Archive for the ‘Physician Practices’ Category

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.

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

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

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.

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

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

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.

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

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

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

Caldwell UNC Healthcare Embedded Case Managers Count Outreach, Not Cases

October 2nd, 2014 by Patricia Donovan

embedded case management

Visibility is the embedded case manager's greatest asset.

A frequently sought metric in case management is the optimal case load. However, embedded case managers at Caldwell UNC Healthcare don't count cases, they count outreach, explains Melanie Fox, director of Caldwell Physician Network's Embedded Case Management program.

For Ms. Fox's team of case managers embedded in seven primary care practices and two work sites, outreach is mostly telephonic, but may also include visits to patients' homes if they see the need.

"We will do anything to make sure patients get to where they need to be. A lot of our home visits occur because of confusion with medications," she explained during Embedded Case Management in Primary Care and Work Sites: Referral, Stratification and Protocols, a September 2014 webinar now available on-demand.

Typically, the embedded case management team averages about a thousand outreaches per month, Ms. Fox estimates. Telephonically, they reach almost all patients within 48 hours of discharge, and most ED discharges, running down a multi-item checklist, from medication and home health needs to scheduled follow-up appointments and advanced illness management (AIM), formerly referred to as palliative care, which was frequently misunderstood as strictly hospice, she noted.

Caldwell is working to establish that reporting linkage with skilled nursing facilities as well.

Medication is a large part of that telephonic conversation, Ms. Fox adds, as is a focus on new Transition Care Management Codes, where practices can be reimbursed for non-face-to-face care provided when patients transition from an acute care setting back into the community.

The visibility of embedded case managers in a practice is a great asset to both providers and patients, she says. "We seem to be more accepted by providers, staff and patients because they see us as part of the team."

At the two work sites, the case manager works alongside a nurse practitioner, where the goals are preventive care and chronic disease management.

With extensive RN experience in home health and schooled in the Geisinger Healthcare System model of embedded case management known as ProvenHealth Navigator℠, Ms. Fox joined Caldwell three years ago to develop and launch the program. Referrals to embedded case managers come from hospital discharge and ED reports, as well as provider and even self-referrals.

Although relatively new, Caldwell's embedded case management approach has helped to halve 30-day hospital readmissions in its Medicare population— from 19.16 percent in second quarter 2012 to 9.09 percent in fourth quarter 2013, she said. Buoyed by this success, Ms. Fox's team is targeting ED visits as its next metric.

During the program, Ms. Fox also shared six qualities of an effective embedded case manager, advantages of embedding case managers in care sites, and tactics for engaging physicians and staff in the embedded model.

Click here for an interview with Melanie Fox.

6 Ways to Overcome Pushback to Embedded Case Management

September 11th, 2014 by Cheryl Miller

Change always incites pushback, and when Sentara Medical Group went from an embedded case management program to a hybrid approach, patient and provider pushback prevailed, recalls Mary M. Morin, RN, NEA-BC, RN-BC, nurse executive with Sentara Medical Group. Among the six ways Sentara overcame resistance was to establish and maintain patient-centered relationships, by conducting comprehensive initial and ongoing assessments with patients, and developing plans of care and coaching education for both patients and their caregivers.

  • We maintained patient lists by populations within our electronic platforms. We came up with a standardized screen or view for all care managers. There was a lot of pushback against standardization but the key is standardizing the workflows. Should someone go out on family and medical leave, you can transfer your patient list. It all looks the same.
  • They were given and are still given assignments. We set expectations, which is critical. We send patient letters from the primary care physician (PCP) on behalf of your primary care provider that state we have this resource to help you should you be admitted to the hospital. We’re very focused on engaging patients. We have a brochure, and each care manager has a bio form that talks about their background.
  • We built workflow within the practices, within care management and within our electronic platform. We had issues: Optima, our health plan, is on a different EMR, as are the practices within our clinically integrated network. Unfortunately, the ambulatory-based care managers, the medical group care managers have to move between these two other platforms as well as our platform.
  • We held many meetings with home health and in-patient care coordination. Putting a face to a name is very helpful, as is lots of education and training. We had to do the electronic medical record (EMR) training. We discussed how to engage and motivate patients. What’s motivational interviewing? We have a requirement that within two years case managers are required to have their specialty certification.
  • We defined the care manager's role. The main piece is to establish and maintain patient-centered relationships. They conduct comprehensive initial assessments and ongoing assessments, identify ongoing needs of the patients and possibly their caregiver, developing care plans and then providing coaching support to the patient, caregivers, and family members.
  • We managed resources such as transportation. We contract with the taxi service for our few patients that don’t drive but need to get to their appointments or to keep them out of the EDs in the hospitals. They manage transitions of care. They conduct advanced care planning.

value-based reimbursement
Mary M. Morin, RN, NEA-BC, RN-BC, is a nurse executive with Sentara Medical Group, where she is responsible and accountable for non-physician clinical practice within the Sentara Medical Group (160 clinics/practices) to ensure integration and alignment with Sentara Healthcare, regulatory compliance, standardization of nursing practice/care, and patient safety.

Source: Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination

4 Goals for Furthering Care Coordination in the Medical Neighborhood

August 28th, 2014 by Cheryl Miller

With the advent of the medical neighborhood, care coordination is no longer the sole domain of the primary care practice (PCP), but a responsibility shared among all providers that touch the patient. But how to formalize co-management of patients by PCPs and specialists — in a way that both assures efficient delivery of high-quality healthcare and addresses the ‘pain points’ of each provider group? Here, Robert Krebbs, director of payment innovation at WellPoint, Inc., discusses the four goals for furthering care coordination in the medical neighborhood.

The care compact isn’t intended to solve all the world’s problems. We know it’s not going to make care coordination perfect, but it’s a starting point. Just like the PCMH provides a foundation for the medical neighborhood, the care compacts provide a foundation for care coordination between practices. It’s an essential starting point to further care coordination expectations across the medical neighborhood.

First, with the care compact, we’re helping the pilot practices by identifying the PCPs they can collaborate with to put care compacts in place. We’re playing connector for these two practices.

Second, we’re assessing the current care coordination capabilities of the specialist practices in the pilot and looking at where they’re starting from in terms of care coordination.

Third, we’re watching them customize the care compact and monitoring how they adapt it to their practice needs so we can come up with a stronger template at the end of this pilot than we started with that guides this last point.

Finally, we’re going to disseminate best practices throughout the process to all participants in the pilot. Everyone will benefit from the hard work of each participating practice.

Excerpted from Care Compacts in the Medical Neighborhood: Transforming PCP-Specialist Care Coordination.