Archive for the ‘Value-Based Reimbursement’ Category

Infographic: Navigating the Merit-Based Incentive Payment System

February 17th, 2017 by Melanie Matthews

The goal of the Centers for Medicare and Medicaid Services' new quality program, the Merit-Based Incentive Payment System (MIPS), is to streamline quality reporting to CMS and improve care, according to a new infographic by athenaInsight, Inc.

The infographic examines how MIPS will impact an average clinician this year…and in 2019 when the 2017 reporting will impact a clinician's reimbursement rates.

Infographic: EHR + CRM = Superior Patient Engagement

Under CMS's "Pick Your Pace" choices for Year 1 Quality Payment Program participation, physician practices may opt for the minimum activity necessary to avoid a payment penalty in 2019: simply submitting some data in 2017.

However, instead of delaying MACRA participation to the later part of this year, physicians should prepare and better position themselves today for MIPS success by analyzing their existing CMS data on their practices' performance and laying a path toward performance improvement.

Physician MACRA-Readiness: Mining QRUR and Other CMS Data to Maximize MIPS Performance describes the wealth of data analytics available from the CMS Enterprise Portal--Quality Resource Use Reports (QRURs) and other reports providing a window into practice performance under the Merit-Based Incentive Payment System (MIPS). MIPS is one of two MACRA reimbursement paths and the one where most physician practices are expected to align.

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Providers, Patients Outline Healthcare Priorities to New HHS Secretary

February 16th, 2017 by Patricia Donovan

As HHS secretary Tom Price begins his tenure, the ACA and physician reimbursement are on constituents' minds.

As HHS secretary Tom Price begins his tenure, the ACA and physician reimbursement are on constituents' minds.

As Rep. Tom Price settles into his new role as secretary of the Department of Health and Human Services (HHS), organizations representing physician practices, nurses, patient groups and actuaries are making their healthcare priorities known to the newly confirmed administrator.

Concerns range from the future of the Affordable Care Act, which President Trump pledged to repeal in a January 2017 executive order, to specifics of new physician reimbursement programs resulting from MACRA (Medicare Access and CHIP Reauthorization Act of 2015).

In a news release from the American Association of Nurse Practitioners, America's leading nursing organizations called on the Trump administration and Congress to prioritize patient health and the patient-provider relationship in any health reform proposals. Representing over 3.5 million nurses, the organizations affirmed their shared commitment to advancing patient-centered healthcare and healthcare policies that reflect five key areas ranging from ensuring patients access to healthcare with affordable coverage options regardless of preexisting conditions to creating greater efficiency in the Medicare system.

On the patient side, I Am Essential, a coalition of more than 200 patient groups, asked Price to preserve key ObamaCare protections, including one that guarantees coverage for those with pre-existing conditions.

In its letter, the coalition said certain ObamaCare provisions have provided improved access to care to millions living with chronic and serious health conditions.

"While it is not a perfect law," the letter stated, "The ACA has provided health coverage and improved access to care for tens of millions of Americans living with chronic and serious health conditions, many of whom were previously uninsured or underinsured. If they lose access and coverage for even one day, their health and well-being can be immediately jeopardized."

The letter concluded with the following statement: "As you make any changes, we urge you not to go back on the promise of affordable and quality care and treatment for everyone, especially those living with chronic and serious health conditions."

Meanwhile, a letter from the Medical Group Management Association (MGMA), which represents more than 18,000 U.S. healthcare organizations in which 385,000 physicians practice, asked the new administrator to "significantly reduce the regulatory burden on physician practices and improve the quality and efficiency of healthcare delivery in this country."

Focused on the federal payor's new Quality Payment Program resulting from MACRA, the MGMA requested the following from Price, who worked in private practice as an orthopedic surgeon for nearly twenty years prior to launching his political career:

  • A reduction in the cost and reporting burden of the Merit-Based Incentive Payment System (MIPS);
  • A careful review of the eligible Advanced Alternate Payment Program (APM) risk standard and contend there is significant inherent risk in moving from fee-for-service to risk-bearing arrangements, including substantial investment and operational costs, as well as misaligned financial incentives between the payment systems; and
  • Legislative relief from the Federal Physician Self-Referral Law, which MGMA referred to as "a regulatory monster of mind-numbing complexity."

MGMA represents physician groups of all sizes, types, structures and specialties, and has members in every major healthcare system in the nation.

And finally, the American Academy of Actuaries released three new issue briefs examining a number of key public policy considerations policymakers should weigh when evaluating specific proposals for reforming or replacing the Affordable Care Act.

The three papers, which address high-risk pools, selling health insurance across state lines, and association health plans, are available on the academy's site.

"Differences in a reform's structure can have wide implications for stakeholders and for how it interacts with other reforms that have been or may be adopted," said Academy Senior Health Fellow Cori Uccello. "For example, high-risk pools can be structured in different ways, with different implications for access to coverage, premiums, and government spending. Further, how regulatory authority is defined for both cross-state insurance sales and association health plans affects whether insurers would compete on a level playing field."

HINfographic: Healthcare Industry Trends for 2017

February 8th, 2017 by Melanie Matthews

Value-based healthcare, the drive for quality and the uncertainty regarding the Affordable Care Act under the President Donald Trump administration are just some of the factors impacting the healthcare industry this year, according to HIN's Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry.

A new infographic by HIN examines the key trends that will impact the healthcare industry this year.

Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry Not in recent history has the outcome of a U.S. presidential election portended so much for the healthcare industry. Will the Trump administration repeal or replace the Affordable Care Act (ACA)? What will be the fate of MACRA? Will Medicare and Medicaid survive?

These and other uncertainties compound an already daunting landscape that is steering healthcare organizations toward value-based care and alternative payment models and challenging them to up their quality game.

Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry, HIN's 13th annual business forecast, is designed to support healthcare C-suite planning during this historic transition as leaders prepare for both a new year and new presidential leadership.

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Physician Supplemental QRUR: Episode-Specific Patient-Level Data Tells Story of High Utilizers

February 7th, 2017 by Patricia Donovan

QRUR reports provide a mirror into physicians' cost and quality performance under MACRA.

As year one of MACRA unfolds, healthcare providers deterred by security hurdles associated with CMS Enterprise Portal access may want to reconsider. The wealth of aggregate quality and cost performance data available through the portal is well worth the trouble of accessing it, advises William Holding, consultant with PDA, Inc.

Specifically, Quality Resource and Utilization Reports (QRURs) downloadable from the portal are essential tools for physician practices that hope to succeed on MACRA-defined reimbursement paths, Holding said—even practices equipped with robust internal reporting systems.

"This is the same system that accountable care organizations (ACOs) use, and that CMS uses for many other things, so it's a good idea to get past those barriers," he explained during Physician MACRA Preparation: Using QRUR and Other CMS Data to Maximize Your Performance, a February 2017 webinar now available for replay.

Originally designed for CMS's value-based modifier, QRURs are good indicators of future cost performance under MACRA, via either Merit-Based Incentive Payment System (MIPS), where most physician practices are expected to fall initially, or Alternate Payment Models (APMs), he said.

After providing an overview of MIPS and APMs, including five essential prerequisites to MACRA preparation, Holding delved into the quality and cost metrics contained in QRURs, from aggregate data in the main report to detailed tables rich with patient-specific information.

The main QRUR report illustrates where a physician practice falls in relation to other practices on the overall composite for cost and quality. The QRUR's Quality portion shows scores for a series of domains, including effective clinical care and patient experience, which offer a great window into how a practice might perform with different selected measures in MIPS.

Next, QRUR cost performance indicates per capita costs for attributed beneficiaries, which will remain a cost measure in MIPS.

Drilling down, Holding characterized seven associated QRUR downloads—including one table on individual eligible professional performance on the 2015 PQRS Measures—as even more useful than the QRURs themselves.

And finally, he termed the downloadable supplemental QRUR "a very powerful tool" that drills down to the beneficiary level, providing a snapshot of some of the highest cost events occurring among a practice's patients.

"For high utilizers, for specific episodes, you can drill right down to the patient to try and understand the story. What's happening to your patient when they're not in your practice, and what can you do about it?" said Holding.

Having presented the available reports, Holding described four key benefits of using QRUR downloads, including as a priority setting tool, and then detailed the myriad of ways QRURs can be analyzed to improve MIPS performance.

However, Holding stressed, even physician practices with the most sophisticated reporting structures will not thrive under MACRA without the right team or culture of provider support in place. He closed his presentation with a formula for determining investment in performance improvement activities and a five-step plan for MACRA preparation.

Listen to an interview with William Holding on the use of QRURs to determine a physician practice's highest value referral pathways.

Infographic: ACO Trends

January 23rd, 2017 by Melanie Matthews

Momentum in value-based care has been building over the last several years, and 2016 was no exception, according to a new infographic by Oliver Wyman.

The infographic maps out the more than 630 ACOs in the United States.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-LifeWhen acknowledging its position as a top-ranking Medicare Shared Savings Program (MSSP), Memorial Hermann is quick to credit its own physicians—who in 2007 lobbied for a clinically integrated network that formed the foundation of the current Memorial Hermann accountable care organization (ACO). Now, eight years later, collaboration and integration continue to be the engines driving the ACO's cost savings, reduced utilization and healthy patient engagement rates associated with Memorial Hermann ACO's highest-risk population.

Care Coordination in an ACO: Population Health Management from Wellness to End-of-Life details Memorial Hermann's carefully executed journey to quality and the culmination of the ACO's community-based care management program.

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Infographic: Maternity Episodes of Care

January 16th, 2017 by Melanie Matthews

Maternity Episodes of CareThe cost of maternity care varies significantly by payer (commercial or Medicaid), by type of birth (vaginal or cesarean section), and by setting (hospital or birth center). Too often, women are not experiencing optimal outcomes in maternity care despite the significant resources spent, according to a new infographic by the Health Care Payment Learning & Action Network.

The infographic examines how an episode of care could be applied to maternity care—from an episode timeline for prenatal through postpartum care; episode parameters; operational considerations; and maternity care design elements.

Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ) has awarded $3 million to 51 specialty medical practices as part of a shared savings arrangement through the company's Episodes of Care (EOC) program. The doctors, in five different specialty areas, earned the payments by achieving quality, cost efficiency and patient satisfaction goals in 2014 while treating more than 8,000 Horizon BCBSNJ members. As the largest commercial payor of Episodes of Care in the United States, Horizon BCBSNJ recently reported far lower hospital readmission rates and improved clinical outcomes for members in its EOC practices versus non-EOC practices in 2014.

During Episodes of Care: Improving Clinical Outcomes and Reducing Total Cost of Care Through a Collaborative Payor-Provider Relationship, a March 31, 2016 webinar, available for replay, Lili Brillstein, director of the Horizon EOC program, shares the details behind the health plan's EOC program, from the episodes they have bundled to the goals and results from the program.

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Infographic: Patient Attribution Guide for Population-based Payment Models

January 2nd, 2017 by Melanie Matthews

Patient Attribution Guide for Population-based Payment Models

Patient attribution is a foundational component of population-based payment (PBP) models, which are based on a simple concept: providers accepting accountability for managing the full continuum of care for their patients, according to a new infographic by the Health Care Payment Learning and Action Network.

The infographic outlines the key steps in patient attribution.

Chronic Care Management Reimbursement Compliance: Physician Requirements for Value-Based RevenueBeyond providing added revenue, billing via Medicare Chronic Care Management (CCM) CPT codes helps to bridge physician practices to value-based care delivery models like the accountable care organization (ACO) or patient-centered medical home (PCMH). Use of the CCM codes is also an opportunity to launch or enhance a chronic care management program. According to 2015 market data, nearly half of responding healthcare organizations lack a formal chronic care management structure, leaving critical reimbursement dollars on the table.

However, practices poised to bill under CCM codes must contend with vague guidance from CMS in certain areas and conflicting interpretations from outside sources on CCM implementation.

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.

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7 Healthcare Movements to Monitor in 2017

January 2nd, 2017 by Patricia Donovan

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Growing population base should be a 2017 priority for healthcare organizations, advises Steven Valentine.

In offering a set of guiding principles for 2017 success, Steven Valentine, vice president, Advisory Consulting Services, Premier Inc., outlines seven key areas healthcare executives should monitor in the coming year.

First, we have seen some commercial plans move to risk adjustment payments. This could be helpful or detrimental. We definitely have seen more time spent as health systems have moved to more risk payments, more two-sided models.

Next, a definition of financial responsibility (DoFR) will be critical: knowing all the various benefits that are offered and perhaps listing them on the left side of a spreadsheet. As you move across the sheet, what remains with a health plan, if anything? What would go with the physician organization? What would go to an inpatient facility acute hospital? To ambulatory providers and post-acute providers? We would advise you to begin to move in 2017 to standardize those DoFRs.

Then, if at all possible, exclude specialty drugs, where we’ve seen tremendous price increases. If you can exclude any new kinds of therapies, and I mention one there that’s been popular and growing in 2016, IVIG, and we expect a pretty good jump in 2017. Some doctors have labeled this the 'feel good infusion.'

Then, determine whether you can do anything on an exclusive basis that would help you capture more population. At the end of the day, strategically, in 2017, you need to grow your population base.

Next is effective use of comanagement agreements and a renewed focus on your risk adjustment factor (RAF) scores: there will be slight adjustments as they go down and you’re going to have to do a better and better job of documenting and trying to push those up.

Then we see patient engagement; we do want to see the patients engaged. The more you use various patient portals, the more helpful it will be.

Finally, we also look at the repatriation of patients, because if you have them under your care, you would be responsible for getting those patients and paying for them.

Source: Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry

http://hin.3dcartstores.com/Home-Visits-for-Clinically-Complex-Patients-Targeting-Transitional-Care-for-Maximum-Outcomes-and-ROI_p_5180.html

Healthcare Trends & Forecasts in 2017: Performance Expectations for the Healthcare Industry, HIN's thirteenth annual business forecast, is designed to support healthcare C-suite planning during this historic transition as leaders prepare for both a new year and new presidential leadership.

2016 Healthcare Headlines: MACRA Monopolizes News Until Election Shake-Up

December 26th, 2016 by Patricia Donovan
top 2016 news stories

The unexpected election of Donald J. Trump to the U.S. presidency threatened some healthcare initiatives from the Obama administration, including the Affordable Care Act.

There was only one thing capable of distracting the healthcare industry in 2016 from MACRA's imminent rollout: the election of Donald J. Trump to the presidency of the United States.

Nevertheless, the majority of the last twelve months was spent on healthcare business as usual—the business of transitioning to value-based models of care delivery and reimbursement.

Here are the headlines that dominated the news feeds of healthcare executives in 2016:

New CMS 'Accountable Health Communities' Model Aims to Improve Patients' Health by Addressing Social Needs

January 2016: In a first-ever CMS Innovation Center pilot project to test improving patients’ health by addressing their social needs, the HHS appropriated $157 million in funding to bridge clinical care with social services.

The new pilot will test whether screening beneficiaries for health-related social needs and associated referrals to and navigation of community-based services will improve quality and affordability in Medicare and Medicaid. Many of these social issues, such as housing instability, hunger, and interpersonal violence, affect individuals’ health, yet they may not be detected or addressed during typical healthcare-related visits.

Medicare Shares 6 Core Principles for 21 New 'Next Generation ACOs'

January 2016: The Centers for Medicare & Medicaid Services (CMS) made waves when it launched a new accountable care organization (ACO) model called the Next Generation ACO Model (NGACO Model). The twenty-one ACOs participating in the NGACO Model in 2016 have significant experience coordinating care for populations of patients through initiatives, including, but not limited to, the Medicare Shared Savings Program and the Pioneer ACO Model.

Providers Slow to Adopt Population Health, Value-Based Models of Care: Study

February 2016: Most healthcare providers continue to lag in implementing population health management despite broad agreement it will be important for future market success, according to a national study by healthcare strategy consultancy Numerof & Associates. The study synthesized survey responses from more than 300 executives and in-depth interviews with over 100 key decision-makers across U.S. healthcare delivery organizations. It provided the first in-depth, national look at the pace of transition from fee-for-service to models based on fixed payments linked to outcomes.

Horizon BCBSNJ 'Episodes of Care' Program Pays $3 Million in Shared Savings to Specialty Medical Practice

February 2016: Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) announced that it paid out approximately $3 million to 51 specialty medical practices as part of shared savings generated through the company’s innovative Episodes of Care (EOC) Program. The doctors, in five different specialty areas, earned the payments by achieving quality, cost efficiency and patient satisfaction goals in 2014 while treating more than 8,000 Horizon BCBSNJ members. The EOC model, also known as bundled payments, is one in which specialists manage the full spectrum of care related to a specific procedure, disease diagnosis or health event—such as a joint replacement or pregnancy.

Bundled Payments Improve Care for Medicare Joint Replacement Patients: NYU Langone Study

March 2016: Implementing bundled payments for total joint replacements resulted in year-over-year improvements in quality of care and patient outcomes while reducing overall costs, according to a new three-year study from NYU Langone Medical Center. The three-year pilot at the medical center reported reductions in patient length-of-stay and readmission rates.

CMS to Test New SNF Payment Model to Curb Readmissions, Foster Multidisciplinary Care

March 2016: The Centers for Medicare & Medicaid Services (CMS) today announced it would test whether a new payment model for nursing facilities and practitioners will further reduce avoidable hospitalizations, lower combined Medicare and Medicaid spending, and improve the quality of care received by nursing facility residents. This next phase of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents seeks to reduce avoidable hospitalizations among beneficiaries eligible for Medicare and/or Medicaid by providing new payments to practitioners for engagement in multidisciplinary care planning activities.

Proposed MACRA Rule Would Streamline Medicare Value-Based Payment Models

May 2016: In issuing a proposal to align and modernize how Medicare payments are tied to the cost and quality of patient care for hundreds of thousands of doctors and other clinicians, the Department of Health & Human Services took the first step in implementing certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

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

May 2016: As they digested the HHS's momentous proposal to modernize how Medicare provider payments are tied to the cost and quality of patient care, physician organizations began assembling arsenals of educational tools to de-mystify MACRA. The federal government's first step in implementing certain provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) was detailed in an April 2016 announcement.

CMS Releases MACRA Final Rule; Creates Two Pathways for Clinician Value-Based Payments

October 2016: The Department of Health & Human Services (HHS) finalized a landmark new payment system for Medicare clinicians that will continue the administration’s progress in reforming how the healthcare system pays for care. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program, which replaces the flawed Sustainable Growth Rate (SGR), will equip clinicians with the tools and flexibility to provide high-quality, patient-centered care.

ACA Afterlife: Unwinding Obamacare Under the Trump Administration

November 2016: If U.S. President-elect Donald J. Trump delivers on his campaign promises, the 'repeal and replacement' of the Affordable Care Act (ACA) should be an early priority for the nation's chief executive-in-waiting. That prospect sent shock waves through the healthcare industry, as evidenced by a snapshot of post-election responses to the Healthcare Trends in 2017 survey sponsored by the Healthcare Intelligence Network.

Trump Taps Orthopedic Surgeon, Medicaid Architect to Helm U.S. Healthcare Posts, Determine ACA Fate

November 2016: Calling his nominees "the dream team that will transform our healthcare system for the benefit of all Americans," President-elect Donald J. Trump announced his plan to nominate Chairman of the House Budget Committee Congressman Tom Price, M.D. (GA-06) as secretary of the U.S. Department of Health and Human Services (HHS) and Seema Verma as administrator of the Centers for Medicare and Medicaid Services (CMS).

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Infographic: Health Data Integration Trends

December 23rd, 2016 by Melanie Matthews

As the U.S. healthcare market evolves from a pay-for-service model to a pay-for-performance/outcome model, healthcare organizations are working to improve their ability to identify, measure, and report treatment outcomes based on clinical procedures, according to a new infographic by dapasoft.

The infographic looks at the state of data and application integration in healthcare in response to these developing reimbursement models.

Health Data Integration Trends

2016 Healthcare Benchmarks: Data Analytics and IntegrationThe 2016 Healthcare Benchmarks: Data Analytics and Integration assembles hundreds of metrics on data analytics and integration from hospitals, health plans, physician practices and other responding organizations, charting the impact of data analytics on population health management, health outcomes, utilization and cost.

2016 Healthcare Benchmarks: Data Analytics and Integration examines the goals, data types, collection processes, program elements, challenges and successes shared by healthcare organizations responding to the January 2016 Data Analytics survey by the Healthcare Intelligence Network. Click here for more information.

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