Archive for the ‘Chronic Care Management’ Category

Population Health Tactics to Boost an ACO’s Medicare Annual Wellness Visit Rates

February 9th, 2018 by Patricia Donovan

One of the most important revenue opportunities for primary care physicians, and for population health nurses under their direct supervision, is the Medicare Annual Wellness Visit (AWV), advises Tim Gronninger, senior vice president of development and strategy, Caravan Health. The AWV offers an opportunity to check a number of Medicare quality boxes, including preventive check-ins, vaccinations and health screenings, to help make sure that a beneficiary’s medical needs are being met.

Here, Gronninger suggests ways that physician practices can improve all-important AWV rates.

Much of increasing annual wellness visit rates is about how to manage expectations of the practice and of the patient. You’ll be chasing your tail a lot if you are looking at your data and saying, “Well, these 1,000 patients haven’t had an annual wellness visit. I’m going to make a thousand phone calls, and then I’m going to make a thousand follow-up phone calls to try to schedule them all.”

It is very important for a practice to create a process where you have the time, the space and the plan, so that when a patient comes in the door for an Evaluation and Management (E&M) visit, the patient is handed off seamlessly to a nurse coordinator to complete an annual wellness visit at the same time. Obviously, different patients will require different handling. But we have found a very high acceptance rate from that approach among patients of clients that we work with.

It’s something that many patients take for granted, that their clinician knows this about them already. However, many times, the physician in practice doesn’t know whether the patient is up to date on their mammograms or other types of screenings.

Editor’s Note: Caravan Health’s ACOs saved more than $26 million in the Medicare Shared Savings Program (MSSP) and achieved higher than average quality scores and quality reporting scores in 2016.

Source: Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success

ACO population health

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

8 Findings from CMS Medicare Chronic Care Management Assessment

January 26th, 2018 by Patricia Donovan

YNHHS embedded care coordination

Medicare Chronic Care Management services reduced healthcare utilization and likelihood of hospital admissions for CCM recipients, according to a new CMS report.

Beneficiaries who received Chronic Care Management (CCM) services experienced a lower growth rate in healthcare expenditures compared to those who did not receive CCM services, according to a new evaluation report from the Centers for Medicare and Medicaid Services (CMS).

The lower rate of growth in total Medicare per beneficiary per month (PBPM) expenditures ranged from $28 to $74, after removing the average monthly CCM fee of $29.

The Medicare and Medicaid payor released the report on the diffusion and impact of CCM payment during the program’s first two years of implementation.

In January 2015, CMS introduced a separately billable non-face-to-face Chronic Care Management service (CPT code 99490). The goal of CCM is to improve Medicare beneficiaries’ access to chronic care management in primary care.

Here are seven more findings from the evaluation report:

  • Over 684,000 beneficiaries received CCM services from January 2015 to December 2016, the first two years of the new payment policy.
  • The decreased rate of growth was driven by decreases in expenditures for inpatient hospital services, skilled nursing facility services, and outpatient services; the decreased expenditures were partially offset by increased expenditures of home health and professional services. Researchers similarly found a lower rate of growth among CCM beneficiaries in hospitalizations and all-cause emergency department visits.
  • Receipt of CCM services was also associated with a reduced likelihood of an admission for the ambulatory care sensitive conditions of diabetes, congestive heart failure, urinary tract infection, and pneumonia among CCM beneficiaries, relative to the comparison beneficiaries.
  • A total of 16,549 individual healthcare providers billed for a total of $105.8 million in CCM fees in the first two years of the new payment policy.
  • Chronic Care Management beneficiaries were generally concentrated in the South and had poorer health status than the general Medicare fee-for-service (FFS) population.
  • About 19 percent of beneficiaries only received one month of CCM services; however the majority of beneficiaries received between four and ten months of CCM services, on average.
  • Primary care physicians (PCPs) billed for 68 percent of CCM claims and 42 percent of CCM billers were solo practitioners. Individual providers billed for $105.8 million in CCM fees during the first 24 months of the program and, on average, managed about 47 patients per month. However, the median number of patients was 10, indicating that the average was skewed by a small number of providers delivering CCM services to many beneficiaries. This translates to about $300 in CCM fees per month for providers furnishing CCM services to 10 beneficiaries.

The report did not examine the impact of 2017 CCM policy revisions that significantly increased payment for providing CCM to more medically complex patients.

Read the complete CMS Chronic Care Management evaluation report.

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.

Guest Post: Patient Engagement Technology Tool for Preventing Hospital Readmissions in Chronic Patients

January 23rd, 2018 by Allison Hart, Vice President of Marketing, TeleVox Solutions at West

While almost all chronic care patients say they need help managing their disease, less than one-third receive regular check-ins from healthcare providers.

During the past decade, the Centers for Medicare and Medicaid Services have increased the pressure on hospitals to prevent readmissions. In response to that pressure, many hospitals made changes that have led to declines in readmission rates. However, even with more measures in place to prevent readmissions than ever before, the risk of being readmitted to the hospital is still high for patients with chronic illnesses.

Studies have shown that the risk of adverse health effects increases with each hospitalization. Unfortunately, it can be difficult to keep chronic patients from readmitting once they have been hospitalized. Because of this, it is important that healthcare teams prioritize chronic disease management, and work to engage and support chronic patients. One tool that can help with this is the patient engagement technology many healthcare teams already have in place.

Survey responses indicate that chronic patients welcome efforts from their healthcare team that are aimed at managing disease and preventing hospital admissions and readmissions. A West survey found that 91 percent of chronic patients say they need help managing their disease, and at least 70 percent would like more resources or clarity on how to manage their condition. Additionally, 75 percent of chronic patients want their healthcare provider to touch base with them regularly so they can be alerted of potential issues.

Although patients with chronic conditions have expressed that they desire more assistance from their healthcare providers, they are not necessarily receiving it. For example, more than half (54 percent) of patients feel a weekly or twice-weekly check-in from their provider would be valuable, yet only 30 percent of patients report receiving regular check-ins. This shows that, in some cases, providers could be doing much more to offer ongoing chronic disease management support.

Providers seem to be underestimating patients’ interest in chronic care and their desire to receive support. Patients have suggested that they not only want assistance with managing chronic conditions, they would also be willing to pay for that extra support. Many providers are unaware that their patients feel this way. When asked if their patients would agree to pay 10 dollars per month for additional chronic care support, just over half (53 percent) of providers answered “yes.” However, two-thirds of patients say they would be willing to pay a nominal amount for chronic care support. The eye-opening response from patients confirms that chronic disease management is in demand—more so than providers realize. It also suggests that some providers may need to do more to offer ongoing chronic disease management support.

Chronic Care Management Enrollment

One way healthcare teams can better serve chronic patients and potentially prevent readmissions is by enrolling patients in chronic disease management programs. Chronic care programs, like Medicare’s Chronic Care Management program, require a lot of communication on the part of the healthcare team. Automating some of the communication and outreach makes it easier for providers to offer ongoing chronic care support. Healthcare teams can use their patient engagement technology to:

  • Send patients messages to invite them to enroll in a chronic care program. Using information from electronic health records, healthcare teams can identify patients that are eligible for chronic care management programs. (Patients must have two or more chronic conditions to enroll in Medicare’s Chronic Care Management program.) Then, they can use their patient engagement technology to send patients automated messages with information about the benefits of participating in a chronic care program, and instructions or links for patients to enroll or get further information.
  • Schedule disease-specific preventive screenings and tests. The Chronic Care Management program mandates that patients receive recommended preventive services. Care managers can schedule and send patients automated text messages, emails or voice messages to notify them when they are due for preventive screenings and tests. Patients with diabetes, for example, would automatically receive messages when they are due for an A1C test, foot exam or eye exam.
  • Send medication reminders and messages. Providers are required to manage and reconcile medications for patients enrolled in the Chronic Care Management program. Providers can assign medication reminders and send automated messages to ensure patients know how and when to take their medication, and that they don’t forget to take it.

Communication that engages chronic patients and aids them in disease management can result in better health outcomes and fewer readmissions. Engagement communications can be easily automated, meaning outreach does not require excessive time or resources. Hospitals and healthcare providers have incentives to reduce readmissions, and in many cases, they have the technology in place to make chronic disease management efficient and effective.

About the Author: Allison Hart is a regularly published advocate for utilizing technology-enabled communications to engage and activate patients beyond the clinical setting. She leads thought leadership efforts for West’s TeleVox Solutions, promoting the idea that engaging with patients between healthcare appointments in meaningful ways will encourage and inspire them to follow and embrace treatment plans – and that activating these positive behaviors ultimately leads to better outcomes for both healthcare organizations and patients. Hart currently serves as Vice President of Marketing for TeleVox Solutions at West, where the healthcare mission is to help organizations harness communications to expand the boundaries of where, when, and how healthcare is delivered.

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.

Assessing MIPS’ Fate: “MedPAC Vote Would Not Affect 2018 Under Any Scenario”

January 18th, 2018 by Patricia Donovan

Tim Gronniger

Tim Gronniger, Senior VP of Development and Strategy, Caravan Health

Amidst healthcare provider outcry over last week’s vote by the Medicare Payment Advisory Commission (MedPAC) to repeal and replace the Merit-based Incentive Payment System (MIPS), an industry thought leader sought to remind physician groups that no change to MIPS is imminent.

“MedPAC is an advisory body, not a legislative one,” said Tim Gronniger, senior vice president of development and strategy for Caravan Health, a provider solutions for healthcare organizations interested in value-based payment models, including accountable care organizations (ACOs).

“Congress would need to adopt MedPAC’s recommendations in order for the changes to go into effect. It is reasonable to expect MIPS to evolve over time, but that evolution will be gradual. [MedPAC’s vote on MIPS] would not affect 2018 under any scenario.”

Gronniger made his comments during Generating Population Health Revenue: ACO Best Practices for Medicare Shared Savings and MIPS Success, a January 2018 webcast sponsored by the Healthcare Intelligence Network and now available for rebroadcast.

Earlier this month, MedPAC voted 14-2 to scrap the MIPS program, describing it in a presentation to members as “burdensome and complex.” According to the advisory commission, “MIPS will not succeed in helping beneficiaries choose clinicians, helping clinicians change practice patterns to improve value, or helping the Medicare program to reward clinicians based on value.”

MedPAC is expected to pass this recommendation along to Congress in coming months, along with a proposed alternative. In MIPS’s place, MedPAC is suggesting a voluntary value program (VVP) in which “group performance will be assessed using uniform population-based measures in the categories of clinical quality, patient experience, and value.”

MGMA’s Anders Gilberg reacts to the MedPAC ruling.

Among the provider groups reacting to MedPAC’s actions was the Medical Group Management Association (MGMA). In a Twitter post, Anders Gilberg, MGMA’s senior vice president for government affairs, called the VVP alternative “a poor replacement,” claiming it “would conscript physician groups into virtual groups and grade them on broad claims-based measures.”

The day prior to the January 11 vote, MGMA had reached out in a letter to Seema Verma, administrator for the Centers for Medicare & Medicaid Services (CMS), requesting CMS to immediately release 2018 Merit-based Incentive Payment System (MIPS) eligibility information, which it called “vital to the complex clinical and administrative coordination necessary to participate in MIPS.”

From Last Place, Bronx Communities Now Prize Culture of Health

December 7th, 2017 by Patricia Donovan

Barely eight years ago, the Bronx landed at the very bottom of the first county health rankings issued by the Robert Wood Johnson Foundation (RWJF) —the least healthy of 62 New York counties, to be exact.

It didn’t help that as a borough, the Bronx topped a few other lists compiled by New York officials, including the highest prevalence of obesity and diabetes and the top consumers of sugary drinks.

Rather than discourage this diverse borough, however, these rankings galvanized residents and a number of Bronx organizations, including the Bronx Institute of Health, to partner and examine facets of community life to see where health might be improved. Under the hash tag and rallying cry of #Not62, the coalition’s reach has extended into Bronx schools, housing and even local food stores known as bodegas as it attempts to reimagine and enhance community health.

During Innovative Community-Clinical Partnerships: Reducing Racial and Ethnic Health Disparities through Community Transformation, a November 2017 webcast now available for rebroadcast, Charmaine Ruddock, project director, Bronx Health REACH, charted the path to some of the innovative community health partnerships forged by her organization.

Formed in 1999 with a grant from the Centers for Disease Control and Prevention (CDC), Bronx Health REACH (shorthand for “racial and ethnic approaches to community health”) is charged with eliminating racial and ethnic disparities in health outcomes, particularly those related to diabetes and heart disease, in Bronx populations. Since its inception, Bronx Health REACH has grown from five to more than 70 community-based organizations, schools, healthcare providers, faith-based institutions, housing, social service agencies and others.

“Those founding partners were particularly concerned that Bronx Health REACH not be seen as a program per se, but as a catalyst for creating a movement around health and well-being in the community,” explained Ms. Ruddock.

From early focus groups, Bronx Health REACH determined that community members not only felt disrespected by the healthcare system, but also powerless to advocate on their own behalf for better services. Those findings helped to shape the Bronx Health REACH mission and subsequent efforts.

Outreach began at the organizational level, such as examining the way a local church provided meals at church events. The coalition brainstormed ways to prepare those meals in a healthier manner, supplementing the church’s work with nutrition training that quickly spread throughout the faith community. From there, the program applied that approach to the food offered during school meals and via vending machines, and eventually within the local food retail environment, which consists principally of bodegas.

Today, the scope of Bronx Health REACH is broad, encompassing street safety, physical activity and overall wellness, among other areas. Its early work with bodegas has grown from demonstrations and tastings of healthy foods to the formation of a Bronx bodega work group and a new Healthy Bodegas marketing initiative. It has engaged farmers’ markets in its objective of increasing healthier food options. To that end, healthcare providers now issue “prescriptions” for fruits and vegetables that are accompanied by ten-dollar coupons.

The transformation is visible in the community, Ms. Ruddock notes. Today, some previously padlocked playgrounds are open; murals by visiting artists that adorn the walls of local housing are left alone for all to enjoy.

However, a great deal of work remains. “We have given ourselves as a goal that by 2020, we will establish a multi-sector infrastructure working with housing groups, economic development groups, and others as the first step in addressing many of the health-related factors and issues,” explained Ms. Ruddock.

But for now, the enthusiasm and contributions of Bronx residents have not gone unrewarded. In 2015, just five years after receiving its disappointing health ranking, the Bronx was one of eight recipients of the RWJF’s Culture of Health prize. The prize is awarded to communities that work to ensure residents have the opportunity to live longer, healthier and more productive lives.

Listen to Charmaine Ruddock explain how early findings from focus groups helped to shape Bronx Health REACH initiatives.

Infographic: The Hyper-Connected Patient

December 4th, 2017 by Melanie Matthews

The hyper-connected patient provides a number of opportunities for healthcare organizations to manage and prevent chronic diseases, according to a new infographic by EMC2.

The infographic examines three ways healthcare organizations can engage and promote health to connected patients.

Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System Encouraged by early success in coaching 23 patients to wellness at home via remote monitoring, CHRISTUS Health expanded its remote patient monitoring (RPM) enrollment to 170 high-risk, high-cost patients. At that scaling-up juncture, the challenge for CHRISTUS shifted to balancing its mission of keeping patients healthy and in their homes with maintaining revenue streams sufficient to keep its doors open in a largely fee-for-service environment.

Remote Patient Monitoring for Chronic Condition Management: Leveraging Technology in a Value-Based System chronicles the evolution of the CHRISTUS RPM pilot, which is framed around a Bluetooth®-enabled monitoring kit sent home with patients at hospital discharge.

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Community Health Partnerships Can Change the Culture of Poverty: 2017 Benchmarks

November 28th, 2017 by Patricia Donovan

Community health partnerships address unmet needs, providing services related to transportation, housing, nutrition and behavioral health.

For residents of some locales, community health partnerships (CHP) —alliances between healthcare providers and local organizations to address unmet needs—can mean the difference between surviving and thriving, according to new CHP metrics from the Healthcare Intelligence Network (HIN).

“We could not survive without community partnerships. Our patients thrive because of them. They are critical to help change the culture of poverty that remains in our community,” noted a respondent to HIN’s 2017 survey on Community Health Partnerships.

Partnerships can also mean the difference between housing and homelessness. According to the survey, more than a quarter of community health partnerships (26 percent) address environmental and social determinants of health (SDOH) like housing and transportation that can have a deleterious effect on population health.

“To date, we have housed 49 families/individuals who were formally homeless or near homelessness,” added another respondent.

“Social health determinants are more important than ever to managing care,” said another. “Community health partnerships make a big impact when it comes to rounding out care.”

Motivated to improve population health, healthcare providers are joining forces with community groups such food banks, schools and faith-based organizations to bridge care gaps and deliver needed services. The majority of community health partnerships are designed to improve access to healthcare, say 70 percent of survey respondents.

Eighty-one organizations shared details on community health partnerships, which range from collaborating with a local food bank to educate food pantries on diabetes to the planting of community gardens to launching an asthma population health management program for students.

Seventy-one percent conduct a community health needs assessment (CHNA) to identify potential areas for local health partnerships. Priority candidates for 36 percent of these partnerships are high-risk populations, defined as those having two or more chronic medical conditions.

Overall, the survey found that 95 percent of respondents have initiated community health partnerships, with half of those remaining preparing to launch partnerships in the coming year.

Other community health partnership metrics identified by the 2017 survey include the following:

  • Local organizations such as food banks top the list of community health partners, say 79 percent.
  • The population health manager typically has primary responsibility for community health partnerships forged by 30 percent of respondents.
  • Foundations are the chief funding source for services offered through community health partnerships, say 23 percent. However, funding remains the chief barrier to community health partnerships, say 41 percent.
  • Forty-five percent have forged community health partnerships to enhance behavioral health services.
  • Two-thirds attributed increases in clinical outcomes and quality of care to community health partnerships.
  • Forty-four percent reported a drop in hospital ER visits after launching community health partnerships.

Download an executive summary of results from the 2017 Community Health Partnerships survey.

Infographic: Impact of New Hypertension Guidelines

November 27th, 2017 by Melanie Matthews

OM1, an AI health outcomes and data company, has released an analysis on the impact of the new American College of Cardiology (ACC) and American Heart Association (AHA) high blood pressure guidelines. Using the OM1 Intelligent Data Cloud, OM1 performed preliminary analyses to evaluate the impact of the new guidelines on approximately 19 million adults over 20 years of age with more than 120 million blood pressure measurements, who had been seen for a scheduled visit over the last year.

A new infographic by OM1 highlights the findings of this data analysis.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results Between Medicare’s aggressive migration to value-based payment models and MACRA’s 2017 Quality Payment Program rollout, healthcare providers must accept the inevitability of participation in fee-for-quality reimbursement design—as well as cultivating a grounding in health data analytics to enhance success.

As an early adopter of the Medicare Shared Savings Program (MSSP) and the largest sponsor of MSSP accountable care organizations (ACOs), Collaborative Health Systems (CHS) is uniquely positioned to advise providers on the benefits of data analytics and technology, which CHS views as a major driver in its achievements in the MSSP arena. In performance year 2014, nine of CHS’s 24 MSSP ACOs generated savings and received payments of almost $27 million.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results examines program goals, platforms, components, development strategies, target populations and health conditions, patient engagement metrics, results and challenges reported by more than 100 healthcare organizations responding to the February 2016 Digital Health survey by the Healthcare Intelligence Network.

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Infographic: New Hypertension Guidelines

November 24th, 2017 by Melanie Matthews

New blood pressure guidelines have been released by the American Heart Association. People with readings of 130 as the top number or 80 as the bottom one now are considered to have high blood pressure, according to these new guidelines.

An infographic by the American Heart Association details the guidelines.

Since the January 2015 rollout by CMS of new chronic care management (CCM) codes, many physician practices have been slow to engage in CCM. Arcturus Healthcare, however, rapidly grasped the potential of CCM to improve patient outcomes while generating care coordination revenue, estimating it could earn up to $100,000 monthly for qualified patients treated in its four physician practices—or $1 million a year.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM Revenue traces the incorporation of CCM into Arcturus Healthcare’s existing care management efforts for high-risk patients, as well as the bonus that resulted from CCM code adoption: increased engagement and improved relationships with CCM patients.

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