Posts Tagged ‘CMS’

Infographic: Broad Support for Medicaid Expansion

November 4th, 2013 by Jackie Lyons

The Affordable Care Act (ACA) provides Americans with better health security by putting in place comprehensive health insurance reforms, according to the Centers for Medicare & Medicaid Services.

Sixty-eight percent of adults favor making Medicaid available to more residents in their states, according to a new infographic from the Commonwealth Fund. This infographic also addresses states’ participation in the ACA and the attitudes of residents in states that are not expanding.

Broad Support for Medicaid Expansion

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.

You may also be interested in this related resource: Medicaid Compliance Strategies for Hospitals and Other Providers: How to Prepare for Federal Health Reform Mandates and State Initiatives.

Deeper Data Dive Improves ACO Performance, Quality

August 1st, 2013 by Jessica Fornarotto

Performance Quality Measurement and Reporting for Accountable Care webinar replay

What started as a closer look at John C. Lincoln Network’s 30-day Medicare readmissions for heart attack, heart failure and pneumonia kicked off a plethora of quality improvements for the Medicare Shared Savings Program, including the hiring of care transition coaches, extension of primary care hours and tightening of key gaps in care.

During HIN’s webinar, Performance Quality Measurement and Reporting for Accountable Care, two experts from JCL shared how their organization modified reporting processes — from workflow changes to customizations within its EMR — to improve performance results during its 2013 reporting year.

For its transition coach program, developed to reduce Medicare 30-day readmissions, JCL hired trained military medics to help recently discharged patients transition more easily from one setting to another, explained Heather Jelonek, chief operating officer for ACOs at JCL.

“These transition coaches go into the hospitals and meet with patients when they are admitted. They get to know the patients, they develop a rapport, and they also start to prepare the patients for discharge.”

After discharge, these coaches follow the patient for a minimum of 30 days to follow up on medical care, monitor blood pressure, explain medications and teach the patient about nutrition with the help of a registered dietician.

A deeper data dive also identified a trend among its Meals on Wheels beneficiaries: 85 percent of these patients were readmitted within 30 days almost always on Friday evenings. The patients did not have enough food to get them through the weekend since Meals on Wheels only delivers during the week.

This program has helped to reduce readmission readmission rates from almost 20 percent to just under 2 percent for those patients receiving Meals on Wheels and became an assessment area for the transitions coaches.

Encouraged, JCL sought to learn what additional data they needed from their system to respond to the reporting requirements for CMS’s 33 quality measures. They determined their course of action for 2012 and the building requirements for 2013. According to Karen Furbush, business consultant for JCL, “we have to continually re-educate each of the practices at the hospital and the ED so that they can continue to remember what’s important. And it’s not just for the ACO measures, but in general for better coordinated care.”

One change implemented immediately was the addition of a new message within EPIC, an ADT inbasket message that alerts the primary care physician (PCP) to schedule a follow-up visit within seven days. The PCP then reviews the message and forwards it to the medical assistant (MA) to schedule the visit. This change helped to meet one of the ACO quality measure as well as the transitional care management incentive.

Realizing that enhancements were needed for quality reporting, JCL added additional logic to its patient health questionnaire for future fall risk, aspirin usage and a depression scale. JCL also has ACO patient navigators who analyze reports to determine which patients were missing required measurement values and then schedule those patients by the end of the year as needed, noted Ms. Furbush. “We learned how to get the information out and quickly assess who hasn’t had the influenza or pneumococcal shots, or […] a mammography or a colorectal screening. We wanted to go out and capture that information as quickly as possible because we still had three months left to be able to find that information, whether it was in a previous system or if it was in our current EMR,” explains Furbush.

“We immediately tried to get on the phone to start scheduling these appointments, working through all the things that we need to do for the ACO, as well as just bringing the patient into the EMR completely,” Furbush continued.

Furbush also started a weekly ACO quality reporting call to discuss a group of measures to see what kind of challenges were being faced and what was being implemented. JCL also hosted two EPIC-specific subset calls to learn how everyone was using EPIC.

Once JCL received its patient sample from CMS, it sent samples to each practice. According to Furbush, “We said [to the practices] this is what CMS said this person happens to be associated with. There are 15 categories and CMS will provide a rank of one to 616, one being the highest. You have to report on 411. We had to let them know where the patients ranked for each of the disease states and that we needed information back from them if we couldn’t get it from the EMR.”

JCL continues to struggle with integration opportunities. According to Jelonek, “This includes talking to other communities and looking at HIEs as we’re making an acquisition of a new practice or signing a new community physician onto the ACO. In other words, bringing everybody to the table so that we’re all speaking the same language.”

Infographic: Stay Out of CMS Penalty Box for PQRS and eRX

March 26th, 2013 by Patricia Donovan

Unless healthcare organizations take certain key steps this year, their Medicare reimbursement level in 2015 could be cut 2 percent or more. That’s because among other areas, the CMS Physician Quality Reporting System (PQRS) and ePrescribing (eRX) programs are shifting from bonus to penalty programs to insure compliance.

More than 80 percent of Medicare providers will face penalties for failing to meet quality thresholds if current performance trends continue. This infographic from Medical Billing highlights these changes and what healthcare entitities need to do to protect their practices.

PQRS and eRX penalties

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.

You may also be interested in this related resource: Avoiding the Readmissions Penalty Zone: Population Health Management for High-Risk Populations.

1 Out of 3 Patients Hospitalized for Heart Conditions, Pneumonia Readmitted Within 15 Days

February 1st, 2013 by Cheryl Miller

Almost 3 million Medicare patients hospitalized for heart failure (HF), heart attack, or pneumonia were readmitted to the hospital within 30 days, and almost two-thirds were readmitted within 15 days, according to a study from Columbia University Medical Center and published in JAMA.

Hospital readmissions are common and can be a marker of poor healthcare quality and efficiency. To lower readmission rates, CMS began publicly reporting 30-day risk-standardized readmission rates for these conditions after these measures were endorsed by the National Quality Forum.

CMS also began penalizing hospitals with high readmission rates; one way to avoid these readmissions penalties is by arming yourself with as much of your own readmissions data as possible, says Amy Boutwell, MD, MPP, president of Collaborative Healthcare Strategies, and co-founder of the IHI STAAR (State Action on Avoidable Rehospitalizations) initiative. Too many hospitals and healthcare organizations are relying on data from vendors and secondary information sources. Hiring a quality analyst run your discharge data can be very helpful. Ms. Boutwell elaborates on this and several other recommendations adapted from the IHI STAAR initiative.

Another way to avoid readmission penalities is to increase the use of telehealth solutions. Telehealth could reach as many as 1.8 million patients worldwide by 2017; studies show that an estimated 308,000 patients were remotely monitored by their healthcare provider for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, hypertension and mental health conditions worldwide in 2012. The majority of these patients were post-acute patients who had been hospitalized and discharged.

One area where high costs aren’t impacting professional decisions is in the use of expensive imaging tests. Despite evidence to the contrary, a new study from Johns Hopkins University School of Medicine shows that price transparency doesn’t influence the way physicians order imaging tests; instead, when it comes to expensive tests like MRIs, it seems that doctors have already decided they need to know the information regardless of their cost.

Read all of these stories in their entirety in this week’s Healthcare Business Weekly Update.

Medication Adherence Gets Boost from CMS Innovation Advisors

August 1st, 2012 by Jessica Fornarotto

“Payors are interested in finding ways that they can improve medication adherence for their members using community pharmacy resources,” says Dr. Janice Pringle, director of the program evaluation research unit at the University of Pittsburgh School of Pharmacy. This is just one of many lessons Dr. Pringle learned after being selected for the Centers for Medicare and Medicaid Services Innovation Advisors Program.

During an interview with HIN’s executive vice president and chief operating officer, Melanie Matthews, Dr. Pringle discussed why she applied for the Innovation Advisors Program, the medication adherence intervention she developed with Highmark and Rite Aid, other initiatives supporting medication adherence, and much more.

HIN: What prompted you to apply for the Innovation Advisors Program?

(Dr. Janice Pringle): I have always been interested in innovations and I teach a course on healthcare innovations at the University of Pittsburgh. I also have been involved in a program where we took some strategies that are used in behavioral health and applied them in community pharmacy services, and we looked to see if that had an impact. I considered that an interesting innovation. And I have to emphasize that I did this with my collaborators: Highmark, which is a commercial payor and is now Gateway, a Medicaid payor; and Rite Aid Corporation and CECity have all been part of this particular program. We’re funded through the Pharmacy Quality Alliance (PQA).

HIN: What have you learned thus far?

(Dr. Janice Pringle): We’ve learned a lot. First of all, we’ve learned that pharmacists want to have a greater impact on their patients, so when you’re giving them the opportunity to do so, they rise to the occasion. We’ve also found that community pharmacy organizations such as Rite Aid are interested in supporting this. We also know that the payors are interested in finding ways that they can improve medication adherence for their members using community pharmacy resources. We know that CECity, which provides some platforms to help us scale things, is a very important and necessary partner.

Finally, the PQA is important because they provide us with the national contacts. We’ve learned that the implementation barriers can be attenuated; we can get over them. Where there’s a will there’s a way. Even though pharmacists are very busy in community pharmacy settings, they can learn to have meaningful discussions with patients about their adherence and learn to fit it into their work. We’ve also learned that once they see this, they can continue to do it even more.

Our preliminary results have demonstrated to us, when we compare the medication adherence rate for the medication classes we’ve studied, that the pharmacy is better involved. 118 pharmacies improved medication adherence for the patients who received services there, compared to the pharmacies that we used as controls that were not using this intervention. What’s really key is that this effect seems to improve or increase over time, which shows us that the pharmacist gets better and better at it as they go forward. We’ve studied these data over a 12-month, or in some cases, a 13-month period. That’s everything that we’ve learned and we’re excited to see if we can continue to push this forward, and maybe change the conversation about the importance of community pharmacy in the healthcare arena and landscape.

HIN: What role do you believe medication adherence will play in the recommendations developed by the Innovation Advisor program?

(Dr. Janice Pringle): Medication adherence is definitely an important issue for many of my advisors. They’re programmed by looking at adherence, and it came up multiple times whether we were looking at transitions of care, palliative care issues, whether it was looking at issues of integrating and doing models using primary care, and so forth. Medication adherence has definitely come up. I would imagine, especially given we know that Dr. Will Shrank is a member of Brigham & Women’s Hospital Department of Medicine, Division of Pharmacoepidemiology & Pharmacoeconomics and his expertise is in medication adherence, it’s an important issue for them, and also for CMS in general and the innovation center.

HIN: Of the innovators selected to participate, what other types of initiatives support medication adherence? How do these programs complement or differ from yours?

(Dr. Janice Pringle): There was much interest in the issue of medication adherence, specifically some of what we were doing in our program and how they could apply it to their models. For most of the models that I heard about, the vast majority seem to have an interest in how they can improve medication adherence because they understood that this was an issue for them in improving health — or their “three-part aim” as they call it, which is improving health, improving care and reducing cost.

HIN: Can you briefly describe the intervention you’ve developed with Highmark and Rite Aid to improve medication adherence rates?

(Dr. Janice Pringle): The intervention involves screening, brief intervention (SBI) of patients for medication adherence issues. This way, you can place them in a risk profile. You use any screen that has validity in that purpose. You can sort your patients based on prior data and information. You can also do a universal screen where you ask them questions when they come in, but you want to bring up those patients that seem to be at greater risk than others. You can then apply a brief intervention, which is a two to five minute conversation that is based on motivational interviewing principles that address the issues of how we can help you improve your medication adherence. This is called a facilitative manner — you’re trying to have the patient and the pharmacist work together to address that issue.

HIN: When you spoke with us in May 2011, you were evaluating the preliminary results for the community pharmacist’s intervention. Can you share what results the program has achieved to date?

(Dr. Janice Pringle): With the pharmacies that were involved in the intervention, we looked at the patients that came to those pharmacies and looked at their formulary claims data. We found that their adherence significantly improved and continued to improve over time, so there was an acceleration of an effect over time. For the 13 months or so that we examined the data, compared to the control pharmacies that were fairly similar in many different ways, we examined the similarities to the intervention pharmacies on the same medication classes and the same adherence measures.

HIN: What did you learn in year one of the intervention and how have you modified the intervention based on these findings?

(Dr. Janice Pringle): One of the things that we’ve learned is that you have to keep in touch with the pharmacists consistently to make them aware, if they’re applying this innovation, that this is an innovation that has importance. Pharmacists have many competing requirements; immunizations, different tasks that come through in a community pharmacy chain. We keep in regular monthly contact with the pharmacists to determine what issues or concerns they may have or limitations. We want to get the issues addressed as quickly as possible. We also keep track of where they stand in the innovation process. That’s one thing that I think is important.

The second is, Rite Aid has reported this whole program and that’s key. Rite Aid put some very talented people in charge, such as Jesse McCullough, who is the clinical services manager for Rite Aid, and Rick Mohall, the director of clinical services at Rite Aid. They cleared the way for this to become an initiative for the pharmacies where we’re implementing so that it would continue to be priority. And they changed how they are evaluating the pharmacists.

There are raises also related to the pharmacy, but not just the pharmacist’s performance. The pharmacies are being evaluated as a unit. We found that one pharmacist could be on board, another may be less on board, and they could cancel each other out as they move forward. If you’re now evaluating the pharmacy as opposed to the pharmacists, that changes the conversation.

HIN: Do you have plans to expand the program to include other pharmacy chains?

(Dr. Janice Pringle): Yes. PQA and CECity have been working on the second phase of this, which is called Equipp. They are targeting the entire state of Pennsylvania, looking at some other pharmacy chains and other payors. They also have been talking to some other states. Dr. David Nau, PQA’s senior director of research and performance measurement, has been involved with CE City and is moving this forward to the other states, especially Pennsylvania.

HIN: Are the pharmacists receiving any higher payment for their services?

(Dr. Janice Pringle): Rite Aid has many programs that they’re using to provide incentives to their pharmacists, or to make up the way in which they’re reimbursed. Some of them relate to this study and some do not. What I’m about to say is one aspect of the many ways in which the pharmacists’ salaries were determined. I’m not privy to all of them.

I do know that Rite Aid has, as of January of this year, decided to look at ways that the entire pharmacy is performing, and adherence is one way to be able to look at that. There are other things that they’re looking at as well, but this was partially in response to our study and in response to other things, too, that indicated that it’s good to have the pharmacy be one unit in terms of how the pharmacy takes on innovation, or approaches ways in which we can be considered productive.

We will also be looking at, with Highmark, ways in which we can provide additional pay for performance, or value-based purchasing strategies for the pharmacist. We’ll be testing and developing some models for our colleagues. I wouldn’t expect those to be moved into the field until some time in 2013.

HIN: The community pharmacists can have a measurable impact on medication adherence, according to the results of your program. After the pharmacists, where should organizations concentrate their efforts to boost medication adherence? What should be done within the primary care practice?

(Dr. Janice Pringle): For our next step, we should bring physicians and pharmacists together. The same strategies we’ve used with the pharmacists can be used in the physician’s business. What could be interesting is having the physicians and pharmacists together with an understanding of common quality metrics, such as what CECity provides and what PQA has suggested regarding the measurement. This way, you can keep track of what’s going on with the patients between the physician’s practice and the pharmacy practice.

I think it would change the whole conversation of how we’re receiving medications in our community — if pharmacists are working in collaboration with physicians and physicians are learning the same skills. We could greatly enhance medication adherence and we could change the health of our communities. Again, it’s a matter of will to do that.

Are Payment Tides Turning for Primary Care?

July 16th, 2012 by Patricia Donovan
Primary Care Pay

Value-Based Payments

Several indicators this month point to more dollars flowing into primary care offices, either in the form of higher provider salaries, increased reimbursement, or both. And new market data finds physicians leading the majority of accountable care organizations (ACO).

A study released last week by Medical Group Management Association found that median pay for primary care physicians (PCPs) grew 5 percent last year to $212,840, capping a five-year increase of 16.7 percent from 2007 to 2011. While an actual PCP paycheck pales next to a specialist’s, of note is MGMA’s finding that PCP compensation grew at a faster rate than specialist pay over the last five years.

The reimbursement stage is being set for patient-centered care delivery models like the patient-centered medical home and the ACO that put a premium on care coordination, with many payors offering a combination of traditional fee for service (FFS) payment topped off with a care coordination fee, with possibly a little shared savings thrown in to sweeten the payment pot.

Sixty-one percent of respondents to the sixth annual HIN 2012 Patient-Centered Medical Home survey reported they operate under an FFS plus care coordination fee model.

And earlier this month, CMS proposed payment increases for family physicians of approximately 7 percent and for other practitioners providing primary care services of between 3 and 5 percent. As it has in other initiatives resulting from healthcare reform, the proposed rule offers additional financial incentives for care coordinated during critical transitions in care, such as when a patient is discharged from the hospital:

For 2013, CMS is proposing for the first time to explicitly pay for the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility. The proposals calls for CMS to make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.

Dr. Carrie Nelson, medical director of special projects for Advocate Physician Partners (APP), lauds CMS’s proposal. “It’s a long time coming that that kind of recognition has translated into reimbursement for primary care physicians,” notes Dr. Nelson, a family physician herself. “I know first-hand the amount of work that goes into making sure your patients aren’t falling through the cracks and getting the care they need in an efficient manner, especially after a hospitalization or major clinical situation.”

However, it’s critical that those dollars given to primary care for care coordination actually go toward that function, Dr. Nelson cautioned, and that quality measures are established in parallel with this funding. “There’s a risk that these funds could be seen as ‘new money,’ she said. “I think primary care feels undervalued and underpaid, and there is some validity to that. But at the same time, reimbursement for care coordination may not translate into actual care coordination unless there are some quality measures associated with that in order to make sure that the dollars go toward the purpose for which they were intended.”

With eight years of clinical integration (CI) under its belt, involving more than 4,000 physicians and 10 hospitals, APP can speak from experience. Its nationally recognized CI effort has achieved record performance in almost all measured areas, resulting in improved patient outcomes and significant cost savings. The CI program laid the groundwork for a value-based payment contract between APP and Blue Cross Blue Shield of Illinois. Dr. Nelson will share lessons learned from contract implementation during a July 18, 2012 webinar, Bending the Cost Curve with a Commercial Value-Based Payment Contract.