Archive for the ‘Healthcare Quality Ratings’ Category

Are You MACRA-Ready? Physician Groups Prep Members for Medicare Payment Modernization

May 16th, 2016 by Patricia Donovan

Physician groups digested the 962-page MACRA notice of proposed rule-making in order to distill the notice for their members.

As they digest the HHS's momentous proposal to modernize how Medicare provider payments are tied to the cost and quality of patient care, physician organizations are assembling arsenals of educational tools to de-mystify MACRA.

The federal government's first step in implementing certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was detailed in an April 2016 announcement.

Just nine days after that bulletin, the AAFP arranged a town hall meeting for its members with two high-ranking CMS officials to discuss the law that will greatly influence how physicians are paid. Comments provided by CMS Acting Administrator Andy Slavitt via conference call are detailed here.

While the HHS window to receive feedback on the proposal remains open through June 27, 2016, the AMA has created an extensive set of online resources to support physician preparations for a post-MACRA Medicare. The resources include a guide to physician-focused payment models, key points of the Merit-based Incentive Payment System (MIPS), and five things providers can do now to prepare for the legislation, among other resources, according to a May 2016 press release.

“The core policy elements in MACRA are surfacing in other public and private insurance programs, so understanding these policies will be essential for most physician practices,” said AMA President Steven J. Stack, MD.

The AMA's MACRA support tools were announced in conjunction with the release of its new interactive module on practicing value-based care authored by Grace Terrell, MD, an internal medicine physician and president of Cornerstone Health Care, who shares the proven steps her clinic used to focus on patients at the center of care.

The value-based care module is the latest in the AMA’s STEPS Forward™ collection of physician-developed practice improvement strategies.

Also readying its membership for MACRA is the AAFP, which last week launched a comprehensive member communication and education effort related to the proposed legislation. The AAFP's MACRA Ready site is a one-stop shop filled with resources family physicians can use right now such as the following:

  • A timeline of important MACRA dates;
  • A list of acronyms to help digest the alphabet soup associated with MACRA's complicated regulations;
  • A "MACRA in a Minute" 60-second overview video;
  • A deep-dive review of what value-based payment means to family physicians;
  • and much more.

In announcing the MACRA tools, AAFP President Wanda Filer, MD, MB, told family physicians that the academy's MACRA communication plan "is designed to help simplify the transition and provide the guidance that you will need to realize the benefits of MACRA and value-based payments."

A recent AAFP survey indicated that some 40 percent of family physicians already were involved in some kind of value-based payment system, she noted.

As she related the history of MACRA, Dr. Filer reminded members that the legislation not only repealed the sustainable growth rate (SGR) but also established an annual positive or flat-fee payment for the next 10 years as well as a two-track program (the MIPS, and Alternative Payment Models, referred to as APMs) for calculating Medicare payments beginning in 2019.

MACRA Transition Bolstered by CMS Quality Measure Development Plan

May 9th, 2016 by Patricia Donovan

payment bundling shared savings

Partnerships are key to the final Quality Measure Development Plan by CMS.

The final Quality Measure Development Plan by CMS is an essential aspect of its transition to the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), according to last week's blog post by Kate Goodrich, MD, MHS, director of CMS's Center for Clinical Standards & Quality.

The Quality Measure Development Plan is a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs), stated Dr. Goodrich.

CMS recently rolled out a proposed rule outlining MACRA's payment incentives for physicians and other clinicians based on quality rather than quantity of care.

The final Quality Measure Development Plan will provide the foundation for building and implementing a measure portfolio to support the quality payment programs under MACRA, Dr. Goodrich said.

After considering comments and suggestions for the plan, CMS finalized the Quality Measure Development Plan to include the following:

  • Identification of known measurement and performance gaps and prioritization of approaches to close those gaps by developing, adopting and refining quality measures, including measures in each of the six quality domains:
    • Clinical care;

    • Safety;

    • Care coordination;

    • Patient and caregiver experience;

    • Population health and prevention;

    • Affordable care.
  • CMS actions to promote and improve alignment of measures, including the Core Quality Measures Collaborative, a work group convened by America’s Health Insurance Plans (AHIP). On February 16, 2016, CMS and the collaborative announced the selection of seven core measure sets that will support multi-payor and cross-setting quality improvement and reporting across our nation’s healthcare systems.
  • Partnering with frontline clinicians and professional societies as a key consideration to reduce the administrative burden of quality measurement and ensure its relevance to clinical practices.
  • Partnering with patients and caregivers as a key consideration for having the voice of the patient, family, and/or caregiver incorporated throughout measure development.
  • Increased focus and coordination with federal agencies and other stakeholders to lessen duplication of effort and promote person-centered healthcare.

Infographic: Comparison of Physician Quality Measures

March 14th, 2016 by Melanie Matthews

The new Physician Quality Metric Consensus Set, released by the Centers for Medicare & Medicaid Services (CMS) and America's Health Insurance Plans (AHIP), is a common set of quality measures from several current measurement sets. These sets were identified by healthcare systems participating in the federal Core Quality Measures Collaborative. Many healthcare providers are already collecting most of these measures, though there are modifications to several, according to a new infographic by Oliver Wyman.

While there is substantial overlap between the Consensus Set and existing STARS and QRS measure sets, providers also need to take heed that the next few years will be a time of flux for physicians as additional Consensus measures are developed and STARS and QRS migrate toward these. The infographic, researched by Oliver Wyman's Health & Life Sciences Provider team, shows the degree of overlap between the proposed and current measure sets.

Physician Value-Based Reimbursement: Quality Rewards for Population Health With more than a quarter-century of experience with value-based reimbursement models, Humana is ideally positioned to help physician practices navigate the transition from fee for service to fee for value. The payor's multi-level Accountable Care Continuum rewards physician practices for care coordination of Medicare beneficiaries along the population health spectrum.

Physician Value-Based Reimbursement: Quality Rewards for Population Health describes the four tiers of Humana's Physician Quality Rewards program as well as the support, training, technologies and outcomes associated with these pay-for-value relationships.

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CHS on Data Analytics in Accountable Care: “No Matter What Happens, This Change is Coming”

February 11th, 2016 by Patricia Donovan

Collaborative Health Systems, the largest sponsor of Medicare ACOs in the United States, recently rolled out an analytics and dashboard portal for its 3,200 providers.

Attention, please. Two aggressive milestones to migrate Medicare providers to value-based healthcare are on the horizon:

  • In 2016, CMS expects 30 percent of Medicare fee-for-service (FFS) reimbursement to be tied to alternative payment models such as accountable care and bundled payments.
  • Also this year, the federal payor wants 85 percent of Medicare FFS payments to be based upon quality metrics.

"If you are a provider, or working with providers who accept Medicare beneficiaries, it's really important to know these changes are coming," advises Elena Tkachev, director of ACO analytics for Collaborative Health Systems (CHS). "It will be the responsibility of physicians to participate in these payments because no matter what happens, this change is coming."

Ms. Tkachev detailed the power of data analytics to drive CHS's success in accountable care during Data Analytics in Accountable Care: Strategies and Case Studies, a January 2016 webinar from the Healthcare Intelligence Network now available for replay.

As the largest sponsor of Medicare Shared Savings Program (MSSP) ACOs in the United States, CHS has a firm handle on HHS's value-based agenda. The organization manages 24 MSSP ACOs, nine of which generated savings of nearly $27 million in 2014, and one that has been accepted as a Next Generation ACO, the newest Medicare accountable care model.

And with CMS expectations for value-based reimbursement slated to rise over the next two years, expectations for data analytics to improve care and costs related to Medicare beneficiaries have never been higher.

"Today, physicians are being measured through claims and the clinical metrics on the population they serve. We see the main responsibility of analytics as providing simple access to actionable, timely and relevant information to help clinicians make better decisions, improve quality of care and enhance the patient experience."

Despite the magnitude of its enterprise, CHS believes its future in accountable care rests upon its primary care physicians (PCPs), which it views as "quarterbacks of care" for its more than 280,000 Medicare beneficiaries.

To foster quality improvement, CHS equips PCPs with an arsenal of analytics capabilities. So that its 3,200 providers can tap into CHS's massive storehouse of CMS, claims, lab, risk stratification and care coordination data collected on its 24 Medicare Shared Savings Program (MSSP) ACOs, the health system recently rolled out an analytics and dashboard portal.

These tools enable providers to monitor the aggregate health of their populations as well as their own performance, even giving providers the ability to track their own performance over time and contrast it with other clinicians'—a capability that pleases CHS's more competitive physicians, Ms. Tkachev notes.

Frequent webinar training keeps provider analytics' use sharp, and dashboard-generated reports and scorecards help physicians to monitor and enhance quality performance and improve patient outreach, Ms. Tkachev explained.

Despite its significant success, CHS still encounters the perennial challenges of access to timely and accurate data, aggregation abilities, and the display of meaningful results. Ms. Tkachev shared some CHS tactics to resolve these issues, including soliciting feedback on the tools from providers who use them.

Listen to an interview with Elena Tkachev on data analytic's potential to drive annual wellness visits and boost beneficiary attribution.

Infographic: Top 11 Health Plans in 2015

October 12th, 2015 by Melanie Matthews

Capital District Physicians' Health Plan (HMO) and Capital District Physicians' Health Network (HMO), both of New York, were the top rated health plans by NCQA in 2015, according to a new infographic by HIMSS Media, which highlights the NCQA findings.

NCQA used combined HEDIS, CAHPS and NCQA Accreditation standards scores as of June 30, 2015 to develop the ranking. The HIMSS infographic shows the top 11 health plans, based on these scores.

Top 11 Health Plans in 2015

A multi-layer, patient-centered approach to care coordination of Memorial Hermann's ACO covered lives is designed to cover these members under a population health umbrella spanning the entire continuum of care from wellness services to supportive services for end-of-life care.

During Care Coordination in an ACO: Managing the Population Health Continuum from Wellness to End-of-Life, a September 29th webinar, now available for replay, Mary Folladori, RN, MSN, FACM, CMAC, system director of care management at the Memorial Hermann Physician Network and ACO, provided the inside details on its care coordination strategy and results.

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Steward Medicare Pioneer ACO ‘Patient Trackers’ Boost Care Management, Improve Performance

July 14th, 2015 by Patricia Donovan

Steward Medicare Pioneer ACO

Steward's Medicare Pioneer ACO was a top performer in performance year two, with gross savings of $19.2 million.

The ability to track patients across a continuum of care sites is a perennial challenge for healthcare organizations—even a top-performing Medicare Pioneer ACO.

"We can't prevent a readmission back to the hospital or redirect unnecessary emergency department visits if we don't know the patients were in the hospital to begin with," noted Kelly Clements, Pioneer program director at Steward Healthcare Network, during Medicare Pioneer ACO: Care Management, Quality Improvement and Data Integration Yields Substantial Performance Gains, a Healthcare Intelligence Network webinar now available for replay.

But Steward's Medicare Pioneer ACO meets this challenge head-on with two tools: a home-grown patient surveillance tracker, and the "Patient Ping" service that provides real-time patient admissions and discharge notifications to providers. Both tools help Steward to identify and coordinate care for Pioneer ACO beneficiaries who seek services from both Steward and non-Steward providers.

These innovations have helped Steward's Medicare Pioneer ACO, aptly named Promise ("For our promise to do the best we can to coordinate beneficiaries' care and increase quality of care," said Ms. Clements), to emerge as one of the top CMS Medicare Pioneer ACO performers in 2013, with gross savings of $19.2 million.

Three Medicare Pioneer ACO Challenges

Care management, including the tracking of its 80,000 Promise beneficiaries, was one of three categories of Medicare Pioneer ACO challenges Ms. Clements touched on during the webinar, along with physician engagement and performance improvement.

Supporting care management, the internally developed patient surveillance tracker is Steward's in-network solution for real-time tracking of care received from Steward providers and facilities; the contracted Patient Ping service allows the Pioneer ACO to communicate with skilled nursing facilities (SNFs) outside their network that care for Steward Pioneer patients, providing the SNF is registered with Patient Ping.

"Through the Pioneer program, we've learned that a large portion of our opportunity to reduce cost and achieve savings as an ACO is in the post-acute care space, particularly in the SNFs," noted Ms. Clements.

To engage physicians in the delivery of accountable care, Steward has done everything from holding road shows for providers to creating performance improvement teams for each geographic "chapter" in the ACO to work with physician practices to improve efficiency and quality. Physician report cards measure stewardship (including attendance at chapter meetings) and other efficiency and quality indicators.

And finally, to drive performance improvement, Steward has worked aggressively on data integration, with a strong focus on the two most popular electronic health records (EHRs) its physician network, in order to feed its 'quality data warehouse.'

This focus, along with efforts by the physician practices, has generated results. Steward saw its Pioneer ACO raw quality scores rise significantly from performance year one to performance year two: a 39 percent jump in the preventive health domain, and a 42 percent improvement in the at-risk domain (care for chronic conditions such as diabetes and coronary artery disease (CAD).

There is one additional hurdle: Steward must decide which ACO program it will participate in next year: Pioneer ACO, Next Generation ACO or Medicare Shared Savings Program (MSSP), Track 3. "The more efficient we become, the harder it will be to achieve shared savings, because the benchmark will keep getting lower, so this is one of our big concerns," said Ms. Clements.

"Our leadership is fully committed to pursuing risk aggressively and it's been worthwhile being at the table with Medicare and advocating for programmatic changes that will benefit our providers and patients in a sustainable way."

Integrated Networks Trigger Rise in Post-Acute Care Accountability

June 25th, 2015 by Patricia Donovan

Healthcare is examining new post-acute care (PAC) delivery and reimbursement models.

As physician-hospital associations (PHOs) and clinically integrated networks increasingly monitor referrals and where patients go once they leave the office or hospital setting, the post-acute care market will be held more accountable for the quality and cost of care they provide and their ability to manage readmissions, predicts Travis Ansel, senior manager with the Healthcare Strategy Group. Here, Ansel suggests how PHOs might prepare for the eventual inclusion of post-acute care in their networks.

Healthcare Strategy Group did a lot of work in Arkansas in 2011 and 2012. As providers started being held accountable for what happened once their patients left the hospital, post-acute care became very relevant in the Arkansas market. This was due to the impact on the providers, and on the physicians of the hospitals in that market. Almost immediately upon the announcement of the models, the hospital started bringing in different post-acute care organizations, saying, These are our incentives. We’re trying to manage patients who have been assigned these diagnosis-related groups (DRGs). We’re trying to manage these factors for those patients. Either you’re going to be the one to help us to do it, or we’ve going to find someone else in the market to do it.

My general expectation would be that as hospitals and physicians get together and start talking more about how post-acute care affects them, we’ll see them bringing in post-acute care to have that discussion: either help us with what we’re being held accountable for, or we will find someone else who can.

The natural market reaction to that is post-acute care organizations will either compete to respond to those requirements, because there will be some opportunity to grow market share or grow reimbursement if they’re effective in responding to those things.

We’ve already seen a tremendous amount of consolidation in the post-acute care world over the last five to ten years. To me, that would signal a lot more consolidation, the same as we’ve seen with the provider market. They’re going to look for a capital infusion and build competencies that will help them respond to PHOs' requests.

Note: Have more thoughts on the rise of accountability for post-acute care? Answer 10 Questions on Post-Acute Care Trends.

Source: Physician-Hospital Organizations: Framework for Clinical Integration and Value-Based Reimbursement

Travis Ansel, MBA, is a Manager, Strategic Services with Healthcare Strategy Group, LLC, with a primary focus on hospital strategic planning, physician alignment planning and clinical integration.

13 Metrics on Care Transition Management

May 7th, 2015 by Cheryl Miller

Care transitions mandate: Sharpen communication between care sites.


Call it Care Transitions Management 2.0 — enterprising approaches that range from recording patient discharge instructions to enlisting fire departments and pharmacists to conduct home visits and reconcile medications.

To improve 30-day readmissions and avoid costly Medicare penalties, more than one-third of 116 respondents to the 2015 Care Transitions Management survey—34 percent—have designed programs in this area, drawing inspiration from the Coleman Care Transitions Program®, Project BOOST®, Project RED, Guided Care®, and other models.

Whether self-styled or off the shelf, well-managed care transitions enhance both quality of care and utilization metrics, according to this fourth annual Care Transitions survey conducted in February 2015 by the Healthcare Intelligence Network. Seventy-four percent of respondents reported a drop in readmissions; 44 percent saw decreases in lengths of stay; 38 percent saw readmissions penalties drop; and 65 percent said patient compliance improved.

Following are eight more care transition management metrics derived from the survey:

  • The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
  • Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
  • A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
  • Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
  • Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
  • Discharge summary templates are used by 45 percent of respondents.
  • Home visits for recently discharged patients are offered by 49 percent of respondents.
  • Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

Care Transition Management

2015 Healthcare Benchmarks: Care Transitions Management HIN's fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.

Infographic: Variations in Surgical Procedure Survival Rates

March 18th, 2015 by Melanie Matthews

Across U.S. hospitals, the survival rates for four high-risk procedures vary significantly, according to a new report by The Leapfrog Group. Moreover, most hospitals surveyed do not meet Leapfrog's standard for each procedure.

The infographic looks at survival rates of four high-risk surgeries, including: removing all or part of the pancreas (pancreatectomy); removing all or part of the esophagus (esophagectomy); repair of the major vessel supplying blood to the body (abdominal aortic aneurysm or AAA); and replacement of the aortic valve in the heart (AVR). The infographic goes on to calculate the number of lives lost between the top and worst performing hospitals.

Quality Assurance in Healthcare Service Delivery, Nursing and Personalized Medicine: Technologies and ProcessesQuality Assurance in Healthcare Service Delivery, Nursing and Personalized Medicine: Technologies and Processes offers a framework for measuring quality of service in the healthcare industry as it pertains to nursing, with insight into how new technologies and the design of personalized medicine have improved quality of care and quality of life. Assessment and feedback are a vital part of developing and designing personalized medicine, and this book details case studies and the latest research in the field of healthcare service delivery assessment. In addition to describing assessment methodology, the book is also a compendium of the latest research into new medical technologies.

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BCBSM Physician Incentives Target 5 Root Causes of High-Cost Healthcare

February 17th, 2015 by Cheryl Miller

Designed to target underlying reasons for high-cost healthcare, Blue Cross Blue Shield of Michigan's (BCBSM) Physician Group Incentive Program (PGIP) rewards and incentivizes providers to enhance the delivery of care. To address poorly aligned incentives, for example, they developed tiered fees based on performance measured at the population level, not just at the individual physician level or patient’s level, says Donna Saxton, BCBSM's field team manager of BCBSM's value partnerships program.

How has the program evolved? The several root causes of high-cost healthcare within our system were readily apparent: poorly aligned incentives, a lack of population focus, very fragmented healthcare delivery, a lack of focus on process excellence or process improvement and a weak primary care foundation. As we’ve developed our Physician Group Incentive Program (PGIP) initiative, we were strategic and deliberate in how we were going to address the root causes of our high-cost system, keeping in mind the tenets and the philosophy of the PGIP program.

To address poorly aligned incentives, we developed tiered fees based on performance measured at the population level, not just at the individual physician level or patient’s level.

Tiered performance fees also addresses the lack of population focus and places emphasis on all patients and payor registries.

The one thing that really makes our PGIP program unique is that we are payor-agnostic. The incentive dollars we have distributed through the life of the program readily help and incentivize other payors in the state, because if these capabilities are implemented, they ultimately serve all the patients in our state. We’re very proud of that because we feel that that is part of the servant leadership we need to do for patients and members in our state.

To attack the fragmented healthcare delivery, we've organized our systems of care, aligning our incentives for primary care physicians, hospitals and specialists.

We also have collaborative quality initiatives, which help sharpen our physicians, specialists and care delivery people on the science of process improvement.

Our PCMH initiative is our pinnacle initiative, which we believe has strengthened our primary care foundation across the state.

generating medical home savings
Donna Saxton, field team manager of Blue Cross Blue Shield of Michigan’s (BCBSM) value partnerships program, currently oversees the team of representatives that support the statewide collaborative relationships with 44 physician organizations (PO) and 39 organized systems of care (OSCs) that participate in the BCBSM Physician Group Incentive Program (PGIP).

Source: Generating Medical Home Savings and Quality Improvements Through Outcome-Based Measures