Archive for the ‘Affordable Care Act’ Category

In Successful ACOs, Population Health Focus Paves Way for Shared Savings Payouts

January 25th, 2018 by Patricia Donovan

Physician practices toiling in fledgling ACOs and obsessing over shared savings that have not yet materialized, take heart: population health offers multiple revenue streams for accountable care organizations waiting for the “gravy” of accountable care.

“Gravy” is the way Tim Gronniger, senior vice president of development and strategy for Caravan Health, refers to ACO shared savings payouts, which he says can take considerable time to accrue.

“It is literally two years from the time you jump into an ACO before you have even the chance of a shared savings payout,” Gronniger told participants in Generating Population Health Revenue: ACO Best Practices for Medicare Shared Savings and MIPS Success, a January 2018 webcast now available for replay.

Obsessing over shared savings is one of the biggest mistakes hospitals in ACOs can make, he added.

This delay is one reason Caravan Health urges its ACOs to adopt a population health focus, whether pursuing the Centers for Medicare and Medicaid Services (CMS) Quality Payment Program (QPP) Merit-based Incentive Payment System (MIPS) or the Medicare Shared Savings Program (MSSP).

Gronniger’s advice is predicated on his organization’s experience of mentoring 38 ACOs. In 2016, Caravan Health’s ACOs saved more than $26 million in the MSSP program and achieved higher than average quality scores and quality reporting scores, according to recently released CMS data.

Walking attendees through a MACRA primer, Gronniger underscored the challenges of the MIPS program, one of three tracks offered under the Quality Payment Program. “Barring a really exceptional performance on MIPS, you can’t even break even over the next few years on physician compensation,” he said.

In the meantime, ACOs should utilize recently rolled out Medicare billing codes, from the annual wellness visit (AWV) to advanced care planning, to generate wellness revenue. With proper planning, reengineering of staffing and clinical work flows, a practice could generate anywhere from five hundred to one thousand dollars annually per eligible Medicare patient, Gronniger estimates—monies that offset the cost of constructing a sustainable ACO business model.

To back up this population health rationale, Gronniger pointed to data from an ACO client demonstrating the impact of a cohesive PHM approach, including the use of trained population health nurses, on completion rates for preventive screenings. For less top-of-mind screenings like falls assessment and smoking cessation, completion rates rose from negligible to near-universal levels, he said.

“These are recommended sets of screens that are required by CMS, but that also help ACOs with quality measures,” he added.

Gronniger also shared examples of dashboards, scorecards and roadmaps Caravan Health employs to help keep client ACOs on track. An ACO success strategy involves “a lot of dashboarding, checking in, and discussion of problems and barriers, discussion of solutions, and monthly and quarterly measurement and reporting back,” he said.

Beyond coveted shared savings, ACO participation offers significant non-financial benefits, including quality improvements under both MSSP and MIPS standards, availability of ACO-specific waivers, and access to proprietary performance data.

Overall, ACO participation can make providers more attractive both to commercial contractors and to potential patients perusing Physician Compare ratings in greater numbers.

Gronniger ended by weighing in on the recent recommendation by the Medicare Payment Advisory Commission (MedPAC) to repeal and replace the MIPS program.

2018 Success Strategy: Differentiate to Survive Next Wave of Healthcare

January 5th, 2018 by Patricia Donovan

Are supermarkets the next wave of healthcare?

Perhaps not, but if a health insurer can move into the community pharmacy, why not the local grocery store?

On the heels of the recent non-traditional CVS Health-Aetna merger and amidst other swirling consolidation rumors, industry thought leaders are encouraging healthcare organizations to embrace similar partnerships and synergies.

And given the presence of pharmacies inside many supermarkets, “there is potential for greater synergies around what we eat, what we buy and how our healthcare is actually purchased or delivered,” suggests David Buchanan, president of Buchanan Strategies.

“The bonanza [from this merger] might be where data can be shared between CVS’s customers and Aetna’s customers and whether we can steer those CVS customers to Aetna,” he added.

Buchanan and Brian Sanderson, managing principal of healthcare services for Crowe Horwath, sketched a roadmap to help healthcare providers and payors navigate the key trends, challenges and opportunities that beckon in 2018 during Trends Shaping the Healthcare Industry in 2018: A Strategic Planning Session, a December 2017 webinar now available for rebroadcast.

Key guideposts on the road to success: data analytics, consolidation, population health management, patient and member engagement, and telemedicine, among other indicators. Also, organizations shouldn’t hesitate to test-drive new roles in order to differentiate themselves in the marketplace.

“If you are not differentiated, you will not survive in what is a very fluid marketplace,” Sanderson advised.

Honing in on the healthcare provider perspective, Sanderson posed five key questions to help shape physician, hospital and health system strategies, including, “What are the powerful patterns?” Industry mergers, an infusion of private equity money into areas like ambulatory care and emerging value-based payment models fall into this category, he suggested.

These patterns were echoed in four primary trends Sanderson outlined as shaping the direction of the healthcare market, which faces an increasingly “impatient” patient. “I could tell you the market wants care everywhere,” he said. “In the same way we have become impatient with our commoditized goods, so have patients become impatient with accessing care.”

Among these trends are “unclear models of reimbursement,” he noted, adding that after a self-imposed “pause” relative to healthcare reimbursement at the start of a new presidential administration, the industry is ready to “restart with some new sponsors now.”

Notably, Sanderson advised providers to embrace population management. “Don’t think population health, think population management. It’s no longer just the clinical aspects of a patient’s or a population’s health. It’s the overall management of their well-being.”

Following Sanderson’s five winning strategies for healthcare provider success, David Buchanan outlined his list of hot-button items for insurers, which ranged from the future of Obamacare and member engagement to telemedicine, healthcare payment costs and models and trends in Medicare and Medicaid.

Healthcare payors should not underestimate the value of engaging its members, who today possess higher levels of health literacy, he stated. “The member must be an integral part of healthcare transactions, as are the provider, the facility and the insurer. The member must have a greater level of personal responsibility and engagement in the process.”

Offering members wearable health technologies like fitness trackers is one way insurers might engage individuals in their health while creating ‘stickiness’ and member allegiance to the health plan.

Telemedicine, the fastest growing healthcare segment, is another means of extending payors’ reach and increasing profitability, he adds. “Telemedicine is not just for rural health settings anymore, but is finding another subset of adopters among people who can’t fit a doctor’s visit into their busy schedule.”

Payors should expect some competition in this area. “I believe the next wave [of telehealth] will be hospitals expanding into local telehealth services as a lead-in to their local clinics,” Buchanan predicted.

The use of artificial intelligence (AI) and robotics in healthcare is growing, but Buchanan and Sanderson agree that adoption will be slow. On the other hand, expect more collaboration between digital players like Amazon, Google and Apple and larger health plans.

“You will see [synergies] when you can put those two players together: the company that can bring the technology to the table as well as those companies that bring the users to the table,” concluded Buchanan.

Listen to a HIN HealthSounds podcast in which David Buchanan predicts the future of mega mergers in healthcare, the impact of the CVS-Aetna alliance on brand awareness, and the real ‘bonanza’ of the $69 billion partnership, beyond bringing healthcare closer to home for many consumers.

Infographic: 2018 Healthcare Outlook

December 29th, 2017 by Melanie Matthews

Hospitals have experienced improvements in uncompensated care revenue due to the Affordable Care Act. But reform and economic uncertainty are creating a perfect storm that could erase this momentum, according to a new infographic by Navigant.

The infographic examines the factors that could reverse the improvements in uncompensated care and what this means for hospitals and health systems.

Healthcare Trends & Forecasts in 2018: Performance Expectations for the Healthcare IndustryGiven the powerful patterns disrupting healthcare, what will it take to succeed as a high-velocity healthcare organization in 2018?

Healthcare Trends & Forecasts in 2018: Performance Expectations for the Healthcare Industry, HIN’s 14th annual business forecast, is designed to support healthcare C-suite planning as leaders react to presidential priorities and seek new strategies for engaging providers, patients and health plan members in value-based care.

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Guest Post: Are You Preparing to Fail Healthcare Compliance in 2018?

December 19th, 2017 by Tim Feldman and Darci L. Friedman

A 2018 roadmap to healthcare compliance should focus on cybersecurity, vendor management and telehealth.

As the year winds down, we see numerous lists of priorities healthcare organizations should focus on in the coming year. However, if you are looking to those end-of-year lists for guidance on what your organization should pay attention to in 2018, you are already behind. If you do find yourself playing catch-up, drafting your 2018 compliance work plan is the best place to start.

As the roadmap for your compliance efforts throughout the year, your annual work plan should indicate key high-risk areas. The Office of Inspector General (OIG) of the Department of Health & Human Services (HHS) has indicated that developing an annual compliance work plan is integral to the administration of an effective compliance program (Measuring Compliance Program Effectiveness – A Resource Guide).

The annual work plan and compliance program administration are but one portion of what is required for an organization to have a robust and effective compliance program. The required elements of a compliance program are the following:

  • Standards, Policies and Procedures;
  • Compliance Program Administration;
  • Screening and Evaluation of Employees, Physicians, Vendors and Other Agents;
  • Communication, Education and Training;
  • Monitoring, Auditing and Internal Reporting Systems;
  • Discipline for Non-Compliance; and
  • Investigations and Remedial Measures.

These elements provide a broad framework for your organization to identify risk, proactively remediate and provide a response mechanism to mitigate when there is an exposure. Working the plan and program throughout the year helps your organization achieve a state of ongoing readiness.

Cybersecurity

Cybersecurity is one item that will likely factor more heavily in your work plan, and appropriately so. Last June, the HHS Health Care Industry Cybersecurity Task Force released a report on improving cybersecurity in the industry. The Task Force concluded that cybersecurity, at its core, is a patient safety issue and a “public health concern that needs immediate and aggressive attention.”

Some of the areas to address in the broader realm of cybersecurity include:

  • Ransomware;
  • Email security, including phishing;
  • Internet of Things (IoT) and devices;
  • Bring your own device (BYOD); and
  • Medical identity theft.

As the Task Force report notes, cybersecurity must be thought about across the continuum of care in your organization. Work to shift the culture and thinking that cybersecurity is simply a technology issue, of concern only to the IT department.

Do this by implementing policies and procedures for key cybersecurity issues and then communicating them across the organization. Follow that with training, including everyone in your organization, from staff to board members. The training should: define cybersecurity; explain how it may manifest in the organization, and address your policies and procedures, making it evident to all what they can and cannot do and how to respond.

Third-Party Vendor Management

The outsourcing of services to third-party vendors is increasingly common and for good reason. Such relationships offer great benefits, but at the same time, these relationships also carry legal, financial, reputational and compliance-related risks. Here are seven questions to evaluate your third-party vendor relationships:

  • Does your organization, as a covered entity (CE) under HIPAA, have a vendor compliance program to help you identify, manage and report on these risks?
  • Do you review and assess your vendors’ risk profile?
  • Are you familiar with each vendor’s hiring practices?
  • Do you know which vendors’ products connect to other IT systems that contain critical data, including protected health information (PHI)?
  • Do you have insight into each vendor’s information security and data privacy capabilities?
  • Do you know with which vendors you have a business associate agreement (BAA)?

For many healthcare organizations, the answer to several of these questions is likely “no,” which creates risk for those organizations. The OIG’s position is clear: healthcare entities have a responsibility to proactively identify, assess and manage the risks associated with their vendor relationships.

All vendors are NOT created equal. A good starting point in managing an effective and efficient third-party compliance program is to perform a risk-ranking of vendors based on their access to critical assets or information. By segmenting your vendor population into “risk tiers” you can focus limited resources on the most serious exposures.

Components of third-party compliance assessment should include, among other things:

  • Due diligence (background, reputation, strategy);
  • Knowledge of, and compliance with, security and privacy requirements;
  • Operations and internal controls (policies and procedures);
  • Workforce controls, background and exclusion checks; and
  • Training and education.

And, of course, with every vendor that meets the criteria of a Business Associate, ensure that a written BAA is in place. BAAs can be complex and are often daunting, but they must be carefully negotiated and acknowledged by both parties.

By ensuring your vendors have strong compliance programs in place and that they are following through on the BAA requirements, your organization is meeting its compliance obligations and doing its best to minimize its risks.

Telehealth

The compliance concerns related to the delivery of care via telehealth are numerous and include the following:

  • Licensing;
  • Credentialing;
  • Security;
  • Regulatory requirements for billing; and
  • Fraud and abuse.

An area to focus some attention on is payment under federal healthcare programs. The OIG currently has two active work items on telehealth, one for Medicaid and one for Medicare. Both of the items relate to the propriety of payment for telehealth services.

If your organization provides telehealth services, consider conducting a risk assessment to determine if you have any exposure in the area. Risk assessments are not strictly one of the 7 required elements of a compliance program, but they are often referred to as the “8th Element” given the focus on them in the Federal Sentencing Guidelines and OIG documents.
Risk assessments, along with the other elements of a compliance program, provide your organization the means to identify, prioritize, remediate and/or mitigate the myriad on-going risks it will encounter. If you are not working your compliance program and specific risk areas throughout the year, you are failing to adequately prepare for an event. By failing to prepare, as one wise man said, you are preparing to fail.

About the Authors: Tim Feldman is Vice President and General Manager of Healthcare Compliance & Reimbursement at Wolters Kluwer Legal & Regulatory U.S. He oversees product development across a vast suite of practice tools and workflow solutions to help professionals stay ahead of regulatory developments and effectively manage compliance activities. Darci L. Friedman, JD, CHPC, CSPO, PMC-III, is the Director of Content Strategy & Author Acquisitions for Healthcare Compliance, Coding & Reimbursement at Wolters Kluwer Legal & Regulatory U.S. She is responsible for supporting the overall strategy for developing new content and features, innovating new product models, and recruiting top content contributors.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remain with them. The company accepts no liability for any errors, omissions or representations.

Healthcare Hotwire: Medicaid Trends

December 2nd, 2017 by Melanie Matthews

Medicaid Trends

Medicaid has moved to the forefront of the national healthcare debate even as states continue to innovate.

2017 marked the year that Medicaid moved to the forefront of the national conversation, as perception—and politics—caught up with the reality that no other social welfare program touches more Americans. While the robust debate remains unsettled, it’s clear that the future of Medicaid coverage, and resulting expenditure impacts, will remain in the spotlight for the foreseeable future, dominating the headlines and permeating the nation’s debate, according to a new report by PwC.

Despite uncertainty about potential federal Medicaid legislative changes, many states are continuing efforts to expand managed care, move ahead with payment and delivery system reforms, increase provider payment rates, and expand benefits as well as community-based long-term services and supports. Emerging trends include proposals to restrict eligibility (e.g., work requirements) and impose premiums through Section 1115 waivers, movement to include value-based purchasing requirements in MCO contracts, and efforts to combat the growing opioid epidemic, according to a Kaiser Family Foundation report.

In the new edition of Healthcare Hotwire, you’ll learn more about Medicaid collaborations, the role of community partners in serving Medicaid beneficiaries and the potential impact of Medicaid cuts.

HIN’s Healthcare Hotwire tracks trending topics in the industry for strategic planning. Subscribe today.

Infographic: Healthcare Premium Implications Under New Senate Tax Bill

November 29th, 2017 by Melanie Matthews

The U.S. Senate tax bill’s repeal of the individual health insurance mandate could lead to additional amounts in annual premium payments for 60-year-olds who buy their own coverage in 2019, according to a new analysis from The Commonwealth Fund.

A new infographic by The Commonwealth Fund provides a list of the 10 States where older adults would face the biggest dollar premium increase as a result of the Senate tax bill.

Trends Shaping the Healthcare Industry in 2018: A Strategic Planning SessionUncertainty regarding the future of the Affordable Care Act (ACA), combined with industry market forces, including consolidations and strategic partnerships, positioning for value-based healthcare, cost containment efforts, an emphasis on technology and efforts to understand and address the whole patient as part of population health management have been the key drivers in the healthcare industry this year.

With the efforts to repeal and replace the ACA now focused on the elimination of the cost-sharing reduction (CSR) payments to insurers and changes to regulations governing association health plans, short-term, limited-duration insurance and health reimbursement arrangements, the healthcare industry can put aside the uncertainty of this year and move forward with the market forces in play.

During Trends Shaping the Healthcare Industry in 2018: A Strategic Planning Session, a 60-minute webinar on December 7th, two industry thought leaders Cynthia Kilroy, principal at Cynthia Kilroy Consulting and Brian Sanderson, managing principal, healthcare services, Crowe Horwath, will provide a roadmap to the key issues, challenges and opportunities for healthcare organizations in 2018.

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Guest Post: Value-Based Care is Dying—But Longitudinal Patient Data Can Revive It

November 16th, 2017 by William D. Kirsh, DO, MPH, CMO at Sentry Data Systems

In 2013, Harvard Business Review (HBR) called value-based care “the strategy that will fix healthcare.” And the concept goes back even further than that—Michael Porter and Elizabeth Teisberg introduced the value agenda in their book, Redefining Health Care, in 2006, accord to HBR. Yet years later, value-based care is still struggling to survive, still in limbo, not quite breathing on its own. At this point, you might say it’s in critical condition.

More than a decade after Porter and Teisberg’s book, the industry is still talking about the “transition” to value-based care. In January of this year, CMS and HHS’ Office of the National Coordinator for Health IT (ONC) issued a vision for the continued shift to value-based care. In April, CEOs from Kaiser Permanente, Medtronic, Novartis and others, along with the Netherlands’ health minister, the head of England’s National Health Service, and Harvard economics professor Michael Porter (author of the 2006 book mentioned above) called for a new approach that would embrace patient-centered care and focus on outcomes.

Also in April, the World Economic Forum, in collaboration with The Boston Consulting Group, released a report, Value in Healthcare: Laying the Foundation for Health-System Transformation. Why are we still seeing words like “a new approach” and “laying the foundation” after all the time we’ve had, as an industry, to embrace value-based care?

After much wandering, it’s apparently a destination we still haven’t found on the map.

Resisting Change

According to a report from professional services organization EY (Ernst & Young) in July, about a fourth of 700 respondents (chief medical officers, clinical quality executives and chief financial officers at U.S.-based healthcare providers with annual revenue of $100 million and higher) polled said they had no value-based reimbursement initiatives planned for 2017. And that’s despite figures stating that healthcare spending in the United States “has now risen to 17.8 percent of GDP,” as the EY report says. So, what’s stopping physicians and hospitals from acting on value-based care?

As Modern Healthcare notes, the EY report points to “the escalating cost of care, a lack of standardization in how quality is defined, a disengaged workforce that leads to more medical errors, and a lack of trust and transparency between providers, payers and regulators,“ as some of the barriers. A 2016 article from Deloitte Insights adds that physician compensation may be part of the problem, stating, “Currently, there is little focus on value in physician compensation, and physicians are generally reluctant to bear financial risk for care delivery…86 percent of physicians reported being compensated under fee-for-service (FFS) or salary arrangements.” Deloitte recommends, “At least 20 percent of a physician’s compensation should be tied to performance goals. Current financial incentive levels for physicians are not adequate.”

But financial incentives alone are not enough. “Regardless of financial incentives to reduce costs and improve care quality, physicians would have a difficult time meeting these goals if they lack data-driven tools,” Deloitte says. “These tools can give them insight on cost and quality metrics, and can help them make care decisions that are consistent with effective clinical practice.”

Achieving Quality Outcomes

The EY report seems to come to the same conclusion as Deloitte about the lack of metrics and data. “Clinical outcomes and healthcare quality are often measured inconsistently by healthcare providers — if they are measured at all,” EY says. One way for hospitals to change that—a vital step in the value-based payment model—is through access to and analysis of longitudinal patient data, which is data that tracks the same patients over multiple episodes of care over the course of many years.

The problem is that hospitals and physicians often do not see the outcomes of particular treatment protocols (prescriptions, diagnostic tests, surgeries, etc.) for a long time, and capturing clinical data with this level of accuracy has historically been the industry’s blind spot. Without having a comparison population, each institution can only compare its data to real-world experience within their own data depository. A critical need is to use a de-identified real-world census population to compare protocols, best practices or specific utilization by National Drug Codes to help identify patterns of interventions that create value consistently across multiple systems, physicians, and patients. To truly answer these challenging questions about value in a meaningful way, hospitals need a comparison longitudinal patient data set.

There are countless questions about patient cohorts that physicians might want answered as they seek to make the best treatment decisions: What treatment protocol will result in the highest quality outcomes for a 50-year-old female diabetic patient with kidney failure? Which medications most effectively keep children with asthma from repeat visits to the ER? What comorbidities and symptoms are seen among patients with acute myelocytic leukemia (AML) in their earliest visits to the ER, and how can that information result in earlier diagnosis or different treatment options down the line? Quality historical longitudinal patient data may answer all these questions.

“Market forces are moving the industry toward a new paradigm; one in which delivering the highest value is an organization’s defining goal,” notes the EY report. “Optimizing patient experiences across the continuum of care while industrializing quality requires more than episodic effort.” This is the crux of value-based care. The only way to bring all stakeholders together and keep value-based care alive is by leveraging real-world, longitudinal patient data and using that information to make actionable treatment and prescribing decisions that lead to overall wellness and financial value, instead of focusing on just acute-care treatment.

William D. Kirsh, DO, MPH, CMO at Sentry Data Systems

About the Author: William D. Kirsh, DO, MPH, is chief medical officer at Sentry Data Systems and a practicing physician, clinically certified in family practice, geriatrics, hospice and palliative medicine. Sentry Data Systems, a pioneer in automated pharmacy procurement, utilization management and 340B compliance, is leading the healthcare industry in turning real-time data into real-world evidence through Comparative Rapid Cycle Analytics™ to reduce total cost of care, improve quality, and provide better results for all.

HIN Disclaimer: The opinions, representations and statements made within this guest article are those of the author and not of the Healthcare Intelligence Network as a whole. Any copyright remains with the author and any liability with regard to infringement of intellectual property rights remain with them. The company accepts no liability for any errors, omissions or representations.

Infographic: The ACA’s Innovation Waiver Program

November 10th, 2017 by Melanie Matthews

Under the Affordable Care Act (ACA), states can pursue “innovation waivers,” sometimes known as 1332 waivers, as of 2017. These waivers allow states to modify key parts of the law, so long as they stay true to its goals and consumer protections, according to a new infographic by the Commonwealth Fund.

The infographic provides a state-by-state look at innovation wavers.

Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations Asked by its C-suite to quantify contributions of its multidisciplinary care team for its highest-risk patients, AltaMed Health Services Corporation readily identified seven key performance metrics associated with the team. Having demonstrated the team’s bottom line impact on specialty costs, emergency room visits, and HEDIS® measures, among other areas, the largest independent federally qualified community health center (FQHC) was granted additional staff to expand care management for its safety net population.

The Care Coordination of Highest-Risk Patients: Business Case for Managing Complex Populations chronicles AltaMed’s four-phase rollout of care coordination for dual eligibles—a population with higher hospitalization and utilization and care costs twice those of any other population served by AltaMed.

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Infographic: The Impact of Cost-Sharing Reduction Payments on Insurance Markets

November 6th, 2017 by Melanie Matthews

The loss of cost-sharing reduction (CSR) payments in the health insurance marketplaces would destabilize insurance markets and add to the federal deficit, according to a new infographic by NEJM Catalyst.

The infographic examines the impact of ending the CSR payments on premiums of silver plans on the exchange as well as for Medicaid expansion and non-expansion states and the impact on the federal deficit through 2026.

Trends Shaping the Healthcare Industry in 2018: A Strategic Planning SessionUncertainty regarding the future of the Affordable Care Act (ACA), combined with industry market forces, including consolidations and strategic partnerships, positioning for value-based healthcare, cost containment efforts, an emphasis on technology and efforts to understand and address the whole patient as part of population health management have been the key drivers in the healthcare industry this year.

With the efforts to repeal and replace the ACA now focused on the elimination of the cost-sharing reduction (CSR) payments to insurers and changes to regulations governing association health plans, short-term, limited-duration insurance and health reimbursement arrangements, the healthcare industry can put aside the uncertainty of this year and move forward with the market forces in play.

During Trends Shaping the Healthcare Industry in 2018: A Strategic Planning Session, a 60-minute webinar on December 7th, two industry thought leaders Cynthia Kilroy, principal at Cynthia Kilroy Consulting and Brian Sanderson, managing principal, healthcare services, Crowe Horwath, will provide a roadmap to the key issues, challenges and opportunities for healthcare organizations in 2018.

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

4 Ways CMS 2018 Quality Payment Program Supports ‘Patients Over Paperwork’ Pledge

November 6th, 2017 by Patricia Donovan

“Patients Over Paperwork” is committed to removing regulatory obstacles that get in the way of providers spending time with patients.

Year 2 of the CMS Quality Payment Program promises continued flexibility and reduced provider burden, according to the program’s final rule with comment issued by the Centers for Medicare and Medicaid Services (CMS) last week.

The Quality Payment Program (QPP), established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), is a quality payment incentive program for physicians and other eligible clinicians that rewards value and outcomes in one of two ways: through the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

A QPP Year 2 fact sheet issued by CMS highlights 2018 changes for providers under the QPP’s MIPS and APM tracks. The Year 2 fact sheet noted that stakeholder feedback helped to shape policies for QPP Year 2, and that  “CMS is continuing many of its transition year policies while introducing modest changes.”

In keeping with the federal payor’s recently launched “Patients Over Paperwork” initiative, QPP Year 2 reflects the following changes:

    • More options for small practices (groups of 15 or fewer clinicians). Options include exclusions for individual MIPS-eligible clinicians or groups with less than or equal to $90,000 in Part B allowed charges or less than or equal to 200 Part B beneficiaries, opportunities to earn additional points, and the choice to form or join a virtual group.
    • Addresses extreme and uncontrollable circumstances, such as hurricanes and other natural disasters, for both the 2017 transition year and the 2018 MIPS performance period, by offering hardship exception applications and limited exemptions.
    • Includes virtual groups as another participation option for Year 2. A virtual group is a combination of two more taxpayer identification numbers (TINs) made up of solo practitioners and groups of 10 or fewer eligible clinicians who come together ‘virtually’ (no matter specialty or location) to participate in MIPS for a performance period of a year. A CMS Virtual Groups Toolkit provides more information, including the election process to become a virtual group.
    • Makes it easier for clinicians to qualify for incentive payments by participating in Advanced APMs that begin or end in the middle of a year. Updated QPP policies for 2018 further encourage and reward participation in APMs in Medicare.
  • CMS describes its Patients Over Paperwork effort as “a cross-cutting, collaborative process that evaluates and streamlines regulations with a goal to reduce unnecessary burden, increase efficiencies and improve the beneficiary experience. This effort emphasizes a commitment to removing regulatory obstacles that get in the way of providers spending time with patients.”