within a primary care practice. And within that, there are three different levels of prevention:

1. Primary prevention – Prevention strategies that seek to prevent disease or injury, generally through reducing exposure or risk factor levels. These strategies can reduce or eliminate risk factors (risk reduction).

2. Secondary prevention – Prevention strategies that identify and control disease
processes in their early stages before signs and symptoms develop (screening and treatment).

3. Tertiary prevention – Prevention strategies that prevent disability by restoring individuals to their optimal level of functioning after a disease or injury is established and damage is done.

 

The goals of population health are to help physicians engage in preventive care, improve care quality, and ultimately, improve health outcomes. There are several benefits of applying a population focus to primary care. Population health tools—especially ones that leverage analytics—allow providers to track care across all of their patients, rather than limiting their attention to the patients who make appointments. One provider explained that “I thought I was doing a really good job” by discussing preventive care during annual physicals or acute visits. However, since adopting a more systematic method of monitoring all of her patients, she said, “now it seems that was not the case. We could not pull all the charts to see who needed [a preventive visit].”

 

Based on the 2017 healthcare reform landscape, there are six areas of initiatives that are currently shaping population health:

Wellness / Preventive health
The second most widely adopted initiative promotes workplace health, school health, weight loss and smoking cessation and are typically implemented to improve overall health and deter more serious conditions from occurring. This initiative category dropped from 79 percent in 2015 to 72 percent in 2016.

Clinically Integrated Network (CIN)
Another model of care, CIN, is a health network of providers/hospitals that use protocols to improve care, lower costs and increase value to a particular market. Roughly half of study organizations with initiatives in place in 2016 leverage this model of care for population health.

Patient-Centered Medical Home (PCMH)
Focuses on acute, chronic and preventative care that is coordinated and integrated across multiple sites with health quality and safety in mind. Care across the continuum could be proving to be difficult as approximately 50 percent of study organizations indicated they utilize this model of care in 2015 and 2016.

At-risk payment structures
At-risk payment structures include Accountable Care, Medicare Shared Savings Program, bundled payment, and employer contracts. An increase in this category since last year indicates the organizational shift to value-based payment but significant gains could take some time as organizations build out their population health programs.

At-risk cost structure
The least adopted program includes Medicare Advantage plans, Medicaid managed care, commercial plan, and self-insured employee plans. This particular initiative grew from roughly 17 percent in 2015 to 19 percent in 2016.

 

MACRA will certainly impact population health in 2017. MACRA was enacted in 2015 to replace the Sustainable Growth Rate (SGR) for physician payment. In 2016, new rules were issued for quality reporting and payment policies that will substantially change the status quo for Medicare’s physician reimbursement in 2017.

Get more in-depth information on the MACRA Quality Payment Program and learn more about Physician Focused Payment Models (PFPMs) Technical Committee.

 

As a physician, below are a few tips to get ready for the new MACRA:

  • Attend webinars.
  • Request a CMS speaker to give your group more details about the Quality Payment Program.

Although hospitals have been subject to the performance-based payment provisions of the Affordable Care Act (ACA), the concept is new to physicians, who need to understand how to improve performance and avoid payment penalties. In essence, this will entail developing more complex governance models, adjusting to more data sharing across the care continuum, and more performance measurement.

With a choice of payment models, physicians will need to conduct financial planning to determine which path presents the greatest benefit given current performance.

Once a payment model is selected, physicians must decide how to organize. Understanding that unprecedented levels of partner collaboration, testing, and co-innovation will be the keys to long-term success.

 

Preparing Your Practice for MACRA: A Plan for 2016 and Beyond

CareSkore

Header - Preparing for MACRA

Significant changes are coming to the way physicians are reimbursed through the Medicare Access and CHIP Reauthorization Act (MACRA). As part of a larger initiative to transition from fee-for-service towards value-based care, one of MACRA’s proposed payment programs, the merit-based incentive payment system (MIPS) will help providers focus on improving clinical outcomes by reducing administrative burdens. In the long run, this will offer more financial certainty and a greater potential for bonus payments. As a healthcare organization, there are action items you must take in order to receive credit for the high-quality care you’re providing.

 

Preparing for MACRA in 2016

In 2015, about 56% of physicians said they were unsure whether or not they were ready to participate in MACRA. Ready or not, the following are things you can start doing today to prepare for the newly proposed payment programs.

  • Understand the impact: Review the proposed changes and explore their implications.
  • Know yourself: There is no one-size-fits-all approach given that each and every provider is unique in their own way, so only you—alongside your administrative team—can complete an accurate self-assessment.
  • Develop a success plan: Outline your strategy with target dates to keep you on track.
  • Educate your team: Get in touch with providers and internal stakeholders to make sure everyone is on the same page.

 

What You Can Do Today

Start thinking about which payment track is most fitting for your practice. Unless you’re part of an accountable care organization (ACO), you will most likely begin with MIPS. You’ll need to review your Quality Resource and Use Report (QRUR) to get a baseline of where you can improve.

 

1. Meet Meaningful Use

If you aren’t already using an EHR or electronic health record system, now is the time. It should allow patients to access and exchange their information across the coordination of their care. Find a solution that enables you to connect with patients and will be easy to adopt.

 

2. Start Reporting

Determine which quality measures you plan to report on. Since this could differ based on specialty, you’ll want to carefully evaluate your strengths. If you’re part of a physician practice, decide whether you want to report as a group or as an individual.

 

3. Understand Resource Use

Once you dig into your data and evaluate your benchmarks, you’ll be able to understand how you’re spending your resources. Knowing which of your patient populations are keeping costs up is critical to developing a plan to improve care. Often, these groups include patients with chronic illness that require frequent visits and engagement. Strategize how your practice can deliver care more effectively to these patients.

 

4. Identify High-Performance Areas

Your practice is probably already performing well in some quality areas. Use this as an opportunity to get credit for the things you do best. Then you can develop a plan and fill in the gaps where you need to improve.

 

5. Evaluate Your Readiness for MACRA

Whether you follow a MACRA checklist or create your own success plan, gauge your progress and understand the timeline in order to set your practice up for success.

 

What You Need To Do in 2017

In January 2017, CMS (The Center for Medicare and Medicaid Services) will begin collecting data to get a baseline for the rest of your performance metrics. You’ll receive your first feedback report in July of 2017, giving you a better idea of your current quality measures. It’s also a chance to quickly adjust any measures during Q3 and Q4.

In 2017, you should decide on your 90-day reporting period. Many factors can influence your choice such as the timing of major holidays or when providers will be on vacation. Choose a time that will provide the complete, most accurate picture of your practice. Your practice will also need to decide which Clinical Practice Improvement Activities to begin. Getting a jump-start on these can help your overall composite score, and improve the patient experience. Talk with your team about which activities will be the most impactful and cost-effective to facilitate and make both short-term and long-term plans.

Make sure it’s meaningful: it won’t be enough just to meet meaningful use. Your EHR technology will be evaluated for efficacy by CMS and will want to know it’s adding value to the patient experience, not just checking off a box. The following are things to look for when evaluating an EHR:

  • Make sure it is secure
  • Make sure patients are actually using it
  • Make sure patients are using it to access health information and receive secure messages

 

Thinking About 2018

By 2018, the CMS’s goal is to have 90% of Medicare payments shifted to quality or value-based care. When you receive your second feedback report in July of 2018, you can compare your progress and understand where you can improve. From creating improvement action plans you’re positioning yourself to maximize payments.

Understanding how all practice operations work together is great if you can easily synthesize all the data and see trends. That’s where CareSkore comes in, giving healthcare providers the ability to:

  • Get a 360-degree view on patients and patient populations by accurately assessing both patient risks and needs, and improve outcomes.
  • Coordinate and manage the most appropriate and timely care through personalized follow-up with high-risk patients and understanding data that will improve quality measures.
  • Improve patient engagement by connecting with patients even after they have left the premises to reduce both no-shows and cancellation rates.

These simple, yet impactful tactics can enhance the patient experience, improve outcomes and reduce administrative and operational challenges that keep your practice from providing the best possible care to every single patient—which is ultimately what MACRA will be evaluating.

 

Sources

 

MACRA Basics: MIPS vs APM - What You Need to Know About the New Rules

CareSkore

Header - MACRA MIPS vs APM (1)

What is MACRA?

The MACRA (Medicare Access and CHIP Reauthorization Act) is the new healthcare reform poised to replace all of the different “patchwork programs” for physicians who receive Medicare payments. As part of the shift towards value-based programs proposed by CMS (Centers for Medicare & Medicaid Services), it’s purpose is to set up a new framework that rewards physicians, not on the amount, but the quality of care they provide. As a provider, you have two different options for how you want to get reimbursed: MIPS (Merit-based Incentive Payment System) and APMs (Advanced Payment Model).

 

What is MIPS?

MIPS determines your reimbursement rates by the quality of care. Payment adjustments under MIPS are based on the MIPS Composite Score, which comprises of 4 key areas:

  • Quality (Formerly Physician Quality Reporting System or PQRS)
  • Advancing Care Information (Meaningful Use)
  • Clinical Practice Improvement Activities
  • Resource Use

If your score is above the threshold, you’ll receive a positive payment adjustment. But if you’re below, you’ll have a negative payment adjustment for the following year. Scores will be compared to both year-over-year improvements and other providers.

 

Benefits of Merit-Based Payments

High performers under MIPS receive a positive payment adjustment for up to 3x the adjustment factor, but physicians still have to report on quality measures to make sure standards are being upheld. Providers can maintain a higher score by simply improving patients’ outcomes through care coordination and ensuring patients have easy electronic access to their health information. Many are already using technology to increase patient engagement. By communicating with their patients in real-time, providers can better serve patients who have a higher risks of complication and readmission to the hospital. Through patient engagement and communications, providers receive credit for helping patients through personalized reminders to take their medicines, monitor their performance, and keeping them healthy throughout the continuum of care. Tying clinical practice improvement activities such as improving patient safety, population health, and long-term outcomes together, ultimately makes your practice much more efficient.

 

What is APM?

Aside from MIPS, the other payment track is an Advanced Payment Model or APM. Currently, patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) use this model. CMS, however, anticipates that more individual providers will qualify for this option. APMs will provide a 5% lump sum bonus based on the prior year’s payment beginning in 2019 over a 6 year time period.

To be eligible for APM, participants must:

  • Have serious quality measures comparable to MIPS
  • Use EHR (Electronic Health Record) technology
  • Bear “more than a nominal financial risk” similar to an ACO or PCMH

Physicians who choose an APM have an opportunity to earn more, but run the risk of paying Medicare back if they don’t meet savings goals. Understanding these risks and determining if they outweigh the potential benefits is a decision that providers will have to make individually or with their practice management team.

 

How to Choose the Best Payment Model

Which path do you take? You and your partners can weighout both payment models under the MACRA, but first, you’ll want to get the facts to make an informed decision.

Know yourself - Dig through the quality data. Are you a high performer? Find out why or why not. Know your current quality metrics and create a plan to improve.

Know your patient population - Do you know you take on patients that have multiple health problems or things you can’t control? That could be a factor in your reimbursement rates.

Under MIPS, there are over 90 activities you can choose from to demonstrate how you’re improving your clinical practice. These tactics can give you credit for helping patients overcome challenges like making sure they’re taking their medicine or adhering to a rehab program.

 

How Meaningful is Meaningful Use Technology

Another thing to consider is your meaningful use technology. Now, you’ll be measured on how well patients are making use of their electronic health information. Is it actually providing value? The intent is that providers and patients are actually sharing information and making prevention and high-quality care more accessible to patients.

 

Start Planning Now

The good news is that the current payment programs requiring reporting on quality metrics will be absorbed into the MACRA. Physician practices have until 2019 to choose their payment track, however, it’s never too early to understand your options and have a general idea of what makes the most sense for your practice. In the meantime, you should honestly evaluate your quality metrics and how you’re meeting meaningful use. Take the time to look for ways to improve and implement tactics that can help your patients now.

 

Sources:

NPRM - Quality Payment Program Fact Sheet

CMS Quality Reporting Programs

Medicare Access and CHIP Reauthorization Act (MACRA) Preview Module

Quality Payment Program - CMS

Quality Payment Program - MIPS and APM

MIPS or APM: Which is better for your practice?

Moving toward improved care through information

MACRA Payment: APM vs MIPS

 

MACRA Basics: The Method Behind MIPS Scoring

Mark Aquino

cover mips scoring

When the sustainable growth rate (SGR) formula was set in stone in 1997, its sole intent was to better control the cost of healthcare payments to physicians. Payments towards clinicians were and still are predicated on volume of services, not value. If the overall physician costs were greater than Medicare expenditure targets, then physician payments were reduced.

Enter in MACRA, otherwise known as The Medicare and CHIP Reauthorization Act and we’re on our way to repeal the SGR formula and create an entirely new system that physicians must follow.

 

Old to the New

As the torch bearer in this shift towards value-based care, MACRA is proposing two payment systems that eligible physicians can choose to operate under; MIPS, or Merit-based Incentive Payment System and APM, also known as the Advanced Payment Model. The goal of MIPS is to provide physicians with the flexibility to choose activities and measure those most meaningful to their practice. With the introduction of Clinical Improvement Activities, a new performance category that physicians will be scored on, MIPS will consolidate the three categories that physicians already measured by; Quality, Resource Use, and Meaningful Use of Technology, forming the MIPS Composite Score as a result. The MIPS Composite Performance Score takes into account the weight across each performance category, performance factors, group performance, availability and applicability of measures, and special circumstances of nontraditional practices (practices located in rural areas and non-patient).

 

Are You Eligible?

First order of business: how do you know if you’re eligible to operate under the MIPS program? MIPS-eligible clinicians in the first and second year of the program include:

  • Physicians
  • PAs
  • NPs
  • Clinical nurse specialists
  • Certified registered nurse anesthetists

After the third year, the eligibility funnel expands, adding:

  • Physical or occupational therapists
  • Speech-language pathologists
  • Audiologists
  • Nurse midwives
  • Clinical social workers
  • Clinical psychologists
  • Dietitians
  • Nutritional professionals

You’re exempt from MIPS if you are:

  • In your first year of Medicare participation
  • Eligible for APM and qualify for bonus payment
  • Below the low volume threshold (Medicare billing charges less than equal to $10,000 and provides care for 100 or fewer Medicare patients in one year).
  • A hospital or facility

As you prepare your practice for MACRA, it’s critical to keep these four performance categories in mind, how they’re calculated, and how they tie-in together to form the MIPS composite score.

 

The Big Four

1. Quality

The quality performance category replaces the Physician Quality Reporting System, or PQRS, accounting for 50 percent of the MIPS composite score. Under the quality performance category, there will be six measures that doctors can choose to report on that best reflects their practice. In addition, doctors must also report on 1 high priority measure; outcome, appropriate use, patient safety, efficiency, care coordination or patient experience, and 1 cross-cutting measure.

Composite Score Weight: 50% in 2019

Maximum Possible Points: 80 to 90 points

Calculation and Scoring: Each measure equates to 1-10 points in comparison to historical reports. If a measure is not reported, score equals 0. Additional bonus points are awarded for patient experience, patient safety, care coordination, and EHR reporting.

 

2. Advancing Care Information

In the Advancing Care Information category, formerly known as Meaningful Use, clinicians are rewarded based on their performance of measures most favorable to them, reporting on key measures on interoperability and the exchange of information. The six objectives required to measure, as proposed by CMS include Protection of Patient Health Information, Patient Electronic Access, Coordination of Care Through Patient Engagement, Electronic Prescribing, Health Information Exchange, and Public Health and Clinical Data Registry Reporting.

Composite Score Weight: 25% in 2019

Maximum Possible Points: 100

Calculation and Scoring: A base score of 50 points is granted if the provider reports one or more use cases across each available measure. For each measure, up to 10 additional points are possible.

 

3. Clinical Practice Improvement Activities

Of over 90 activities to choose from, clinicians have the choice to measure activities best suitable for their practice. Those participating under medical homes earn full credit while APM participants earn half. Activity categories include Expanded Practice Access, Beneficiary Engagement, Achieving Health Equity, Population Management, Patient Safety and Practice Assessment, Emergency Preparedness and Response, Care Coordination, Participation in an APM, Integrated Behavioral, and Mental Health.

Composite Score Weight: 15% in 2019

Maximum Possible Points: 60

Calculation and Scoring: Each of the 90 activities is worth 10 points and “high-value activities” are given double the weight.

 

4. Resource Use

For clinicians and physicians, the score for the Resource Use or Cost category is based on claims and volume sufficiency. For this category, doctors need not report anything as CMS does the calculations. Clinicians that provide high-quality care for their patients achieve better performance, thus resulting in a higher score through being the most efficient in resource use.

Composite Score Weight: 10% in 2019

Maximum Possible Points: Average score of resources measures that can be attributed.

Calculation and Scoring: 1-10 points based on performance benchmarks.

 

What’s Ahead

As the final MACRA ruling is just a few months away, physicians—and hospitals—must prepare themselves by understanding the implications of MACRA—both MIPS and APM—and have actionable information on what they can do to address the proposed payment systems. While MACRA—if passed—goes into effect in 2019, both 2017 and 2018 performance and payments will be accounted for.  you can, not only improve your processes and workflows but more importantly, enhance how you serve your patients better in the continuum of care.

Are you looking to learn more about MACRA? Join us as we cover how to directly approach the new payment systems in our upcoming webinar, MACRA: Addressing the Transition, this Thursday, August 11th at 11AM PDT.

 

References:

CMS Quality Payment Program NPRM

CMS The Medicare, The Merit-Based Incentive Payment System: MIPS Scoring Methodology Overview