value based care

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.

 

Transitioning from Fee-for-Service to Value-Based Care: How to Manage Your Revenue

Jas Grewal

It’s no secret that the shift to value-based is leading more physicians and nurses to be employed by hospitals. Patients feel the height of these effects because Medicare reimbursement rates have not yet kept pace with inflation. So how can physicians and nursing facilities manage their bottom line while losing money caring for this growing group of patients? Some will simply take care of fewer patients, which will reduce overall revenue in an effort to minimize the financial impact. However, there are things doctors and nurses can do to balance out the loss and actually improve margins during the slow transition to value-based care.

 

Overcome the Obstacles

First things first, you’ll need the right infrastructure and tools to make sure you’re accurately tracking all patients, so you can measure your performance and revenue. While this happens annually or quarterly, hospital CEOs and CFOs should be regularly accessing and evaluating this data in order to make continuous adjustments. Once you’ve synthesized all this information, you’ll want to rethink your traditional KPI’s (key performance indicators) associated with fee-for-service. Rather than focusing on traditional, one-dimensional metrics like headcount in beds or number of surgeries, you’ll need to get the full picture of your quality metrics. Instead, focus on metrics like:

  • Cost per case
  • Readmission rates
  • Length of stay
  • Complication rates

When you dive deeper into the data, you will probably find there are plenty of areas you can improve. Are there specific diagnoses codes that you struggle with? Are there other factors that contribute to readmission rates that might not be happening at your hospital?

 

Improve Care Coordination

Readmission rates are a major metric that is evaluated by CMS. However, even if you provide the best care, a patient could still be readmitted because they aren’t following up with their primary care provider. Skilled nursing facilities and home health solutions are also important factors to evaluate the quality of a patient’s care after they leave your hospital. Choosing the right partners and holding them to a high standard will help lessen readmissions and provide better continuity of care.

 

Become More Efficient

In come cases, you might find that the length-of-stay is longer for patients that receive an MRI, for example. If you only have one MRI for both inpatients and outpatients, your teams may be prioritizing outpatient diagnostic tests simply to accommodate business hours. But that leaves inpatients to wait until evening (around 8 pm) to get their MRI, which increases overall length-of-stay.

 

Other Strategies to Optimize

 

1. Expand access points

Free-standing ERs; outpatient diagnostic centers and urgent care facilities can all increase your volume of services you provide without the additional costs and potential penalties from inpatient stays.

 

2. Telehealth technology

Physicians or nurses that travel between hospitals, practice offices, and outreach. Clinics can reduce travel time and see more patients through virtual visits. Offering convenient telemedicine services can also be a market differentiator and attract more patients with commercial insurance that prefer the convenience of virtual visits.

 

3. Focus on specialization

By developing signature services you can focus on recruiting top-notch physicians and creating centers of excellence. Especially for procedures like joint replacement and bariatric surgery, you will draw patients that are potentially willing to pay more for a unique, high-quality experience. Ultimately, all of these efforts will result in better access to high-quality care for your patients, which will improve your composite scores and increase reimbursement potential.

 

A Moment of Truth: Population Health Management Myths Debunked

Mark Aquino

What is population management? At its core, it is the assemblage of strategies and tactics providers use to identify, measure, and improve the health of your at-risk patient populations. And under the umbrella of population management efforts are:

  1. Predictions; predicting future risks across your populations
  2. Engagement; communicating with patients
  3. Reporting; performance and regulatory measures reporting

With population health management still in its infancy, it can be easy to misinterpret what it actually entails. To shed some light on the subject, we’ll address the most common myths around population health management, both as a strategic initiative and technology component.

 

1. “Population Management is a People- and Strategy-Only Initiative”

Without best-of-breed health IT, population health management can be challenging. To be successful, population management requires a uniformed effort from both a talented team—doctors, administration, IT, to operations and everything inbetween—and an ensemble of robust, clinician-centric technology. You need modern, up-to-date platforms that don’t get in between you and your patients, but instead, amplifies your workflows. Such processes include intimately knowing risk factors and what to do about them, communicating with patients even after they’ve left the premises, and in tandem, measuring all doctor-to-patient activities for actionable insights on how you can improve them.

 

2. “Population Management is a Software-Only Initiative”

On the other hand, software itself can’t tackle population health management alone. While population management software itself brings merit to the table, your team—in partnership with the right population health management vendor committed to helping you and your patients—guiding the reins can only be favorable towards your population health initiatives. Without one or the other (people or technology), your path to improved health and financial outcomes could be filled with uncertainty.

 

3. “Population Management Can Be Addressed by an EHR System Alone”

We’ve discussed how EHRs are critical to the care continuum, yet falls short on providing you complete guidance over your populations. For instance, a hospital system may have multiple EHRs that are unable to communicate, resulting in unnecessary silos for patient data. Chaos aside, providers run the risk of having critical information on a patient in one EHR, while in another is nowhere to be found. EHRs also lack the complete picture on your patient populations falling short on all the information you need (clinical, demographics, economic, behavioral, and social data for example) into one aggregated source. More importantly, EHRs don’t enable you to take action, whereas population management platforms allow you to take initiative and address any concerns across your patients. The ultimate takeaway is that providers must unify their EHR systems with a population management platform. But to clarify another myth: one system does not replace the other. Instead, they work together in parallel to further improve how you provide quality care to your patients.

 

4. “Population Management is Unnecessary”

With MACRA (The Medicare and CHIP Reauthorization Act) becoming a reality, measuring care quality will be more table stakes than ever before. This seed change to how providers are reimbursed is one of the many reasons providers should start thinking about population health management. It demands providers be forward-thinking, collaborative, and to be able to deeply know the health of their populations. Knowing the past and present in order to plan for the future, requires providers to include population health management as part of the equation.

 

What To Look For In a Population Health Management Platform

Mark Aquino

Population health management platforms are a fundamental element of the healthcare IT stack. Along with EHRs, they’re a staple for organizations when it comes to improving and measuring the health of your patients. They enable doctors to engage at-risk patients, see data in aggregate, meet reporting efforts, and ultimately help improve the health of your patients. Navigating the vendor landscape can be a challenging task, so we’ve come up with things to keep an eye out for when looking into a population management platform:

 

1. Does it utilize predictive modeling with internal and external data?

Data in your EHR is undoubtedly critical, yet it’s not enough to get a 360-degree view of your patients. You need patient-specific information—both internal and external—from clinical, economic, and demographic, to geographic and economic data to give you this holistic view. With a complete picture of your patient population, you can predict risks and address their leading factors across the continuum of care. When looking into a population health management platform, look into whether a vendor has the ability to utilize any and all patient data—in and outside your clinic.

 

2. Does it support regulatory and performance reporting capabilities?

Reporting, whether it’s performance or regulatory, is vital. Providers must be able to report on measures like clinical improvement activities and care quality. Look for a platform that allows you to easily generate actionable reports, and enables you to address those measures—care programs and patient engagement for example—without having to leave the same system.

 

3. Does it interrupt existing workflows and processes?

Look for ways a population management platform can complement existing workflows and processes. Can the solution communicate with existing technologies in your organization? Are you able to implement the solution without complications? Being able to get up and running should not take months (or years).

 

4. Does it enable personalized and automated communication?

Personalized experiences—which is what patients want—are critical. The challenge is being able to do that without hindering other parts of your organization such as optimizing your staff. You need a solution that enables personalization and automation in tandem. One that is able to connect with patients 24/7 and knows how and how often to engage. To help you oversee patients throughout the care continuum, look for a vendor that enables bi-directional communication. Personalization and automation functionalities help you get what patients need, when they need it.

 

5. Does ease-of-use exist?

A population health management system—or any healthcare IT—shouldn’t create barriers between you and your patients. Whether it’s usability or accessibility, today’s healthcare IT should be able to help you continue providing and improving high-quality care to your patients. End-users, managers, administrators, and patients must be able to use the solution without difficulty.

 

6. Does it help me and my patients through and beyond the journey to value-based care?

MACRA is soon to be a reality and value-based care is a transition you’re likely to face. With changes to how providers go about their reimbursements and care quality measurements, you’ll need to have visibility into which patients fall under fee-for-service contracts and which fall under value-based care. Look for a vendor that is dedicated to helping you through and beyond the transition to value-based care, on providing the right solution.

 

Deciding on a population health management platform to go with isn’t a process that’s neither easy nor quick. It’s important to think about the functions and capabilities that matter and make sure the vendor aligns with your goals. With this checklist, we hope you can find the right solution for you and your patients.

 

Join Us at The Value Based Health Care Congress 2016

Mark Aquino

Untitled design

The Value-Based Health Care Congress is just a week away and we’re excited to announce we’ll be there, standing alongside industry veterans and learning more about the state of value-based care. Under The Value-Based Health Care Congress are 3 individual tracks for providers, each covering some of the key pillars of the landscape today:

  1. The MACRA Strategy Collaborative Summit
  1. Value-Based Network and Contract Management Summit
  1. ACO Strategy Summit

We went ahead and listed some of the conference sessions around care quality and health care IT that we’ll be looking forward to attending, and hopefully you will too. Be sure to stop by the CareSkore booth in the exhibit hall to see our Personalized Population Management™ platform, and learn how your healthcare organization can improve both clinical and financial outcomes. Without further ado, here are some of the sessions that we’re excited to see (exact times subject to change):

 

1. Measuring for Value – Panel Discussion

Track and Time: Main Summit, Day 1 @2:05pm

Core quality measure sets are in place and we’ve taken a significant leap forward in providing accurate, useful information on healthcare quality that can inform decisions. The next step in this transition to value-based care rests on our ability to integrate quality and resource use performance to ultimately drive better outcomes.

  • Understand the quality-spending relationship and how it promotes provider buy-in and success in risk-based contracts
  • Learn how to incorporate the patient voice to develop meaningful measures
  • Align measures across the continuum of care to reduce burden and improve efficiency

Speakers:

David Introcaso (@HealthcareIssue)

Helen R. Burstin (@HelenBurstin) – Sr VP, Performance Measures at National Quality Forum

Kate Goodrich – Director, Center for Clinical Standards and Quality at CMS

John S. O’Shea – Sr Fellow, Center for Health Policy Studies at The Heritage Foundation

Stephen L. Ondra (@StephenOndra) – Chief Strategy Officer at Amida Technology Solutions

Linda Walker – VP, Health Security at AARP

 

2. Examine the Role of Health IT in Delivery System Transformation

Track and Time: MACRA Summit, Day 2 @10:45am

Healthcare IT is undoubtedly a critical piece to how we advance quality and value. ONC’s Elise Anthony gives us the catch-all on healthcare technologies—from flow of health info to patient data access, and care delivery—required for participating in CMS programs.

  • Understand how health IT is the foundation to better care, smarter, spending and healthier people
  • Learn about new health IT initiatives that can support practical needs of patients and providers

Speaker:

Elise Sweetney Anthony (@Policy2Progress) – Director, Office of Policy at ONC

 

3. Explore the Ingredients of a Health IT Value Strategy

Track and Time: MACRA Summit, Day 2 @11:30am

Implementing health IT does not guarantee success. These technologies—focused on improving care must allow stakeholders to be able to find usability and usefulness that also support processes—both business and clinical—of a value-based reimbursement system.

  • Review the HIMSS STEPS™ model and its five components
  • Identify areas where health IT has proven value and non-technical barriers to IT optimization
  • Explore potential new functions of health IT that should support value-based care

Speakers:

Peter Basch – Medical Director, Ambulatory EHR and Health IT Policy at MedStar Health

Patricia Wise – VP, Health Information Systems, HIMSS

 

4. Engage Physicians in ACO and Other Value-Based Models to improve Quality

Track and Time: ACO Summit, Day 2 @2:15pm

Successfully engaging physicians ensures that ACOs and other value-based endeavors reach potential, but that is easier said than done. It’s especially challenging when physicians continue to receive fee-for-service and value-based payments simultaneously.

  • Understand physicians’ risk-based payment and MACRA, and how to transition to a value-based mix
  • How to coordinate for optimal management of complex patients
  • Utilize integrated and actionable claims data, not multiple EHRs, and learn how to report data that demonstrates the impact of clinical decisions

Speaker:

Abigail Chen – Medical Director, Quality and Clinical Integration at Mount Sinai

 

5. Achieve Better Quality, Less Effort, and Greater Savings – How You Can Have All Three

Track and Time: ACO Summit, Day 2 @3:00pm

Through organizing information and communicating it with providers in addition to focusing on specific efforts such as cardiac and respiratory conditions, providers can improve cost and quality metrics in parallel and demonstrate the value throughout the health care community.

  • Explore feasibility of collecting and tracking patient data to understand quality performance
  • How cutting costs and increasing quality scores can earn shared savings
  • Illustrate examples of payer-provider engagement and alignment around shared objectives

Speaker:

John Haughton (@haughton_md) – CIO at Chautauqua AMP; CQO at Independent Health Plan

 

Beyond MIPS: A Look into the 90+ Clinical Improvement Activities

CareSkore

Header - Look into 90 activities

Under the MACRA, providers will be reimbursed according to a composite score that reflects how well you’re providing value-based care. This composite score comprises of four key categories: the quality of care you provide, the efficiency of your resource use, meaningful use of EHR, and last but certainly not least, clinical practice improvement activities (CPIA).

 

Image - 90 Clinical Improvement Activities

A rising tide lifts all boats, right? The great part about MIPS—one of the two payment programs as part of MACRA—is that all of these metrics tie-in to improve clinical outcomes and patient engagement. This leads to cost savings, efficient resource use, and improved adoption of your EHR. Maximizing your composite score will not only affect your payments positively, but it will help you provide efficient patient care.

 

Not all activities are created equal

Certain categories are worth more than others due to their impact on patient care. High-weighted activities are worth 20 points, whereas medium-weighted activities value at 10 points. While these CPIAs only account for 15% of your total score, leveraging the highest-weighted tactics can be easy wins for your practice. Planning, completing and reporting 3 activities is much easier to pull off than 6 different initiatives. During your 90-reporting period (here’s a plan for when should start thinking about it), you must achieve 60 points by completing these clinical practice improvement activities in which there are over 90 tactics across 8 categories, in the combination of your choice.

 

Here’s a look at some of the types of activities in each category per ASCRS:

Expanded Practice Access: expanded practice hours, telehealth services, and improving access to services

Population Management: chronic care management programs, community and rural healthcare programs

Care coordination: health information sharing, timely communication and follow-up, care coordination training to handle transitions of care, and active referral management

Beneficiary Engagement: EHR to document patient-reported outcome,enhanced patient portals

Patient Safety and Practice Assessment: ongoing practice assessments and patient safety improvements, and use of tools such as the Surgical Risk Calculator

Achieving Health Equity: seeing new and follow-up Medicaid patients in a timely manner, and use of QCDR for demonstrating performance of processes for screening for social determinants

Emergency Response and Preparedness: participate in disaster medical teams or participation in domestic or international humanitarian volunteer work

Integrated Behavioral and Mental Health: tobacco intervention and smoking cessation, and integration with mental health services.

 

Choosing your activities

With several ways to maximize points in these categories, many activities may overlap and will have a bigger benefit for your patients.

Let’s take the Beneficiary Engagement and Population Management categories for example. You can implement specific programs and protocols to help patients with chronic illness like heart disease and diabetes. Helping patients manage their care at home with blood pressure testing and glucose measurements will help keep them on track and reduce the risk of readmission.

Bonus: Have a tool where patients can electronically share data and communicate with providers.

 

Convenience is king

Anything you can do to make life easier for your patients will most likely be a highly weighted CPIA. Expanding access to care with extended hours or e-visits can significantly decrease appointment cancellations or no-shows. Also, providing 24/7 real-time communication with care teams and reminders will greatly improve patient engagement and overall outcomes.

Another highly weighted activity is participation in CMS’s Transforming Clinical Practice Initiative which aims to help:

  • Exchange patient data information for the best continuity of care
  • Track patients through the entire process and integrate information from specialists to make sure care is documented
  • Coordinate phone calls, communication, navigation post-discharge
  • Communicate timely results for follow-up
  • Create individualized care plans for high-risk patients to share with other providers

 

Attaining Full Credit with Reporting

Given that the entire healthcare industry is shifting towards value-based care, reporting will be one of the most critical components within the continuum of care. If you haven’t already, begin to determine what measures you will report on and evaluate your strengths. Identify what gaps can be filled and put in the necessary plans to improve those gaps. Here at CareSkore, we envision providers getting the credit they deserve.

Through CareSkore, providers can:

  • Generate reports for measures including MACRA, PQRS, and HEDIS
  • Manage your patient population with real-time assessments
  • Understand patient data and quality metrics in order to improve outcomes

Whether it’s reporting for Clinical Improvement Activities or any of the mentioned categories, understanding your patient population through reporting is the first step to cultivating the provider-to-patient relationship.

 

Sources:

MIPS, MACRA & MU - The Next Evolution of Healthcare Payment Reform

MIPS: Clinical Practice Improvement Activities Category

MIPS Program: 2017 Clinical Practice Improvement Category Proposed Rule Guide

Federal Register - Subcategories

Medicare Program; MIPS and APM Incentive Under the Physician Fee Schedule

Transforming Clinical Practice Incentives

 

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

 

Where EHRs Fall Short: 3 Reasons Doctors Need Personalized Population Management

Mark Aquino

photo-1465161191540-aac346fcbaff

Look into the center of a hospital’s information technology stack, and you’re bound to find electronic health record systems (EHRs) to be the cream of the crop, costing healthcare providers tens to hundreds of millions of dollars for implementation and use. As the core system of record within a healthcare organization, when it comes to providing the 360-degree view on any given patient or patient population, EHRs fall short on giving the complete picture.

 

The State of Electronic Health Record Systems

It’s no doubt that EHRs are critical to a hospital or health practice. An EHRs’ core capability rests on being able to store significant amounts of patient data records and is used across multiple functions—care quality, finance, and operations—within a health organization. Whether it’s capturing notes on patient encounters, insurance claim information, or data on historical visits, you name it—EHRs are effective in that regard. This, however, is what EHRs were designed to do, and nothing more; to operate as silos of unstructured data.

Storing data and interpreting data are two independent undertakings. It’s important for doctors to be able to distinguish between the two without overspending on time and resources. In order to capture the complete picture on a patient population, clinical and financial departments need a dedicated system that allows for seamless interpretation of patient data, predictability, and personalized patient communication at will. Keep an eye out for the following when looking into a population management solution:

 

 1. Predicting no-shows and patient risks

Tracking historical patient data is fundamental. But what about predicting and planning for the future? As healthcare providers continue to amass increasingly large amounts of patient data from socioeconomic to demographic inputs, not leveraging that data is an opportunity missed. Where EHRs lack, a Personalized Population Management™ can make up in value, as EHRs were not designed to predict future occurrences from their stored data. Doctors need a solution that not only enables them to manage no-show and cancellation rates but addresses dire questions like, Which patients within my population are at-risk? What are the leading factors for my patients’ risks? How can I improve the health of my patient population?

 

 2. The need to engage patients

Doctors and physicians want to spend more time doing what they do best: caring for their patients, not trying to make sense of high volumes of unstructured data. When relying on EHRs for patient engagement, physicians and nurse practitioners can face barriers; meeting personalized demands, usability issues, unnecessary workload. What doctors and physicians seek is a tool that not only gives back lost time from using EHRs but a tool that enables bi-directional patient communication even when patients leave the premise. This calls for a communication medium to be put in place dedicated to engaging patients and helping doctors get what patients need when they need it.

 

 3. Meeting regulatory reporting requirements

One thing is true. It’s becoming much more difficult for doctors to focus on their population. While the rise of the health IT landscape was meant to automate certain tasks, the reality is it’s taking up more and more of a doctor’s time. With new reporting and payment regulations underway, doctors must have a solution fixated to handling this department. EHRs alone aren’t enough and extracting data from these systems can be a daunting task. Orchestrated in alignment, however, EHRs and predictive analytics make a formidable pair. Together as the bread-and-butter of the health IT stack, EHRs and predictive analytics empower healthcare providers to capture data, interpret it for actionable insights—regardless of complexity or magnitude—and help providers with their patients in the continuum of care.

 

Personalized Population Management does not replace an EHR. Rather, Personalized Population Management complements a robust EHR system. In this new era of healthcare, predictability tied with communication and reporting gives doctors the ability to ultimately improve their financial and clinical outcomes and focus on what matters most, the patient.

 

The Medicare Access and CHIP Reauthorization Act (MACRA) is underway to completely change how healthcare providers approach medicare payments. Are you ready? Join us as we discuss how to approach MACRA in our upcoming webinar, MACRA: Addressing the Transition.