Archive for the ‘Value-Based Reimbursement’ Category

Guest Post: Value-Based Care is Dying—But Longitudinal Patient Data Can Revive It

November 16th, 2017 by William D. Kirsh, DO, MPH, CMO at Sentry Data Systems

In 2013, Harvard Business Review (HBR) called value-based care “the strategy that will fix healthcare.” And the concept goes back even further than that—Michael Porter and Elizabeth Teisberg introduced the value agenda in their book, Redefining Health Care, in 2006, accord to HBR. Yet years later, value-based care is still struggling to survive, still in limbo, not quite breathing on its own. At this point, you might say it’s in critical condition.

More than a decade after Porter and Teisberg’s book, the industry is still talking about the “transition” to value-based care. In January of this year, CMS and HHS’ Office of the National Coordinator for Health IT (ONC) issued a vision for the continued shift to value-based care. In April, CEOs from Kaiser Permanente, Medtronic, Novartis and others, along with the Netherlands’ health minister, the head of England’s National Health Service, and Harvard economics professor Michael Porter (author of the 2006 book mentioned above) called for a new approach that would embrace patient-centered care and focus on outcomes.

Also in April, the World Economic Forum, in collaboration with The Boston Consulting Group, released a report, Value in Healthcare: Laying the Foundation for Health-System Transformation. Why are we still seeing words like “a new approach” and “laying the foundation” after all the time we’ve had, as an industry, to embrace value-based care?

After much wandering, it’s apparently a destination we still haven’t found on the map.

Resisting Change

According to a report from professional services organization EY (Ernst & Young) in July, about a fourth of 700 respondents (chief medical officers, clinical quality executives and chief financial officers at U.S.-based healthcare providers with annual revenue of $100 million and higher) polled said they had no value-based reimbursement initiatives planned for 2017. And that’s despite figures stating that healthcare spending in the United States “has now risen to 17.8 percent of GDP,” as the EY report says. So, what’s stopping physicians and hospitals from acting on value-based care?

As Modern Healthcare notes, the EY report points to “the escalating cost of care, a lack of standardization in how quality is defined, a disengaged workforce that leads to more medical errors, and a lack of trust and transparency between providers, payers and regulators,“ as some of the barriers. A 2016 article from Deloitte Insights adds that physician compensation may be part of the problem, stating, “Currently, there is little focus on value in physician compensation, and physicians are generally reluctant to bear financial risk for care delivery…86 percent of physicians reported being compensated under fee-for-service (FFS) or salary arrangements.” Deloitte recommends, “At least 20 percent of a physician’s compensation should be tied to performance goals. Current financial incentive levels for physicians are not adequate.”

But financial incentives alone are not enough. “Regardless of financial incentives to reduce costs and improve care quality, physicians would have a difficult time meeting these goals if they lack data-driven tools,” Deloitte says. “These tools can give them insight on cost and quality metrics, and can help them make care decisions that are consistent with effective clinical practice.”

Achieving Quality Outcomes

The EY report seems to come to the same conclusion as Deloitte about the lack of metrics and data. “Clinical outcomes and healthcare quality are often measured inconsistently by healthcare providers — if they are measured at all,” EY says. One way for hospitals to change that—a vital step in the value-based payment model—is through access to and analysis of longitudinal patient data, which is data that tracks the same patients over multiple episodes of care over the course of many years.

The problem is that hospitals and physicians often do not see the outcomes of particular treatment protocols (prescriptions, diagnostic tests, surgeries, etc.) for a long time, and capturing clinical data with this level of accuracy has historically been the industry’s blind spot. Without having a comparison population, each institution can only compare its data to real-world experience within their own data depository. A critical need is to use a de-identified real-world census population to compare protocols, best practices or specific utilization by National Drug Codes to help identify patterns of interventions that create value consistently across multiple systems, physicians, and patients. To truly answer these challenging questions about value in a meaningful way, hospitals need a comparison longitudinal patient data set.

There are countless questions about patient cohorts that physicians might want answered as they seek to make the best treatment decisions: What treatment protocol will result in the highest quality outcomes for a 50-year-old female diabetic patient with kidney failure? Which medications most effectively keep children with asthma from repeat visits to the ER? What comorbidities and symptoms are seen among patients with acute myelocytic leukemia (AML) in their earliest visits to the ER, and how can that information result in earlier diagnosis or different treatment options down the line? Quality historical longitudinal patient data may answer all these questions.

“Market forces are moving the industry toward a new paradigm; one in which delivering the highest value is an organization’s defining goal,” notes the EY report. “Optimizing patient experiences across the continuum of care while industrializing quality requires more than episodic effort.” This is the crux of value-based care. The only way to bring all stakeholders together and keep value-based care alive is by leveraging real-world, longitudinal patient data and using that information to make actionable treatment and prescribing decisions that lead to overall wellness and financial value, instead of focusing on just acute-care treatment.

William D. Kirsh, DO, MPH, CMO at Sentry Data Systems

About the Author: William D. Kirsh, DO, MPH, is chief medical officer at Sentry Data Systems and a practicing physician, clinically certified in family practice, geriatrics, hospice and palliative medicine. Sentry Data Systems, a pioneer in automated pharmacy procurement, utilization management and 340B compliance, is leading the healthcare industry in turning real-time data into real-world evidence through Comparative Rapid Cycle Analytics™ to reduce total cost of care, improve quality, and provide better results for all.

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: A State-by-State Value-Based Reimbursement Comparison

November 15th, 2017 by Melanie Matthews

There is a range of value-based reimbursement approaches and significant variation in the scope, leadership commitment, and resources devoted to the transition from fee-for-service to value-based reimbursement across the United States, according to a new infographic by Change Healthcare.

The infographic provides an aggregated look at which strategies states have adopted, whether they have chosen to set value-based payment (VBP) targets, the scope of their initiative (Medicaid or multi-payer), and the approximate year that the VBP initiative was implemented.

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. Click here for more information.

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Infographic: Healthcare Payment Model Reform

November 3rd, 2017 by Melanie Matthews

As the 79 million baby boomers turn 65, they will grow the
Medicare-eligible cohort from 13.1 percent to 20.3 percent in 2030, according to a new infographic by HORNE Healthcare.

The infographic provides advice for providers to prepare for success in the ever-changing healthcare reimbursement environment.

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

October 20th, 2017 by Patricia Donovan

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

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

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

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

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

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

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

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

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

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

Infographic: Precision Medicine Meets Precision Benefit Design

October 18th, 2017 by Melanie Matthews

Advances in precision medicine may specify immediate use targeted therapies, nullifying recommendations for use of standard first line treatment, according to a new infographic by the University of Michigan Center for Value-Based Insurance Design.

The infographic examines how precision medicine benefit design removes administrative barriers and lowers cost-sharing to improve access to clinically indicated therapies.

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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Infographic: Banking the Upside from Value-Based Reimbursement

October 11th, 2017 by Melanie Matthews

As healthcare reimbursement shifts toward paying for value, there’s significant revenue at stake for physician practices, according to a new infographic by athenahealth, Inc.

The infographic examines five different types of physician practices and how participation in value-based reimbursement models would impact practice revenue.

No matter which level of participation physician practices choose for the first Quality Payment Program performance period beginning January 1, 2017, CMS’s “Pick Your Pace” announcement means practices should proactively prepare for the impact of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) on physician quality reporting and reimbursement.

MACRA Physician Quality Reporting: Positioning Your Practice for the MIPS Merit-Based Incentive Payment System delivers a veritable MACRA toolkit for physician practices, with dozens of tips and strategies that lay the groundwork for reimbursement under Medicare’s Merit-based Incentive Payment System (MIPS), expected to begin in 2017 and one of two payment paths Medicare will offer to practices.

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Cityblock Health to Open First ‘Neighborhood Health Hub’ for Underserved Urban Populations in NYC

October 6th, 2017 by Patricia Donovan

Cityblock Health neighborhood health hubs for underserved urban populations: “Where health and community converge.”

Cityblock Health expects to open its first community-based clinic for underserved urban populations, known as a neighborhood health hub, in New York City in 2018, according to a Medium post this week by Cityblock Health Co-Founder and CEO Iyah Romm.

Cityblock Health is a spinout of Sidewalk Labs focused on the root causes of health for underserved urban populations. Sidewalk Labs is an Alphabet company focused on accelerating urban innovation.

The neighborhood health hub, where members can connect with care teams and access services, is one of several key member benefits outlined on the Cityblock Health web site. Other advantages include a personalized care team available 24/7, a personalized technology-supported Member Action Plan (MAP), and a designated Community Health Partner to help members navigate all aspects of their care.

According to Romm, who brings a decade of healthcare experience to the initiative, the neighborhood hubs will be designed as visible, physical meeting spaces where health and community converge. Caregivers, members, and local organizations will use the hubs to engage with each other and address the many factors that affect health at the local level, Romm said.

For example, Cityblock Health states it will offer members rides to the hub if needed. Transportation, care access, and finances are among multiple social determinants of health that drive health outcomes, particularly for populations in urban areas.

Where possible, the hubs will be built within existing, trusted spaces operated by its partners and staffed with local hires, he added. Cityblock envisions offering a range health, educational, and social events, including support groups and fitness classes.

The hubs are part of Cityblock Health’s larger vision to provide Medicaid and lower-income Medicare beneficiaries access to high-value, readily available personalized health services in a collaborative, team-based model, Romm explained in his post. The organization will partner with community-based organizations, health plans, and provider organizations to reconfigure the delivery of health and social services and apply “leading-edge care models that fully integrate primary care, behavioral health, and social services.”

Three key health inequities related to underserved urban populations motivated the formation of Cityblock Health: disproportionately poor health outcomes, interventions coming much later in the care continuum, and the significantly higher cost of interventions in urban areas as compared to other populations.

Cityblock Health will use its custom-built technology to enhance strong relationships between members and care teams, while simultaneously empowering and incentivizing the health system to do better, he added.

Data Analytics, SDOH Screenings Flag Disengaged and 12 More Patient Engagement Trends

October 5th, 2017 by Patricia Donovan

More than 70 percent of healthcare organizations have created formal patient engagement initiatives, according to 2017 benchmarks from the Healthcare Intelligence Network.


To identify individuals that are poorly engaged in their health, nearly two-thirds (63 percent) of healthcare organizations mine clinical data analytics, according to the 2017 Patient Engagement Survey by the Healthcare Intelligence Network, while 37 percent screen patients for social determinants of health related to housing, care access, transportation, nutrition and finances.

Patients who screen positive for social determinants of health (SDOH) and individuals with diabetes are typically the most difficult populations to engage, according to 2017 survey benchmarks.

Thirty-five percent of respondents to the September 2017 survey said the presence of SDOHs, which the World Health Organization defines as “conditions in which people are born, grow, live, work and age,” pose the greatest challenge to health engagement, while 26 percent said a diabetes diagnosis presents the top clinical challenge to engagement interventions.

One-quarter report some resolution of SDOH factors resulting from engagement efforts.

To improve engagement, 75 percent of respondents rely on education of patients, family and caregivers, supported with telephonic outreach (13 percent) and home visits (13 percent).

Efforts by 71 percent of respondents to create a formal patient engagement program underscore the critical role of engagement in healthcare’s value-based care and reimbursement models, particularly in regards to chronic illness.

In other survey findings:

  • Patient experience rankings are the most reliable measure of engagement program success, say 43 percent.
  • For one quarter of respondents, patient engagement is the primary domain of case managers.
  • Eighty-three percent saw quality metrics improve as a result of patient engagement efforts.
  • Half attributed a drop in hospital emergency room visits to their patient engagement interventions.

Download an executive summary of the 2017 Patient Engagement Survey.

Infographic: Industry Perspectives on Value-Based Payment

October 4th, 2017 by Melanie Matthews

The shift to value-based payment is a slow one, with most health plans not yet making the transition to risk, according to a new infographic by HealthScape Advisors.

The infographic examines the percentage of plans in upside and downside risk contracts, the impact of health plan sponsor on risk contracts, cost and quality impacts for risk contracts, value-based payment enablers and recommendations for success in value-based contracts.

The accountable care organization, or ACO, has become a cornerstone of healthcare delivery system and payment reform by raising the bar on healthcare quality and reducing unnecessary costs. There are now more than 700 ACOs in existence today, by a 2017 SK&A estimate.

2017 Healthcare Benchmarks: Accountable Care Organizations, HIN’s fifth compendium of metrics on ACOs, captures ACO operation in today’s value- and quality-focused healthcare environment.

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Guest Post: 3 Key Reasons Companies Should Embrace Corporate Clinics

September 26th, 2017 by Rob Indresano, COO, Barton Associates

A number of large corporations are taking a unique approach to healthcare by employing a resident physician, nurse practitioner or physician assistant to tend to the needs of workers and their families.

Models range from small clinics, such as the CVS Minute Clinic, to larger facilities that offer a full array of primary care services. While many companies opt to house the clinics on-site, some organizations have partnered with internal branches or outside firms to provide healthcare services at off-site locations.

For companies and employees alike, corporate clinics are an attractive option. These clinics keep costs in-house, giving companies greater control of healthcare expenditures. Corporate clinics can also reduce the time employees take off work to receive basic medical care, encouraging workers to seek routine care more regularly. In turn, this leads to better overall employee health and fewer sick days.

Better yet, these in-house clinics are available to employees as well as their dependents. Corporations spend less money to provide employees and their loved ones with more and better care. It’s a win-win situation.

The corporate clinic movement stems from a dramatic rise in overall healthcare costs and the amount of time employees aren’t at work for minor medical issues. The movement stuck because employees and their families became healthier and happier, with productivity booming for companies that adopted the model.

As corporate clinics became more popular, many factors combined to guarantee their success. Locum tenens, for instance, made it possible for corporations to seamlessly launch and staff corporate clinics as the need arose. Telemedicine continues to grow in popularity — Kaiser Permanente reported 52 percent of its 110 million patient visits in 2015 were done via telemedicine — making it possible for corporations to expand the scope of care while driving down costs.

Making the Case for In-House Care

The average American spends more than 90,000 hours at work over the course of her life. As the Centers for Disease Control and Prevention has noted, personal and family health problems cost companies about $226 billion annually in lost productivity. It’s easy to understand why a healthy work environment is vital to a happy and productive workforce.

Some companies already enjoy the benefits of on-site clinics. The clinics bring employees everything from primary and preventive healthcare to physical therapy, pharmacists, dentists, optometrists, and more. These clinics help lower insurance costs, improve health and job satisfaction, and increase productivity.

Toyota in 2007 opened a $9 million corporate clinic at its San Antonio truck manufacturing plant. The company has reported a 33 percent decrease in specialist referrals and a 25 percent drop in employee visits to urgent care clinics and emergency rooms.

Intel had similar goals when the technology titan launched its own corporate clinics in 2011. Company officials hoped workers would be more likely to visit the in-house doctors, ideally curtailing chronic issues such as heart disease and diabetes in the process. The company paid about $1 million to build and another $1.5 million to operate each clinic, though Intel has since managed to break even on those operating costs.

Employers enjoy short-term benefits such as greater control over direct costs for specialist visits, prescriptions, and trips to the emergency room. In the long run — and perhaps more important — corporate clinics can help establish new healthcare policies and wellness programs to promote healthier lifestyle choices for employees.

How Corporate Clinics Will Change the Business World

With perpetually increasing healthcare costs and a tremendous potential for return on investment, the corporate clinic model is set to alter healthcare and business in three important ways:

1. Reduced healthcare spending. Corporations with on-site or near-site health services spend less money on healthcare. It’s as simple as that. HanesBrands, for example, reports saving about $1.40 for every $1 the company spends on its in-house clinic. Companies can then take that savings and instead invest in other business-related purposes.

2. Healthier, happier, and more productive employees. Rather than taking time off work to visit a doctor or risking lost income, employees often forgo care for relatively minor issues. This becomes problematic, considering the chronic diseases doctors often detect through repeat visits account for 75 percent of U.S. healthcare spending. Easy access to primary care services means employees are willing and able to see on-site providers for more routine health concerns they might have otherwise neglected.

3. Greater transparency regarding treatment costs. Almost everyone has received a bill from his insurance at some point listing a litany of codes and featuring a hefty amount due at the end. On the flip side of that coin, most physicians are kept in the dark about the costs of treatments so they can prioritize patient care above all else. Corporate clinics can alleviate some of the secrecy surrounding healthcare costs by being transparent about employee treatment. This can actually lead to improved care and lowered costs, with on-site physicians working in tandem with company leaders to drive down expenses.

As more companies find value in corporate clinics, an increasing number of large corporations will likely bring medical services in-house to help drive down bloated healthcare costs. Mid-sized businesses might also be tempted to explore the possibility of creating their own clinics given the potential cost savings. The shift will help foster a culture of health in the United States that benefits employers, employees, and communities.

Rob Indresano, Chief Operations Officer, Barton Associates

About the Author: Rob Indresano is president and COO of Barton Associates, a national recruiting and staffing firm based in the Boston area that specializes in temporary healthcare assignments. Rob is responsible for managing operations as well as the company’s strategic vision. Before joining the Barton team, Rob was vice president and general counsel for Oxford Global Resources Inc. and corporate counsel for Oracle Corp.

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.