Posts Tagged ‘healthcare reimbursement’

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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Infographic: Using Technology-Enabled Communications To Address Revenue Cycle Challenges

September 22nd, 2017 by Melanie Matthews

Healthcare providers are missing opportunities to drive timely payments, grow revenue and maximize reimbursements, according to a new infographic by Televox.

The infographic examines the revenue opportunities that healthcare providers are missing and how providers can avoid penalties and earn additional reimbursement.

Since the January 2015 rollout by CMS of new chronic care management (CCM) codes, many physician practices have been slow to engage in CCM. Arcturus Healthcare, however, rapidly grasped the potential of CCM to improve patient outcomes while generating care coordination revenue, estimating it could earn up to $100,000 monthly for qualified patients treated in its four physician practices—or $1 million a year.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM Revenue traces the incorporation of CCM into Arcturus Healthcare’s existing care management efforts for high-risk patients, as well as the bonus that resulted from CCM code adoption: increased engagement and improved relationships with CCM patients.

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Infographic: Provider Payments Trends

October 6th, 2014 by Melanie Matthews

The healthcare payments industry is changing rapidly due to consumerism and regulatory mandates, according to the fourth annual Trends in Healthcare Payments Report by InstaMed. Patient payments to providers have increased 72 percent since 2011 due to these market forces.

InstaMed’s new infographic based on the report looks at how patient provider payments are changing administrative requirements by providers, the need for payment plans and how credit card and mobile will impact provider payments in the future.

Provider Payment Trends

The New Hospital-Physician Enterprise: Meeting the Challenges of Value-Based Care Shifting reimbursement models are forcing hospital executives to rethink their approach to physician relationships. New cost and quality demands require hospitals to explore all alternatives—including tighter alignment with physicians. The New Hospital-Physician Enterprise: Meeting the Challenges of Value-Based Care provides expert advice on structuring and sustaining hospital-physician relationships in the post-reform environment.

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The PHO in 2013: More Flexibility, Less Risk Than Eighties Model

January 31st, 2013 by Patricia Donovan

Unlike the hospital-dominated physician-hospital organization (PHO) prominent 30 years ago, today’s PHOs are largely physician-centric, notes Travis Ansel, manager of strategic services for the Healthcare Strategy Group. And make no mistake: in the new fee-for-value healthcare universe, payors and employers understand that physicians are the one that control process and control cost, he asserts.

“Hospitals and physicians have a great incentive right now to figure out how they should be working together going forward, and how they need to align legally and what model to use in order to engage those populations,” Ansel notes. Providers unable to provide efficient quality care that’s going to help hospitals survive under value-driven reimbursement will face losses in market share and reimbursement, he continues.

Ansel and Greg Mertz, director of Healthcare Strategy Group, recently explored the key contractual elements to consider when creating a PHO during a webinar on Physician Hospital Organizations: Developing a Collaborative Structure for Shared Savings Agreements.

Today’s PHOs are jointly governed by physicians and hospitals, they explain, with the common goals of quality and cost management and the sharing of savings from any joint contracts or arrangements — elements that weren’t necessarily part of the eighties’ PHO equation.

Compared to other emerging shared savings arrangements — the Medicare Shared Savings Program, commercial accountable care organizations (ACOs) and public and private bundled payments — PHOs offer more flexibility, notes Mertz. For example, a PHO has the option of expanding into an ACO in the future, as well as target multiple populations, something that can be more challenging in an ACO due to its reporting requirements. “Today’s PHO is scalable. It can start with a single client and grow to ACO.”

But flexibility doesn’t preclude serious considerations around forming a PHO, he continues, including its legal structure, number and type of participating physicians, size of the patient population, compensation plans, data support, and most importantly, evidence-based protocols against which to measure PHO performance. And while cost reduction is paramount, patient satisfaction levels are getting equal attention.

“The big difference between today’s programs and the gatekeeper HMO’s back in the eighties is that nobody worried about whether the patient was happy with the HMO,” says Mertz. “Now within public programs, there’s a formal process of monitoring and reporting on patient satisfaction.”

What will the typical PHO look like? Owner physicians and hospitals, plus contracted providers such as imaging, pharmacy and other ancillary services. The PHO team will also rely heavily on nurse case managers, nurse navigators to really interact with the patients as they help to coordinate their care. “It’s cheaper to intervene now than in the emergency room,” Mertz notes.

It is also important to have an accurate picture of the patient population. “Diabetes, pulmonary, cardiac, and depression are the top cost drivers, but dual eligibles (Medicare-Medicaid patients) and patients with behavioral issues are chronically non-compliant and are the biggest cost consumers. It’s important to identify those people up front and develop a patient registry-managed plan for those patients.”

Of course, key to any shared savings model is quantifying the cost of services and then savings gleaned from the PHO’s clinical protocols and quality efforts — then distributing the savings equitably.

The challenge for fledgling PHOs will be changing provider behaviors. “Participants have to believe that the PHO is better than the alternative,” says Mertz. “Creating a culture of collaboration is key; success hinges on provider engagement.”

And not just the physicians that are part of the PHO. “The PHO is really a vehicle to involve all physicians, including community doctors,” concludes Ansel. “Community physicians that aren’t a part of employed networks are just as important and have just as much insight as to how the industry succeeds under this new reality.”

Listen to an expanded interview with Travis Ansel and Greg Mertz about today’s physician-hospital organizations.

Rollout of Florida Blue Medical Home Exercise in Quality, Innovation

May 30th, 2012 by Patricia Donovan

Don’t rely on technology, and don’t expect busy doctors to take on added administrative tasks. Those are just two lessons that have shaped Florida Blue’s programs to improve the quality of primary care over the last eight years.

And while Florida Blue’s name may be new, its mandate to identify and close critical gaps in patient care is longstanding.

The organization formerly known as Blue Cross Blue Shield of Florida (Florida BCBS) has had a quality-focused program to recognize excellence in primary care since 2004, explained Barbara Haasis, RN, CCRN, Florida Blue’s senior clinical lead, quality reward and recognition programs in a recent webinar on The Patient-Centered Medical Home: Lessons from a Statewide Rollout.

In 2004, Florida BCBS rolled out Recognizing Physician Excellence (RPE), its first statewide pay-for-performance (PFP) quality program for more 4,000 primary care physicians.

Seven years later, when the Florida payor decided results from the RPE program had topped out, it shifted direction to a patient-centered medical home (PCMH) approach, which reflected both industry trends and requests from employer groups.

In parallel with RPE, it piloted its PCMH program with a small number of practices in 2010, focusing on patients with diabetes and hypertension. The practices in the pilot were offered a registry to record patient data, but the expectation that electronic health record (EHR) data could be dropped into the registry was not met. Neither were busy physicians willing to complete the patient information forms themselves.

Based on lessons learned in the pilot, Florida Blue opted not to require any type of e-connectivity or EHR when it rolled out the program statewide in 2011, aligning instead with the e-connectivity standards of national programs such as the NCQA medical home recognition program.

However, mandates to utilize e-prescribing and to provide at least six hours of after-hours coverage are included in the program’s eligibility requirements.

Today there are more than 1,800 physicians in the program covering 25 counties; well over half a million Florida Blue members see a physician participating in the PCMH.

Florida Blue issues quarterly scorecards to its PCMH physicians that contain the results of their quality metrics in six key ares as well as feedback on their total cost of care. Overall, Florida Blue finds that physicians participating in the medical home program are more efficient in their total cost of care and have better quality outcomes than those who have never participated in a quality program before.

Nurse educators and medical field directors from Florida Blue support the physicians in the delivery of patient-centered care. Ms. Haasis said Florida Blue will also add four practice transformation coordinators to assist practices in the transition to the medical home model of care.