Archive for the ‘Incentives’ Category

2016 ACO Results: Majority of Next Generation and Pioneer ACOs Earn Shared Savings

October 20th, 2017 by Patricia Donovan

Six of eight Pioneer ACOs and eleven of eighteen Next Generation ACOs earned shared savings in separate initiatives in 2016, according to newly released quality and financial data from the Centers for Medicare and Medicaid Services (CMS).

In 2016 Performance Year Five of the Pioneer ACO program, one of several new accountable care organization (ACO) payment and service delivery models introduced by CMS to serve a range of provider organizations, only Monarch HealthCare and Partners HealthCare were not among shared savings earners.

Banner Health Network emerged as the top 2016 Pioneer ACO performer, earning nearly $11 million in shared savings based on care provided to its more than 42,000 beneficiaries.

In order to receive savings or owe losses in a given year, Pioneer ACO expenditures must be outside a minimum corridor set by the ACO’s minimum savings rate (MSR) and minimum loss rate (MLR).

The Pioneer ACO model is designed for healthcare organizations and providers already experienced in coordinating care for patients across care settings. It allowed these provider groups to move more rapidly from a shared savings payment model to a population-based payment model on a track consistent with but separate from the Medicare Shared Savings Program (MSSP).

The Pioneer ACO Model began with 32 ACOs in 2012 and concluded December 31, 2016 with eight ACOs participating.

Meanwhile, at the conclusion of 2016 Performance Year One of the Next Generation ACO model, Baroma, Triad and Iowa Health topped the list of ACO earners in this program, with each organization accumulating more than $10 million shared savings.

Building upon experience from the Pioneer ACO Model and the Medicare Shared Savings Program, CMS’s Next Generation ACO Model sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.

According to a CMS fact sheet, 18 ACOs participated in the Next Generation ACO Model for the 2016 performance year, and 28 ACOs are joining the Model for 2017, bringing the total number of Next Generation ACOs to 45. The Next Generation ACO Model will consist of three initial performance years and two optional one-year extensions.

CMS’s ACO models are one of seven Innovation categories designed to incentivize healthcare providers to become accountable for a patient population and to invest in infrastructure and redesigned care processes that provide for coordinated care, high quality and efficient service delivery.

Guest Post: Winning the Healthcare Revolution with Technology for Care Coordination, Collaboration & Communication

September 8th, 2015 by Richard Purcell, intelliSanté president & CEO

Healthcare is in the middle of a revolution. Health systems continue to integrate and expand, acquiring private practices and hospitals. Insurance carriers still navigate the Affordable Care Act, and merge to build actuarial risk pools. Providers deal with changing payment models, transitioning from traditional fee-for-service to merit-based incentive payments, though the exact definition of pay-for-performance is not yet codified. And in the midst of these radical changes, doctors, hospitals, and health systems are implementing an array of electronic medical records (EMRs) to finally replace paper records.

Two things are clear with all of this upheaval in the medical world: providers are frustrated, and the patient is nowhere to be found.

Doctors, nurses, and healthcare administrators are all under financial and workload pressures; they are trying to comply with healthcare IT requirements for meaningful use, and everyone is uncertain about the future. Patients are exasperated with figuring out insurance plans and in-network versus out-of-network provider coverage; obtaining medical records from their doctors is a challenge; and they are left to their own devices to navigate the complexities of the healthcare system.

Technology is the answer for healthcare transformation, but the entire healthcare ecosystem is a decade behind the information technology boom that has transformed every other industry.

6 Barriers to Health IT Integration

Why has it been difficult to bring technology to healthcare? Based on two years of interviewing dozens of stakeholders across the healthcare continuum, we can point to several reasons:

  • HIPAA, short for the Health Insurance Portability and Accountability Act passed in 1996 that legislates data privacy and security provisions designed to safeguard medical information.;
  • Reimbursement: Only this year and last has CMS provided CPT codes for care coordination, Chronic Care Management 99490 and Transitional Care Management 99495 and 99496. Shared savings models provide inconsistent results and are still largely undefined;
  • Limited investment: Providers already have invested heavily in EMRs, spending money and time on workflow management, and are therefore reluctant to add new workflows and software unless integrated with their current EMR systems, which are not built for patient-centric care coordination;
  • Technology proficiency: Medical personnel, especially physicians, are not broadly trained in technology and software other than the specific EMR in the practice or hospital, and that training is lagging. Patients, especially senior citizens, have widely varying and often negligible technology access and knowledge;
  • Data overload: There is so much unintegrated data from internal EMR and billing systems, claims forms, labs, and metabolic measures from myriad devices that no person can comprehend. Doctors and patients need clinically meaningful reports, not just data.
  • Transformation: The medical system has been trained and operated as a treatment-focused, fee-for-service business; that is how healthcare professionals earn their living. Population health management and the primary care medical home (PCMH) models of healthcare require a realignment of the provider-patient relationship, transformation of business focus from in-office visits to out-of-the-office management, new staff and resource allocation—all without a defined financial model for future practice.

What’s Needed for a Patient-Centric Collaboration?

So, how in the current tumultuous environment can we ever achieve the Triple Aim of better health and improved care delivery at lower costs? The answer is patient-centric collaboration—working together to achieve a common outcome. But in order to make collaborative care work, we need patients, nurses, and doctors to embrace technology for collaboration. To this end, a new role in healthcare, the care coordinator, is the lynchpin to connecting patients to the healthcare system. Plus, an array of new and emerging software platforms like GetRealHealth and C3HealthLink for population health management can foster the personal communication necessary to engage patients outside the office environment, with the system-driven performance to drive efficiency.

Fortunately, the care coordinator position is currently being championed in several areas. For example, in New Jersey, Horizon Blue Cross Blue Shield has promoted care coordination for many years by funding practices for on-site care coordinators. The PCMH movement embraces the care coordinator role and collaborative care, and The Patient Centered Primary Care Collaborative (PCPCC), a not-for-profit trade group, is dedicated to healthcare transformation through primary care.

Plus there is hope on the patient technology front. According to the Pew Research Center, 64 percent of Americans own a smartphone, and for those seniors who do own smartphones, 82 percent describe the phone as “freeing.” Plus, broadband access is expanding through initiatives like the recently announced ConnectHome Pilot Program that will bring Internet access to underserved areas.

4 Ways Technology Will Optimize Healthcare Delivery

Through technology, we can optimize care delivery if we can provide care coordinators and patients with the tools they need to engage in health, and systems that provide interconnected data exchange through the patient’s health record, enabling the following:

  • Patients to engage in health practices that promote adherence to medication schedules, self-monitoring, and care planning, together with HIPAA-compliant communications tools that foster responsibility and collaboration with a care team;
  • Medical practices to manage patient populations inside and outside of the healthcare system to optimize care coordination (treatment, transition, communication, monitoring), while establishing workflows for the impending reimbursement changes to pay for performance;
  • Health systems to establish new care coordination and data sharing models using cloud-based, HIPAA-compliant data exchange and communications channels that integrate clinically relevant data;
  • Payors to evaluate and measure patient engagement in health and provider practices for care coordination and collaborative care in order to reimburse providers for performance.

The challenges in healthcare are many, but we can emerge from this healthcare revolution with a stronger healthcare system through collaboration: with patients taking responsibility, providers communicating and sharing data, health systems funding new delivery models, and payors enabling a sustainable financial model that provides benefits to all stakeholders.


Richard Purcell

About the Author: Richard Purcell is president and chief executive officer of intelliSanté. He has played a lead role in founding the company, molding the corporate vision, and leading the commercial launch of C3HealthLink. Purcell has extensive experience in drug development, clinical data management, and business operations in a regulated environment. Previously, he was president of ClinPro, Inc., a mid-sized clinical research organization. In addition, he participated in the start-up of the medical Web site Medscape through sales and business development initiatives. Rich holds a B.S. in Biochemical Sciences from Princeton University, and attended Rutgers Graduate School of Management majoring in marketing and finance. He is an executive member of the Patient Centered Primary Care Collaborative (PCPCC), a member of the Licensing Executives Society, and an active member of the New Jersey Technology Council and HIMSS. (rich@intelliSanté.com)

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.

Predictors of PHO Longevity and Financial Success

April 15th, 2014 by Patricia Donovan

Today, value-based payment models encourage hospitals and physicians to work together and make each more accountable for the other’s actions in a physician-hospital organization (PHO). But what are predictors of PHO longevity and financial success?

Here, Healthcare thought leaders Travis Ansel, MBA, manager of strategic services, Healthcare Strategy Group, and Greg Mertz, MBA, FACMPE, director of consulting operations, Healthcare Strategy Group, debate the question.

Response (Greg Mertz): It’s pretty evident that no one entity is going to be able to meet the needs of the population. If you’ve got a hospital that employs physicians, there’s an excellent chance that the employed physician network isn’t the total answer for caring for the population. They’re going to have to embrace non-employed physicians, other specialties, larger based primary care. Some entity is going to have to be created to make that happen.

But the PHO is an excellent model. Basically, it creates a collaborative entity that can bring in hospitals, employed physicians, non-employed physicians, ancillary providers. The PHO this time is something that is going to be necessary. Value is inevitable. I don’t see any reason that it would not have great longevity.

Response (Travis Ansel): I definitely agree. I think the biggest predictor of long-term success is the culture, but it’s going to be how the governance of the PHO is set up. It’s going to be giving the physicians, both employed and independent, a real voice in the organization and getting their expertise leveraged going forward. That’s going to be the biggest predictor. Beyond that, a willingness to experiment.

We’re in a situation now where organizations can’t really afford to sit on the sidelines for too long with all the different models that CMS and private payors are putting up in order to encourage shared risk between providers and hospitals. A willingness to experiment would be another key to success in my mind because it’s really the only way to learn how to be successful in this new environment, how to get involved in it and not hang on to the current FFS environment until it withers and dies.

Excerpted from Essential Guide to Physician-Hospital Organizations: 7 Key Elements for PHO Success.

HINfographic: 12 Questions to Guide a Physician Compensation Strategy

March 28th, 2014 by Jackie Lyons

A successful physician compensation strategy includes organizational goals, governance and physician engagement, according to Cynthia Kilroy, senior VP of provider strategy and business development at Optum.

This new infographic from the Healthcare Intelligence Network features 12 questions to guide the implementation of a physician compensation strategy for healthcare organizations. Addressing all three areas of the strategy can improve satisfaction while creating an environment and structure that supports transparency and enables quality and efficiency.

You may also be interested in this related resource: 6 Value-Based Reimbursement Models: Strategies for Selection, Alignment and Engagement. This 40-page resource examines a set of provider compensation models across the collaboration continuum, advising adopters on potential pitfalls and suggesting strategies to survive implementation bumps.


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Infographic: The State of Healthcare Innovation

February 17th, 2014 by Jackie Lyons

With the changing healthcare landscape, healthcare providers are looking toward innovation to reduce costs, improve patient care and increase patient safety and satisfaction.

Sixty-five percent of healthcare providers rely on internal staff networks as their main innovation resource, according to a new infographic from HIMSS and AVIA. The infographic also includes the top priorities of healthcare providers, top barriers to innovation, organizational return expectations and impacts, average innovation budgets and more.

The State of Healthcare Innovation

You may also be interested in this related resource: Healthcare Innovation in Action: 19 Transformative Trends. Want to know more about healthcare innovations? This 40-page resource examines a set of pioneering efforts supporting the industry’s seismic shift from a volume-based culture to one rewarding value and patient-centeredness.


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Infographic: Health Management Is the Norm

February 14th, 2014 by Jackie Lyons

Employee health management is one of employers’ top strategies for slowing health benefit costs and creating more engaged and productive workforces, according to Mercer’s National Survey of Employer-Sponsored Health Plans.

Eighty percent of large employers offer programs with disease management, 78 percent offer health assessments, and 66 percent offer lifestyle management, according to a new infographic from LifeHealthPro. This infogaphic also contains program ROI measurements, financial incentives used to drive results and new health management activities that are gaining traction.

Health Management is Now the Norm

You may also be interested in this related resource: 57 Population Health Management Metrics: Assessing Risk to Maximize Reimbursement. This resource delivers performance benchmarks in six key areas of population health management, based on feedback by hundreds of healthcare organizations: population health management, health risk assessment, medication adherence, health coaching, care coordination, reducing readmissions and ED use.


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Infographic: The Doctor Shortage

January 7th, 2014 by Jackie Lyons

A recent report from the American Academy of Family Physicians estimates 52,000 new physicians will be necessary by 2025 to keep up with growing healthcare demands.

Population growth, aging populations and increased access to healthcare are among the reasons for the increased need for more physicians, according to a new infographic from Soliant Health. This infographic also details the particular shortage in primary care, potential solutions to the increased demand and more.

The Doctor Shortage

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You may also be interested in this related resource: Case Studies in Comprehensive Primary Care: Guidance from Group Health Cooperative and Geisinger Health System.

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New Market Data: Carrots, Sticks and Technology Trigger Upswing in HRA Completion Rates

December 10th, 2013 by Patricia Donovan

2013 HRA survey data indicate completion rates of health risk assessments have more than doubled.

The news about health risk assessments is not that their use has risen dramatically —our 2013 Health Risk Assessments survey noted only a slight bump from 67 to 70 percent in HRA use since we last surveyed in 2010—but that HRA completion rates have spiked considerably.

In particular, HRA completion rates of greater than 80 percent have more than doubled in the last three years, from 8 percent to 17 percent, according to 123 organizations who completed the October 2013 HRA survey.

What’s behind this upswing in a risk stratification tool that is the backbone of population health management? A plethora of factors are likely contributing to this trend, starting with a jump in mandatory HRAs from 15 to 21 percent in the three-year period. Then there are the rewards: while the use of incentives remained level at around 55 percent, favored incentives have shifted from the trinkets, gift cards and cash rewards evident in 2010 to this year’s premium-based incentives, which may be more appetizing to participants faced with consumer-driven plans and higher deductibles to meet.

Overall, the use of gift cards and cash awards dropped about 66 percent over the last three years, while reductions in insurance premiums rose from 44 to 52 percent. About one-fifth of respondents contribute to an individual’s HSA in exchange for HRA completion, a new benchmark from this year’s survey.

Then, respondents’ favored stick-over-carrot approach must be factored in: from 2010 to 2013, the number of organizations imposing penalties for HRA non-completion jumped from 15 to 21 percent.

Technology also may have improved HRA accessibility and facilitated completion: Web-based HRAs jumped from 69 to 79 percent, while the use of print and telephonic HRAs dropped about 20 percent. And these technologies are not limited to younger beneficiaries. Tempted to mail an HRA to a Medicare beneficiary? Not so fast: Medicare patients are readily able to adapt to an electronic form of the HRA from paper documents, noted one respondent.

Despite IT backing and more integration of HRAs into the care process, respondents stressed that when it comes to HRAs, there is no ‘One size fits all’ approach.

“Each population is unique demographically,” contributed one respondent, while another noted: “One size does not fit all. We have different core HRAs for use in Medicare, Medicaid and commercial populations.”

For more 2013 HRA trends, download a complimentary executive summary of survey results or view this infographic.

HealthFitness Refines Population Health via Engagement, Tools and Technology

November 19th, 2013 by Jessica Fornarotto

Integrated health coaching continues to move the needle on population health management with interventions that keep the healthy, healthy without compromising the clinical support needed for high-risk, high utilization individuals. Dr. Dennis Richling, chief medical and wellness officer for HealthFitness, and Kelly Merriman, vice president of service delivery for HealthFitness, believe coaching offers a great opportunity to change the health status of a population.

In HIN’s special report, Integrated Health Coaching: Reducing Risk and Empowering Change across the Health Continuum, these industry experts detail HealthFitness’ move toward integrated health coaching, including the rules of participant engagement, the role of technology, and the range of self-management tools provided for participants.

Question: What strategies reach the population and increase engagement in health and wellness coaching?

Response: (Dr. Richling) One of the key strategies has been the use of an incentive that draws people toward the program. Incentives are fairly effective in getting people to do certain kinds of activities. If we provide an incentive for taking a health assessment, for instance, then we can engage them in a health advising session. We can take that external incentive and try to leverage it into an intrinsic motivation to go into our health coaching program. We see a better engagement rate when we offer an HRA, and when we provide screenings and advisement.

(Kelly Merriman) Engagement is also how long participants are choosing to engage with their coach. One of the main reasons we created our EMPOWERED Coaching program, or coaching across the continuum, is to more appropriately assign those individuals who have a chronic condition that is being well managed with somebody specially trained in lifestyle engagement techniques. Individuals working with our advanced practice coaches are much more likely to remain engaged with their coach because they’re focusing on those things that are most important to them.

Question: What is the role of technology in the various levels of health and lifestyle coaching?

Response: (Dr. Richling) We have developed a sophisticated algorithm that uses claims data and HRA data to decide which coach would be the best coach for the participant. The algorithm evaluates whether the individual has the appropriateness of care compared to chronic care guidelines, whether they are compliant to those guidelines, if they are having trouble with functions of daily living, and it also evaluates the risk for high cost in the future. These all go into identifying which professional coach would be the best fit for an individual. Technology continues to play a role after a person and coach are matched:

  • Assessment of risk is ongoing; HealthFitness’ data and technology platform can reassess a participant’s health status whenever new data becomes available.
  • Health coaches access a unique dashboard of participant-specific information via a proprietary HealthFitness technology platform. The technology populates a record with personal health risk factors, claims data, biometric screening results and previous contact with the coach and other program personnel, as well as complete activity and program information feeds.
  • The platform also displays a 360-degree interactive view of client-specific program options so the coach can reference participants to health management activities and programs from their employer, whether HealthFitness provides the services or not.

Question: What tools do you provide to your coaching participants to help them self-manage their conditions?

Response: (Kelly Merriman) We have a series of educational and self-management tools available for participants via their wellness Web site and/or the mail. For example, a coach can share documents and resources with a participant through a toolbox, which then integrates with the wellness portal. Additionally, participants are able to set up and track their focus area goals of interest. The coaching program has a mobile phone interface that allows users to track their progress remotely and stay in touch with their coach.

Infographic: The High Cost of Low HCAHPS Scores

November 12th, 2013 by Jackie Lyons

Approximately $850 million value-based incentives depend on HCAHPS scores, according to a new infographic from Voalte. Therefore, it is a crucial tool for hospitals to consider.

Furthermore, noise is the number one patient complaint on the HCAHPS survey. This infographic includes sample questions from the survey, other common patient complaints and specific ways for hospitals to improve their HCAHPS scores.

Caring for Veterans' Healthcare Needs

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You may also be interested in this related resource: 33 Metrics for Care Transition Management.