Archive for the ‘Physician Practices’ Category

Infographic: 10 Things You Should Know About PQRS for 2015

January 21st, 2015 by Melanie Matthews

CMS’ Physician Compare website has begun listing physician participation in its Physician Quality Reporting System (PQRS), which could potentially mean a loss of new patients based on nonparticipation in the program, according to a new infographic by HealthFusion.

The infographic lists 10 key features of the PQRS program.

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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Infographic: Physician Quality Transparency

January 12th, 2015 by Melanie Matthews

Independent and objective public quality data are only available for 16 percent of U.S. physicians, and in some states no data is available, according to the second annual State Report Card on Transparency of Physician Quality Information report from the non-profit Health Care Incentives Improvement Institute (HCI3).

HCI3 has released an infographic on the study results that details the importance of transparency as the growth of high-deductible health plans for healthcare consumers continues, along with details on the availability of quality information.

Healthcare Trends & Forecasts in 2015: Performance Expectations for the Healthcare Industry From collaboration and consolidation to the inevitable acceptance of a value-based system, the state of healthcare continues to stimulate health plans, providers and employers.

Healthcare Trends & Forecasts in 2015: Performance Expectations for the Healthcare Industry, HIN's eleventh annual industry forecast, examines the factors challenging healthcare players and suggests strategies for organizations to distinguish themselves in the steadily evolving marketplace.

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Incentives Advance PCP-Specialist Communications in Value-Based Health System

January 6th, 2015 by Cheryl Miller

In a value-based reimbursement model, primary care physicians need to be quarterbacks for their patients, taking an additional interest in their care and following them to the end zone, or to other specialists providing care, says Chip Howard, Humana’s vice president of payment innovation in the provider development center of excellence. This will foster communication between physicians and specialists, a fundamental problem of the classic fee-for-service model.

Question: How can you manage and reward the complex interactions between primary care physicians (PCPs) and sub-specialists?

Response: (Chip Howard) That’s a pretty common question in the industry these days. If you think back to the old model, the classic fee-for-service model, the PCP potentially loses track of the member as they go to a specialist. The volume-based model is very fragmented. You don’t have communication, a fundamental problem of the model. But I think we’re on a discovery to potentially address that. Some thoughts that come to mind are putting incentives in place that will promote communication between PCP and specialists.

At the end of the day in a primary care model, we’re encouraging the PCPs to be the quarterback of the member’s care, to take that additional interest and follow the member through the path to other specialists that are providing care. There are also obligations on the specialist’s part that you would have to engage because it’s a two-way street.

Some other thoughts: we are starting to explore specialist engagement programs, whether it’s looking at bundled payments or at other sorts of programs that incentivize the specialist to achieve the Triple Aim: higher quality, lower cost, best outcomes. Then, putting data and analytics into the hands of PCPs that will enable them to potentially steer those members to specialists that are proving that they can work to achieve the Triple Aim on behalf of the patient.

There are also some ideas about how to promote interactions between PCPs and sub-specialists and start the ball rolling. That is a lot easier in an integrated system-type environment where there is one system that owns the continuum of care for the most part from PCP to specialist, to outpatient, inpatient, etc.

value-based reimbursement
Chip Howard is vice president, payment innovation in the Provider Development Center of Excellence, Humana. He is responsible for advancing Humana’s Accountable Care Continuum, expanding its Provider Reward Programs, innovative payment models and programs that enable providers to become successful risk-taking population health managers.

Source: Physician Value-Based Reimbursement: Quality Rewards for Population Health

Infographic: Getting Paid for the New Chronic Care Management Code

November 21st, 2014 by Melanie Matthews

Under CMS' new Chronic Care Management (CCM) program, which takes effect in 2015, physician practices can receive reimbursement for non-encounter based follow up care to coordinate care for those with chronic conditions.

A new infographic by HealthFusion provides details on the physician practice and patient responsibilities for practices to be eligible for this reimbursement.

Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care CoordinationStarting January 2015, physician practices will be eligible to receive reimbursement for chronic care management services provided by physicians, advanced practice nurses, physician assistants, clinical nurse specialists and certified midwives to Medicare beneficiaries with multiple chronic conditions. The 2015 Medicare Physician Fee schedule, which finalized the Chronic Care Management reimbursement, was just released, leaving healthcare organizations with little time to prepare for the final aspects of this new reimbursement opportunity.

During Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care Coordination a November 19th webinar, now available for replay, Rick Hindmand, attorney with McDonald Hopkins, will share critical insight into how physician practices can best structure their practice to receive this additional reimbursement. The McDonald Hopkins law firm advises a nation-wide client base extensively on healthcare reimbursement.

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Infographic: CMS’ Value-Based Modifier Program

November 3rd, 2014 by Melanie Matthews

CMS' new Value-Based Modifier program is designed to assess both quality of care and the cost of that care under the Medicare Physician Fee Schedule. Starting in 2015, all providers who participate in fee-for-service Medicare need to prepare for VBM because their 2017 Medicare payments will be adjusted based on their 2015 performance.

In a new infographic, Health Fusion examines how the value-based modifier is calculated, how physician practices might measure up and what practices will need to do in 2015.

CMS' Value-Based Modifier Program

Value-Based Reimbursement Answer Book: 97 FAQs on Healthcare Models, Measures and MethodologyIf one trend has transformed the healthcare industry post-ACA more than any other, it is the market's new business model rewarding value over volume.

Value-Based Reimbursement Answer Book: 97 FAQs on Healthcare Models, Measures and Methodology provides a framework for healthcare's new value proposition, with advice from thought leaders steeped in the delivery and reimbursement of value-based care.

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5 Requirements for Highmark Pay-for-Performance Participation

October 28th, 2014 by Patricia Donovan

Highmark Inc.'s well-established physician pay for performance program, Quality Blue, continues to evolve, providing its 6,300 enrolled primary care physicians the opportunity to earn bonus payments across a variety of measure sets. Here, Julie Hobson, RN, BSN, manager of provider engagement, performance and partnership at Highmark Inc., describes minimum requirements for physician participation in the program.

Our program is open to all the primary care providers (PCPs) in our network. However, there are some participation requirements. The incentive payment is rewarded to the practices based on their total score and is in addition to their fee-for-service (FFS) schedule.

There are over 113 evaluation and management (E&M) claims, both outpatient/inpatient, that we provide the incentive monies to. The quality scores are calculated on a quarterly basis and the incentive payment that the practice receives is paid for on that particular quarter.

There are five requirements that must be in place to be able to participate in our program. First, there has to be a participating provider agreement signed and in Highmark’s hands; second, an incentive participation agreement must be completed as well.

The third requirement is IT capabilities: the practice must have a Web-based provider application in their office. This is the Web-based application that we choose and it allows for real-time transactions. It is HIPAA-compliant and allows for sending and receiving of information to us and from us, as well as to them and from them.

Fourth, the practice must meet certain thresholds of E&M claims and electronic claims submission in a 12-month period.

And finally, they must achieve a minimum total score within the program.

Source: Guide to Value-Based Reimbursement: Profiting from Payment Bundling, PHO Shared Savings, and Pay for Performance

Julie Hobson, RN, BSN, is a manager in Highmark Inc.'s provider engagement, performance, and partnership department, which is accountable for advancement and deployment of strategic design and development of provider driven health management transformation.

Infographic: Concierge Medicine

October 22nd, 2014 by Melanie Matthews

There was a notable increase in the number of concierge physician practices in cardiology, dental and pediatrics, according to a new infographic by Concierge Medicine Today.

The infographic also examines the number of concierge physicians in the United States; states with the greatest concentration of demand, what's included in a concierge practice and demographic data on the typical concierge patient.

Concierge Medicine

The Business of Medical Practice: Transformational Health 2.0 Skills for Doctors, Third Edition The Business of Medical Practice: Transformational Health 2.0 Skills for Doctors, Third Edition presents a progressive discussion of management and operation strategies. It incorporates prose, news reports, and regulatory and academic perspectives with Health 2.0 examples, and blog and internet links, as well as charts, tables, diagrams, and Web site references, resulting in an all-encompassing resource.

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Maturity of Physician Compensation Models from Fee-for-Service to Value-Based

October 9th, 2014 by Cheryl Miller

To be successful, a physician compensation model must mature slowly, as it moves from fee-for-service (FFS) to a productivity-based model to salary with performance incentives, where many organizations are today, says Cynthia Kilroy, senior vice president of provider strategy and business development at Optum. Here, she describes the steps that need to be taken.

As you move and mature from a clinical transformation perspective, you need to balance the financial risk transformation as well. If you get off kilter on any of those, then you are going to be off balance.

Early on in clinical and financial risk transformation, you are seeing more of the FFS and a FFS with pay-for-performance (PFP). When you start to move up, organizations typically start with salary guarantee. That salary is driven by productivity. It is usually a year that organizations support that, then you move up to productivity with a guarantee.

Finally, organizations are providing compensation based on productivity. As you start to move into these risk contracts and as the market matures, you need to look at productivity with a performance incentive. These are systems to find their alliance with the market, and they should be aligned with your payor contracts. Each payor typically likes to have its own incentives. You need to align the incentives the payor is focusing on and have your physicians focus on them as well, because if they are not in sync, you are not going to meet your ultimate goals of shared savings or even gain-sharing.

The other key question is, what can the organization achieve? We can put numbers out there and measure incentives, but if we do not think we are going to be able to achieve it, we need to be realistic about what can be measured. What is realistic to change reimbursement for compensation from a physician perspective? That is a key area as you start that inflection point.

Ultimately you start to see a larger percent of incentives. This is where you start to shift from maybe 5 or 10 percent, where there is more skin in the game. Organizations said change in behavior does not happen until 20 to 25 percent of compensation is tied to incentives.

Then what I see is the employed model, which is a salary with a performance incentive, then moving up to a larger percentage of the salary with the larger percentage from the incentive model.

Regarding the salary with the population incentives, as you start to look at maybe taking capitation, how does that tie into population incentives around efficiency and quality?

dual eligibles care
Cynthia Kilroy is the senior vice president of provider strategy for Optum Accountable Care Solutions, where she is responsible for business development, go-to-market strategy, strategic consulting, solution design and cross-company relationships. Her focus is on helping providers navigate the transformation to value-based reimbursement and accountable care models.

Source: 6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability

Bon Secours Blueprint for Advanced Medical Home: From Mortar to Measurement

October 7th, 2014 by Patricia Donovan

The building of Bon Secours Health System's Advanced Medical Home1 began with a walk-through—an assessment of bricks and mortar, explains Robert Fortini, vice president and chief clinical officer at Bon Secours Health System.

In Phase 1 of our Advanced Medical Home project, my team goes into a practice and does a basic workflow discovery—an assessment of bricks and mortar. Oftentimes, the physical plant is not effectively used.

Our objective in a primary care practice is to give each physician at least three or four exam rooms whenever possible. We will do that in a number of different ways, even if it means putting up walls or moving charts out now that we are electronic, or eliminating sample medication closets. We will do whatever it takes to achieve those three rooms per physician.

Next, we review the staff that is providing clinical support. We have developed competency assessment tools for patient service representative (PSR) staff, medical assistant (MA) staff, several different levels of licensed practical nurse (LPN) and our registered nurse (RN) navigator, which is the embedded case manager.

Third, we do an analysis of the physician’s panel size and risk acuity levels and form teams. Team formation is a difficult thing to do because you not only have to assess skills, licensures, panel size and patient acuity, but you also have to take personalities into consideration as well. That is the single most difficult obstacle to being effective.

Fourth, we introduce equipment and training on that equipment so the staff has tools they can use. We do wave testing point of care again, the objective being to eliminate that patient behavioral component and capture an actionable result on the spot before they leave the office. Their hypoglycemic agent or their Coumadin® dose could be titrated accordingly.

Fifth, we do optimization training with the use of our electronic medical record (EMR). We make sure everyone knows how to navigate and is comfortable with the documentation we require. We also use a coding training for the physician’s staff.

Finally, we have a set of metrics to establish baseline so we measure performance.

1. The Advanced Medical home is a model developed by the American College of Physicians involving the use of evidence-based medicine, clinical decision support tools, the Chronic Care Model, and other strategies to manage a patient population.

embedded case management

Robert Fortini, PNP, is vice president and chief clinical officer for Bon Secours Medical Group in Richmond, Virginia. He is responsible for facilitating provider adoption of EMR, coordinating clinical transformation to a patient-centered medical home care delivery model, and facilitating participation in available pay for performance initiatives as well as physician advocacy and affairs.

Source: Case Managers in the Primary Care Practice: Tools, Assessments and Workflows for Embedded Care Coordination

WellPoint Referral Preparedness Tools Support Physician-Specialist Care Compacts

October 2nd, 2014 by Cheryl Miller

With the help of care compacts that drive accountability between primary care physicians and specialists, WellPoint has launched a medical neighborhood pilot for three specialties with clear care coordination alignment opportunities with primary care medical homes. Here, Robert Krebbs, director of payment innovation at WellPoint, Inc., discusses how Wellpoint supports the care compact model with Referral Preparedness Tools— add-ons devised for physician/specialist patient handoffs.

One thing we found interesting was the uniform request from physicians for what we call ‘Referral Preparedness Tools.’ That’s a name we made up. These are add-ons to care compacts that call out common conditions for a given specialty, the conditions for which they often get referrals or consult requests from PCPs. It specifies for that condition what the specialist would like to see for the initial consult or regular repeating referral, and what they want the PCP to do first and send to them and specifically, what they want the PCP not to do—that is, things to avoid before sending the patient over.

On the flip side, the tool lists for that condition what the specialist intends to send back to the PCP. The practice will work on this together for common conditions. The tool doesn’t list everything that could possibly happen, but rather specifies the patient flow for common conditions.

We didn’t initially include this tool in our care compact expectations. The practices asked us for this; they see this as a true opportunity to drive improvement and efficiency in the system, to avoid unneeded care and to make sure that the correct care is provided for all patients.

We’re going to monitor development of these tools throughout the pilot to determine common themes so we can provide a good template starting place on this run as well as for future pilot practices in this program. We’re excited that specialists have made this template their own. They’re hard at work identifying what they’d like to see in these scenarios.

dual eligibles care
Robert Krebbs is the director of payment innovation at WellPoint where he has accountability for the design, development and rollout of value-based payment initiatives. He works directly with network physicians and facilities on innovative performance measurement programs aimed at delivering healthcare value by promoting high quality, affordable care.

Source: Care Compacts in the Medical Neighborhood: Transforming PCP-Specialist Care Coordination