Archive for the ‘Value-Based Reimbursement’ Category

Infographic: 2019 Merit-based Incentive Payment System Adjustment for 2017 Performance Year

October 15th, 2018 by Melanie Matthews

Clinicians will receive a positive, neutral, or negative payment adjustment factor based on their 2017 Merit-based Incentive Payment System (MIPS) final score, according to a new infographic by the Centers for Medicare and Medicaid Services.

The infographic examines the MIPS final score and payment adjustment factors.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: Using Machine Learning To Unlock Value Across the Healthcare Value Chain

September 21st, 2018 by Melanie Matthews

Machine learning (ML) is transforming the healthcare industry by changing the way care is delivered, and its impact is poised to increase, according to a new infographic by McKinsey & Company.

The infographic examines potential ML healthcare use cases and challenges to overcome to best leverage ML techniques.

2018 Healthcare Benchmarks: Telehealth & Remote Patient MonitoringArtificial intelligence. Automation. Blockchain. Robotics.

Once the domain of science fiction, these telehealth technologies have begun to transform the fabric of healthcare delivery systems. As further proof of telehealth’s explosive growth, the use of wearable health-tracking devices and remote patient monitoring has proliferated, and the Centers for Medicare and Medicaid Services (CMS) has added several new provider telehealth billing codes for calendar year 2018.

2018 Healthcare Benchmarks: Telehealth & Remote Patient Monitoring delivers the latest actionable telehealth and remote patient monitoring metrics on tools, applications, challenges, successes and ROI from healthcare organizations across the care spectrum. This 60-page report, now in its fifth edition, documents benchmarks on current and planned telehealth and remote patient monitoring initiatives as well as the use of emerging technologies in the healthcare space.

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Guest Post: Innovative, Specialized Palliative Care Programs Help ACOs Improve Patient Care, Achieve Success in Medicare Shared Savings Program

September 13th, 2018 by Greer Myers

Home-based Palliative Care

A structured, systematized approach to home-based palliative care: One of the most effective ways to manage and enhance care delivery for vulnerable, costly populations.

Under the new Medicare Shared Savings Program (MSSP), Accountable Care Organizations (ACOs) will be required to take on more risk as a rule of engagement and participation. The Centers for Medicare & Medicaid Services (CMS) is also shrinking the amount of time ACOs can be in an upside-only model to two years, putting additional pressure on ACO leaders to initiate changes. Currently, 82 percent of ACOs participating in the MSSP are in an upside-only model.

This has prompted many organizations to seek innovative strategies that will enable them to remain in the program and achieve success. One proven approach involves the adoption of a structured and systematized home-based palliative care program designed to identify patients with serious or advanced illness earlier in the disease process and offer them services outside of the hospital setting.

The palliative care team, primarily specially trained nurses and social workers, addresses the unique needs of the patient and family, taking into consideration their culture and values when developing a patient-centered approach to care. The team coordinates patient care across the continuum, which may include specialty care, acute, post-acute and community-based care needs.

For ACOs facing tight timeframes for implementing programmatic changes, this structured approach to community-based palliative care can be rapidly deployed in any geographic area and quickly scaled for larger populations.

Supporting the Medical Home

Home-based palliative care programs align with the medical home model through the provision of specialized care for people living with serious or advanced illness. Sharing priorities with the medical home, both emphasize the importance of care in the home, providing appropriate social services, clinical assessments and referrals, and partnering with physicians to deliver a solution that is patient-centered, data-driven and evidence-based.

A structured, systematized approach to home-based palliative care is one of the most effective ways to manage and enhance care delivery within this vulnerable, costly population. Quality controls and reporting are essential to improving quality and decreasing cost. Programs offering modular continuing education to palliative care team members, as well as guided tools and electronic patient assessments, enable highly skilled clinicians to maximize the impact of member outreach, enrollment and engagement.

Palliative care teams extend the reach and frequency of patient engagement, establishing collaborative relationships and reporting with the medical home that further strengthen care coordination. This level of connectivity and interaction with the medical home represents a significant opportunity to affect quality and cost.

Advantages for Patients and ACOs

Populations burdened by a serious or advanced illness place incredible strain on ACO resources, compromising the organization’s ability to improve care while generating shared savings under the MSSP model. By adopting the medical home/home-based palliative care approach, ACOs can turn this high cost population into an opportunity: improving quality and patient satisfaction while reducing cost and generating shared savings through reduced unnecessary hospital admissions, readmissions and ICU stays. Furthermore, this approach avoids over-medicalized care and high-cost services that may not align with the patient’s goals of care.

Integrating home-based palliative care within the medical home model ensures that each member is treated with respect, dignity, and compassion. This leads to a better quality of life, thanks to strong and trusting engagement with specialized palliative care professionals. Overall, this integrated model aims to improve quality and care coordination, so that individuals access care in the right place, at the right time, and in the manner that best suits a patient’s goals of care.

What’s more, specially trained palliative clinicians act as an extension of the primary treating physician and strengthen the medical home. The palliative nurses and social workers establish goals of care, provide supportive home-based care and assess patient and caregiver status, reporting relevant information to the primary treating physician to fill gaps in care and better align goals with care received.

Innovation in the Real World

Let’s consider a typical patient experience that is all too familiar: An 89-year old man with congestive heart failure (CHF) experienced five emergency room visits and five hospital admissions in one year before his condition worsened and he was intubated in the ICU. Prior to this, he had been seeing his cardiologist and primary care provider for adjustments to his medications, which he was unable to manage at home.

Now consider the vastly better approach of in-home palliative care: This same patient would have informed providers he did not want to go to the hospital or have intubation. When his health deteriorated, his social worker would have met with him and his family to discuss palliative care and supportive care options. He would have also been placed on the palliative care program with home visits made by palliative care specialists as needed. When the time came, his palliative care specialist would have evaluated hospice options with the patient and his family, and he would have died in the manner of his choosing – peacefully at home.

An innovative palliative care approach provides specialized patient/caregiver support and enhances communication with the primary treating physician. This facilitates a shared decision-making model, which results in better congruence between a patient’s individual goals of care and medical care received. It is a recipe for improving quality of life and satisfaction with the care that is delivered.

Greer Myers

Greer Myers

About the Author: Greer Myers is the president, Turn-Key Health and executive vice president, chief development officer, Enclara Pharmacia. With more than 20 years of healthcare experience, Mr. Myers joined Enclara Healthcare in 2014, and maintains dual roles as its President of Turn-Key Health and its EVP of Corporate Development of Enclara Pharmacia. Bringing strengths in post-acute operations, mergers and acquisitions, pharmacy benefits management, strategy and business development, he also has strong vertical experience in payer, provider and healthcare IT verticals.

Infographic: Current State of Healthcare Analytics and Artificial Intelligence

September 12th, 2018 by Melanie Matthews

Some 58 percent of healthcare executives say analytics are an important part of value-based healthcare strategy, according to a new infographic by GE Healthcare and Intel.

The infographic examines where analytics will help, the biggest analytics opportunities and the biggest analytics wins so far.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results Between Medicare’s aggressive migration to value-based payment models and MACRA’s 2017 Quality Payment Program rollout, healthcare providers must accept the inevitability of participation in fee-for-quality reimbursement design—as well as cultivating a grounding in health data analytics to enhance success.

As an early adopter of the Medicare Shared Savings Program (MSSP) and the largest sponsor of MSSP accountable care organizations (ACOs), Collaborative Health Systems (CHS) is uniquely positioned to advise providers on the benefits of data analytics and technology, which CHS views as a major driver in its achievements in the MSSP arena. In performance year 2014, nine of CHS’s 24 MSSP ACOs generated savings and received payments of almost $27 million.

Health Analytics in Accountable Care: Leveraging Data to Transform ACO Performance and Results examines program goals, platforms, components, development strategies, target populations and health conditions, patient engagement metrics, results and challenges reported by more than 100 healthcare organizations responding to the February 2016 Digital Health survey by the Healthcare Intelligence Network.

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Infographic: Proposed Changes to ACO Involvement in the Medicare Shared Savings Program

August 29th, 2018 by Melanie Matthews

The Centers for Medicare and Medicaid Services has proposed a new “Pathways to Success” rule to increase the financial risk doctors and hospitals participating in the Medicare Shared
Savings Program take on to increase accountability of healthcare quality and spending for patients, according to a new infographic by the South Dakota Association of Healthcare Organizations.

The infographic examines the key changes proposed in the “Pathways to Success” rule.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: Are EHRs Delivering Value-Based Care?

August 15th, 2018 by Melanie Matthews

The majority of health system executives surveyed report that electronic health records (EHRs) alone are not delivering the data solutions needed to succeed with value-based care contracts, according to a new infographic by Philips Wellcentive.

The infographic examines the top-rated technology challenges EHRs lack; where executives are going for needed solutions; and how rip and replace scenarios are not being pursued.

A New Vision for Remote Patient Monitoring: Creating Sustainable Financial, Operational and Clinical OutcomesAs healthcare moves out of the brick-and-mortar traditional setting into patients’ homes and their workplaces, and becomes much more proactive, the University of Pittsburgh Medical Center (UPMC) has been expanding its remote patient monitoring program. The remote patient monitoring program at UPMC has its roots in the heart failure program but has since expanded to additional disease states across the integrated delivery system’s continuum of care.

A New Vision for Remote Patient Monitoring: Creating Sustainable Financial, Operational and Clinical Outcomes delves into the evolution of UPMC’s remote patient monitoring program from its initial focus on heart failure to how the program was scaled vertically and horizontally. Click here for more information.

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Infographic: Reducing the Use of Low-Value Healthcare Services

July 16th, 2018 by Melanie Matthews

The United States spends more, both per capita and as a percent of GDP, on healthcare than any other country, yet fails to achieve commensurate health outcomes. One reason for this discrepancy between health spending and outcomes is the significant amount—upwards of $200 billion per year—that the United States spends on low-value care, according to the University of Michigan Value-Based Insurance Design (V-BID) Center.

A new infographic by the V-BID Center provides a list of the top five low-value clinical services for purchasers to target for reduction. The selected services were chosen based on their association with harm, their cost, their prevalence, and the availability of concrete methods to reduce their use.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: Succeeding in the New World of Healthcare

July 9th, 2018 by Melanie Matthews

From big data disruption to the rise of consumerism and the shift to value-based care, there are powerful shifts reshaping the healthcare industry—and only healthcare executives who capitalize on them will thrive in the midst of an ever-changing marketplace, according to a new infographic by NovuHealth.

The infographic examines five trends that are having a significant impact on the industry.

Healthcare Trends & Forecasts in 2018: Performance Expectations for the Healthcare IndustryHealthcare Trends & Forecasts in 2018: Performance Expectations for the Healthcare Industry, HIN’s 14th annual business forecast, is designed to support healthcare C-suite planning as leaders react to presidential priorities and seek new strategies for engaging providers, patients and health plan members in value-based care.

HIN’s highly anticipated annual strategic playbook opens with perspectives from industry thought leader Brian Sanderson, managing principal, healthcare services, Crowe Horwath, who outlines a roadmap to healthcare provider success by examining the key issues, challenges and opportunities facing providers in the year to come. Following Sanderson’s outlook is guidance for healthcare payors from David Buchanan, president, Buchanan Strategies, on navigating seven hot button areas for insurers, from the future of Obamacare to the changing face of telehealth to the surprising role grocery stores might one day play in healthcare delivery. Click here for more information.

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Infographic: Clinical Documentation to Optimize Value-Based Care in the Outpatient Setting

June 22nd, 2018 by Melanie Matthews

A strong commitment to clinical documentation improvement (CDI) can help healthcare organizations maximize claims reimbursement while improving quality of care, according to a new infographic by Galen Healthcare Solutions.

The infographic examines CDI goals and the impact of improved CDI on the healthcare bottom line.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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.

Guest Post: Lab Data is the Missing Link in Healthcare Risk Adjustment

June 19th, 2018 by Jason Bhan, MD

Data informing risk adjustment programs is critical under value-based healthcare reimbursement models.

For health plans, value-based care means a continuous need to innovate and improve their risk adjustment, clinical quality, and care management programs. Unless payers identify and receive the correct amount of reimbursement, it is difficult for them to invest appropriately into member care programs for better outcomes while remaining financially successful.

The data informing risk adjustment programs are critical, as they build the foundation for accurate member risk stratification. In that respect, those data sources are directly related to the correct amount of reimbursement payers receive and can invest in proactive care management. In other words, high-quality clinical data delivered quickly enough for a plan to get a member into a care management program early enough is important to the health of the member and the business. The approach leads to improved clinical outcomes and reduced costs in emergency room visits, hospitalizations and chronic condition management.

Lab Data: An Untapped Resource

To achieve such clinical granularity, at scale, plans can turn to diagnostics—or lab—data. Lab data drives approximately 70 percent of medical decisions and, unlike claims data, is available in near real-time. It also provides an unrivaled level of specificity for clinical conditions. When lab data is integrated into plans’ claims- and chart-based programs, it enables earlier, more comprehensive and accurate clinical insights to benefit care management of both existing and new members. Utilizing the same information that clinicians use to make decisions, within the same timeframe, provides a powerful and unique opportunity to intervene and impact a patient’s health.

What Can Lab Data Do for You?

Expanding and improving their clinical data supply with diagnostics data can help health plans to:

  • Provide historical insights on members where claims are unavailable to improve risk adjustment. For new enrollees, this enables the health plan to get new members into the appropriate care/disease management programs from day one.
  • Serve as an early detection system for care management of all enrollees. Plans can identify patients in need of additional or alternative therapy from lab data earlier than from any other data source. For existing members, the detailed results uncover needs that may have been overlooked based on a claims analysis alone.
  • Identify high-risk members for case management and provider interventions from lab data. Optimized risk adjustment aligns reimbursements to health status, enabling the plan to more heavily invest in member care programs.

Applying AI Solutions

When it comes to gaining actionable insights from diagnostics data, plans can benefit from partnering with healthcare artificial intelligence (AI) specialists in the field. Healthcare AI organizations use techniques such as machine learning and natural language processing—coupled with massive computational power—on big data sets, to make sense out of non-standard, complex, and heterogeneous data.

Healthcare AI, when applied to diagnostics clinical lab data, improves risk stratification by identifying diagnoses earlier in the year versus waiting for the claim or searching charts. Rich in clinical details, it presents a more complete picture of the member’s health. Better risk stratification leads to better care management programs; and successful programs have been shown to reduce costs by targeting those most likely to benefit and keeping intervention costs low.

Dr. Jason Bhan

About the Author: Jason Bhan, MD, is co-founder and Chief Medical Officer at Prognos, an innovator in applying AI to clinical lab diagnostics. More than half of the Prognos team is made of engineers, data scientists, and clinicians. Prognos aims to increase the usefulness of disparate healthcare data to better inform clinical decisions and ultimately improve patient outcomes.