Archive for the ‘Value-Based Reimbursement’ Category

Infographic: The Financial Impact of Value-Based Healthcare Contracts

April 26th, 2019 by Melanie Matthews

As health systems evaluate their ability to transition from fee-for-service medicine toward value-based care, they must understand the financial impact of their strategy, according to a new infographic by Lumeris.

The infographic examines key decision points and outcomes for a health system.

11 Profitable Value-Based Reimbursement Models: Lessons from Early AdoptersCMS’s ambitious agenda for moving Medicare into alternative payment models is driving the U.S. healthcare system toward greater value-based purchasing at a furious rate. Private payors also have pledged to continue to shift payments away from fee for service and into alternative payment models such as accountable care organizations (ACOs). Fortunately, many healthcare organizations are already exploring value-based payments—often a single innovation at a time—testing models that reward providers for meeting Triple Aim goals of improving patient experience and population health while reducing healthcare’s per capita cost.

11 Profitable Value-Based Reimbursement Models: Lessons from Early Adopters encapsulates nearly a dozen such approaches, from Bon Secours’ building of a business case for its multidisciplinary care team to the John C. Lincoln ACO’s deep dive into data analytics to identify and manage the care of high-risk, high-cost ‘VIP’ patients to ‘beat the benchmark’ to WellPoint’s engagement of specialists in care coordination.

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Infographic: 5 Steps to Transform Care Delivery

April 22nd, 2019 by Melanie Matthews

Failures of care delivery accounted for an estimated $102 billion to $154 billion in wasteful spending in 2011, according to a new infographic by Premier.

The infographic provides five steps recommended by Premier to transform care delivery.

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: Turning Data into Actionable Value-Based Care Insights

April 19th, 2019 by Melanie Matthews

In today’s healthcare economy, value-based care remains top of mind for payers and providers alike. However, misalignment between payers and providers can hinder their ability to achieve cost and quality goals, according to a new infographic by MedeAnalytics, Inc.

The infographic examines obstacles to alignment, the role of analytics in value-based care and perceived misalignment.

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 documents the accomplishments of CHS’s 24 ACOs under the MSSP program, the crucial role of data analytics in CHS operations, and the many lessons learned as an early trailblazer in value-based care delivery.

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Infographic: Transitioning to Value-Based Care

April 17th, 2019 by Melanie Matthews

Market and regulatory pressures continue to drive health systems toward value-based payment models. In a survey of leading health systems, half of executives state that the shift to value-based care is happening either quickly or very quickly at their organization. Moreover, respondents indicate that 23 percent of total care delivery in the last quarter of 2018 was value-based, up 5 percent from 2017, according to a new infographic by Lumeris.

The infographic examines the acceleration of the transition to value-based reimbursement.

11 Profitable Value-Based Reimbursement Models: Lessons from Early AdoptersCMS’s ambitious agenda for moving Medicare into alternative payment models is driving the U.S. healthcare system toward greater value-based purchasing at a furious rate. Private payors also have pledged to continue to shift payments away from fee for service and into alternative payment models such as accountable care organizations (ACOs). Fortunately, many healthcare organizations are already exploring value-based payments—often a single innovation at a time—testing models that reward providers for meeting Triple Aim goals of improving patient experience and population health while reducing healthcare’s per capita cost.

11 Profitable Value-Based Reimbursement Models: Lessons from Early Adopters encapsulates nearly a dozen such approaches, from Bon Secours’ building of a business case for its multidisciplinary care team to the John C. Lincoln ACO’s deep dive into data analytics to identify and manage the care of high-risk, high-cost ‘VIP’ patients to ‘beat the benchmark’ to WellPoint’s engagement of specialists in care coordination.

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Guest Post: Cracking the Care Management Code: How Providers Can Get Paid for Remote Services

February 21st, 2019 by Melanie Matthews

With a successful remote care management model in place, healthcare organizations can increase annual revenues by about $500 per patient.

Healthcare organizations and physician practices are stepping up efforts to reduce avoidable healthcare utilization and ensure patients receive care in lower-cost settings when appropriate.

As part of these efforts, many providers are considering remote care services, such as e-visits, remote health monitoring, secure messaging, and regular check-in calls with patients. These remote interactions can increase patient adherence to treatment plans and lead to faster interventions when problems arise.

While payers have been slow to reimburse for remote care services (despite the clinical benefits), providers today can take advantage of Centers for Medicare and Medicaid Services reimbursement for Chronic Care Management (CCM) services to improve care management for many of their Medicare patients.

To qualify for CCM reimbursement, practitioners must spend at least 20 minutes of non-face-to-face clinical staff time per month on care coordination for CCM patients. To be included in a CCM program, patients must have two or more chronic conditions expected to last at least one year or until death, and those conditions must place patients at significant risk of death, acute exacerbation, or functional decline.

Payments for CCM services, which can be provided by physicians, physician assistants, nurse practitioners, nurse midwives and their clinical staffs, can range from approximately $43 to $141, depending on how complex a patient’s needs are, according to CMS.

When a successful remote care management model is put in place, healthcare organizations can increase annual revenues by about $500 per patient, which translates to $50,000 per year for an organization with 1,000 CCM patients.

Getting Involved

Recent data show that many providers have yet to take advantage of CCM. In fact, as of 2016, the program had touched only 684,000 Medicare patients, according to a 2017 CCM report. That’s less than 2 percent of all Medicare recipients.

One reason is that providers face many barriers when attempting to implement remote care programs. Technology, of course, is one hurdle, but CCM services also take clinical and administrative staff time and resources (such as time spent billing for CCM services and ensuring compliance).

This is why many organizations are turning to outside partners that specialize in remote care management to deliver CCM. These partners can enroll patients into the CCM program (a step that is much harder than most practices anticipate), deliver remote services each month, ensure compliance, and bill for services.

The Wright Center, a safety-net primary care provider in northeastern Pennsylvania, is one provider that sought outside help to achieve its CCM goals. The result of its partnership with a remote services provider included net new revenue within 14 days of partnering with the company, an additional $536 per enrolled patient per year, a 73 percent patient retention rate after two years, lower hospital admission rates, and higher patient satisfaction scores.

Four Key Attributes

Because many providers have found delivering remote services challenging, it’s important to select a partner that has the right model and proven success improving patient engagement and outcomes. Key capabilities to look for in a partner include:

  1. Being staffed with nurses or other clinicians who become a trusted and integral part of the healthcare organization’s team. These clinical staff members should have a strong record of establishing productive relationships with providers in the healthcare organization and with patients remotely.
  2. Working seamlessly with the EHR and population health tools already in place at the healthcare organization. The partnership should not result in an additional burden on IT staff members at the healthcare organization.
  3. Providing a customized program to suit the healthcare organization’s specific needs, goals, and workflows. An organization’s CCM needs will vary depending on the patient population, in-house resources, and technology already in place. The partner should be able to tailor its services accordingly.
  4. Proactively addressing social determinants of health and barriers to care. For example, it should be able to share results that showcase its ability to engage a senior population and address their unique needs.

As value-based reimbursement gains traction, healthcare organizations that don’t start exploring remote healthcare services will fall behind. It’s time to get involved, and CCM is a great way to start.

Drew Kearney

Drew Kearney

About the Author: Drew Kearney has been a healthcare leader since 2010, with expertise in post-ACA market opportunities and experience leading expansion initiatives in multiple markets. In 2015, he co-founded Signallamp Health, a company that offers a unique solution operationalizing population health.

Infographic: Alternative Healthcare Payment Model Trends

February 13th, 2019 by Melanie Matthews

Public and private health plans, managed Medicaid fee-for-service (FFS) states, and Medicare FFS voluntarily participated in a national effort to measure the use of Alternative Payment Models (APMs) as well as progress toward the Health Care Payment Learning & Action Network’s (LAN) goal of tying 30 percent of U.S. healthcare payments to APMs by 2016 and 50 percent by 2018, according to a new infographic by the Health Care Payment LAN.

The infographic examines APM trends for commercial, Medicare Advantage, Medicare fee-for-service and Medicaid populations.

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: Precision Outcomes-Based Contracting Driving More Health per Dollar

December 3rd, 2018 by Melanie Matthews

Tying healthcare payments to the achievement of pre-specified goals better aligns healthcare spending with desired clinical outcomes, according to a new infographic by the University of Michigan V-BID Center.

The infographic provides examples of outcomes-based contracts as well as key elements of outcomes-based contracts.

2018 Healthcare Benchmarks: Population Health ManagementAs the healthcare industry’s pace from volume-based to value-based healthcare payment models accelerates so does the demand for more effective management of population health. With the growth of these payment models, healthcare organizations are taking on more risk in terms of shared savings and shared risk arrangements and are investing heavily in programs to support population health. These programs are expanding in both scope of services and health conditions and disease states managed. With the help of advanced technologies in healthcare, this growth will only continue.

2018 Healthcare Benchmarks: Population Health Management is the fourth comprehensive analysis of population health management by the Healthcare Intelligence Network, capturing key metrics such as populations, health conditions and health risk levels targeted by population health management programs; risk stratification criteria; prevalence of value-based payment models supporting population health management programs; population health management processes, tools, workflows and forms; and program outcomes and ROI from responding healthcare organizations. Click here for more information.

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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.