Archive for the ‘Primary Care Practice’ Category

Infographic: ACA’s Impact on Primary Care Practitioners

November 27th, 2015 by Melanie Matthews

Most primary care practitioners are reporting no change in their ability to provide quality care after the Affordable Care Act’s (ACA’s) major coverage provisions took effect in January 2014, according to a new Visualizing Health Policy infographic. Their opinions about the healthcare law are sharply divided along political party lines. Generally, primary care physicians have a more negative view of health reform’s effect on the cost of patient care, but a more positive view of the law’s impact on patient access to healthcare and insurance.

The infographic looks at the number of primary care clinicians who say they’re seeing more newly insured patients or patients covered by Medicaid since the ACA’s major coverage provisions took effect in January 2014.


Dual-Eligibles Demos: Early Results and Their Implications offers timely intelligence about efforts to provide integrated care programs for beneficiaries who are dually eligible for Medicare and Medicaid—so-called “dual eligibles”—a group of 9 million beneficiaries who account for more than $300 billion in annual health care spending.

Dual-Eligibles Demos: Early Results and Their Implications also includes a case study of the nation’s largest CMS-backed duals demo in California—one that has many insurers participating, including national for-profit firms, large local non-profits and smaller plans.

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Medicare Chronic Care Management Reimbursement: Clarifying EHR Use and Electronic Requirements

October 22nd, 2015 by Patricia Donovan

Just one-fifth of U.S. physician practices participate in CMS's Chronic Care Management Program.

Nearly 70 percent of physicians nationwide admit they do not fully understand the Medicare Chronic Care Management (CCM) program, according to an August 2015 study by Smartlink Mobile Systems. The survey of 45,000 American physician practices determined that while 20 percent do participate in CCM, there is a great deal of confusion surrounding the CMS program designed to curb the cost of coordinating care for 34.4 million Medicare fee-for-service beneficiaries with two or more chronic diseases—particularly when it comes to meeting CCM’s electronic requirements.

The CCM initiative pays participating physician practices a monthly fee for twenty minutes of non-face-to-face patient care.

Earlier this year, Dr. Paul Rudolf, partner, Arnold & Porter LLP, and Nicole Liffrig, counsel, Arnold & Porter LLP, delved into CMS requirements and discussed approaches and challenges to meeting the CCM requirements, including a practice’s requirements for electronic health records (EHRs):

The CCM care plan is all the clinical staff needs to have access to in order to count time toward the 20 minutes. In terms of the EHR itself, the practice is only required for certain specified services within the Chronic Care Management. For example, the practice has to create a structured recording of demographics, problems, medications and allergies within the EHR, and then that information must inform the care plan. The care plan will include that type of information but doesn’t have to include everything that is in the EHR.

The practice also must put into the EHR a structured clinical summary record, which is discussed at some length in the final rule. In addition, the EHR must document that there’s written consent for the CCM services and all the other things the practice explained to the patient when the patient gave consent.

In addition, the care plan must be provided to the patient. That could be a hard copy or an electronic copy. The communication to and from home with community-based providers regarding their psychosocial needs and functional deficits also must be in the EHR.

Essentially, the electronic care plan is a distilled version of the EHR containing the pertinent information clinical staff would need to provide CCM services.

However, in spite of this interpretation, one Medicare contractor recently suggested that in order to count time toward the 20 minutes, the clinical staff has to have access to the EHR. We believe that is an incorrect interpretation of the rule. We believe the practitioners only need access to the electronic care plan.

The last thing I would like to mention about the EHR is that use of the EHR to provide care plans and other information to all off-site clinical staff and to other practitioners could theoretically raise privacy concerns. These are not new privacy concerns, but any practice that is going to provide CCM services needs to be cognizant of potential HIPAA issues and make sure they are in compliance. One thing that can be done in this regard is to have the individuals with EHR access sign business associate agreements.

Source: Chronic Care Management Reimbursement Compliance: Physician Requirements for Value-Based Revenue

http://hin.3dcartstores.com/Chronic-Care-Management-Reimbursement-Compliance-Physician-Requirements-for-Value-Based-Revenue_p_5027.html

Chronic Care Management Reimbursement Compliance: Physician Requirements for Value-Based Revenue sets the record straight on CCM reimbursement compliance, offering strategies for navigating obstacles and meeting requirements. In this 25-page resource, attorneys Dr. Paul Rudolf, partner, Arnold & Porter LLP, and Nicole Liffrig, counsel, Arnold & Porter LLP, drill down into chronic care management requirements outlined in the 2015 Medicare Physician Fee Schedule.

Guest Post: 7 Ideas to Improve Communication and Coordination between Care Sites

September 22nd, 2015 by Richard A. Royer, CEO, Primaris

With access to some of the most highly educated and trained medical professionals in the world, providing Americans with the best patient care possible should be simple. Unfortunately, that’s not often the case. Poor communication between specialists, duplicate tests and unnecessary procedures are frequently the norm rather than the exception, leading to costly, dangerous and sometimes deadly consequences. With so many specialists and resources readily on hand, how is this happening?

The problem is a lack of care coordination. Simply put, care coordination is the idea that all specialists treating a patient should communicate and share information to ensure that everyone acts as a team to meet patient needs. This includes reporting all results back to a primary care practice or to someone coordinating patient care, and ensuring that labs, specialists, hospitals, and long-term care facilities work together to communicate information quickly and appropriately. It’s about primary care physicians, nurses, technicians, specialists, and caregivers collaborating on patient care rather than working as separate entities.

The average Medicare beneficiary interacts with seven physicians in four different practices during a single year, according to the New England Journal of Medicine. For those with chronic conditions, the numbers can be even higher. And, nearly one-fifth of Medicare patients who are hospitalized are readmitted within 30 days of discharge, and 75 percent of these readmissions could have been prevented by improved care coordination.

Too often, patients discharged from hospitals don’t get the support and encouragement they need to take their medicine, follow their diets, and adhere to the regimens doctors have prescribed during their stay. Many of these problems can be solved by improving care coordination, and that starts with communication between care sites.

Here are seven suggestions for improving communication between care sites—as well as across the care continuum:

  • Start the dialog: As a rule of thumb, improving communication between care sites begins with healthcare providers asking themselves what they know that others need to know, and sharing that information with the patient’s care team. What do patients need to know when they’re referred to a specialist? What do the specialists that patients are being referred to need to be aware of, e.g. what tests have already been completed? Has the primary care physician been informed?
  • Create a team and make it accountable: Organizations should start by assigning a team of people to be accountable for managing patient care. Define the extent of their responsibilities for key activities such as following up on test results and communicating information to other physicians. Establish when specific responsibilities should be transferred to other care providers—whether that means specialty physicians, long-term care facilities, or home care providers.
  • Designate care coordinators: Designate staff that will act specifically as care coordinators can help to reduce hospital readmissions. Before patients leave the hospital, care coordinators should meet with them to make sure they understand the treatment plans they need to follow at home as well as any changes to their medication regimens. The hospital care coordinators also must follow up on any pending labs and imaging studies and contact primary care physicians to communicate updated medications, treatment plans, and test results for their patients. The likelihood of readmission drops significantly when patients leave with a clear understanding of their treatment plans and when their primary care physicians know what is necessary during follow-up care.

    This same communication protocol should also apply to patients who leave the hospital for long-term care facilities. In this instance, the hospital care coordinator should communicate discharge instructions to the long-term care staff. As soon as residents return to the long-term care facility, staff there should meet with residents to review their discharge instructions, answer their questions, and communicate with the hospital if any further clarification is needed. Long-term care staff should also follow up regularly with these residents to ensure they continue to comply with instructions the doctor has recommended and intervene if any problems arise.

  • Standardize communication processes: Create a protocol for filling out patient charts in a standard way so they are easy to interpret and key elements aren’t overlooked. You also should standardize communication by using structured forms to ensure primary care providers, specialists, and long-term care providers all have the same and necessary information.
  • Develop a referral tracking system: Creating a system to internally track and manage referrals and transitions— including consultations with specialists, hospitalizations and ER visits, and referrals to community agencies—can go a long way towards improving communication between care sites. It will help to ensure patients are well prepared for their referral visit and know what to expect afterwards. And, it simplifies follow-up with referral providers about findings, next steps and treatment plans.
  • Follow up on referrals: When a primary care physician refers a patient to a specialist, for example, office staff should follow up to make sure the appointment was made and completed. In addition, office staff needs to ensure the specialist shares his findings with the primary care physician so he can be well versed on the patient’s progress and any additional steps to be taken.
  • Notify providers in the patient’s medical neighborhood: Similarly, when patients visit the emergency room or are admitted to the hospital, communication should be a priority. In this instance, hospital staff should notify the primary care practice so the primary care doctor can follow the patient’s progress through discharge and institute a care plan to prevent future admissions. In addition, the practice can reach out to patients when they leave the hospital to make sure they understand discharge instructions and schedule follow-up appointments. When the patient comes in for follow-up care, the primary care physician should have a complete history of specialists seen during the hospital admission, their recommendations, and tests performed, along with the results.

The healthcare industry can no longer simply “discharge” patients. Providers must now work collaboratively with all others across the continuum of care to transition and coordinate the ongoing care of every patient. That’s what care coordination is all about.


Richard Royer

About the Author: Richard A. Royer has served as the chief executive officer of Primaris since 2001. He has extensive administrative healthcare experience and is actively involved in several statewide healthcare initiatives. In 2006 he was appointed by the Missouri governor to the Missouri Healthcare Information Technology Task Force and chaired the resources workgroup. He also serves on the board of directors as treasurer for the Excellence in Missouri Foundation. In his over 35 years of medical business experience he has held positions as chief executive officer at Cuyahoga Falls, Ohio, General Hospital; executive director of Columbia Regional Hospital in Missouri; and founder and president of Avalon Enterprises, a medical financial consulting firm.

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.

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.

Infographic: Primary Care’s View of Changing Healthcare Landscape

August 12th, 2015 by Melanie Matthews


Primary care providers are seeing a host of changes in the delivery and reimbursement of the care they provide.

A new infographic by the Commonwealth Fund looks at the perception of physicians and nurse practitioners and physician assistants of these emerging models.

6 Value-Based Physician Reimbursement Models: Action Plans for Alignment, Analytics and Profitability In today’s value-based healthcare sphere, providers must not only shoulder more responsibility for healthcare outcomes, cost and quality but also align with emerging compensation models rewarding these efforts—models that often seem confusing or contradictory. The challenges for payors and partners in creating a common value-based vision are sizing the reimbursement model to the provider organization and engaging physicians’ skills, knowledge and behaviors to foster program success.

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