Posts Tagged ‘Medicare’

Infographic: Healthcare Providers Are Prepared to Increase Risk Model Participation

July 26th, 2019 by Melanie Matthews

Healthcare providers are ready and planning to assume increased levels of risk through commercial payer and Medicare contracting models and Medicare Advantage, according to a new infographic by Navigant, based on an analysis of survey conducted by HFMA.

The infographic examines how providers are partnering on or launching provider-sponsored health plans (PSHPs) as a part of their risk-assumption strategy.

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: Prescribing Healthy Food in Medicare/Medicaid

July 3rd, 2019 by Melanie Matthews

Health insurance coverage for healthy food could improve health, reduce healthcare costs and be highly cost-effective after five years, according to a new infographic by Tufts University.

The infographic examines the health and economic effects of healthy food prescriptions in Medicare and Medicaid.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community ServicesLeveraging the experience of several physician practices already screening patients for social determinants of health (SDOH), Montefiore Health System recently rolled out a two-tiered assessment program to measure SDOH positivity in its predominantly high-risk, government-insured population.

Assessing Social Determinants of Health: Screening Tools, Triage and Workflows to Link High-Risk Patients to Community Services outlines Montefiore’s approach to identifying SDOH markers such as housing, finances, healthcare access and violence that drive 85 percent of patients” well-being, and then connecting high-need individuals to community-based services. Click here for more information.

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Infographic: Medicare Beneficiaries at a Glance

March 8th, 2019 by Melanie Matthews

There were some 57 million Americans enrolled in Medicare in 2016—with the majority (68 percent) still enrolled in the traditional Medicare fee-for-service program, according to a new infographic by the Centers for Medicare and Medicaid Services.

The infographic examines Medicare demographic data, service use, average total payments, beneficiary satisfaction rates and the top 10 chronic conditions among enrollees.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM RevenueSince 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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Guest Post: Medicare Advantage Environment Sparks Effective Risk, Quality and Care Strategies to Battle New Challenges

January 17th, 2019 by Jay Baker

Commercial insurers remain interested in competing for MA beneficiaries.

Projections show that national health expenditure growth is expected to average 5.5 percent annually to reach $5.7 trillion by 2026—higher than the projected increase in Gross Domestic Product (GDP). Fortunately, trends of insurers entering and exiting the program show that the Medicare Advantage (MA) market is stable yet dynamic—roughly the same numbers of plans enter/exit the program each year. Data shows that commercial insurers remain interested in competing for MA beneficiaries.

Given the benefits and challenges of value-based healthcare, stakeholders should gain a full understanding of Medicare Advantage (MA) plans, as well as strategies for optimizing this approach. What’s more, research indicates that the successes of MA are already having a positive impact on the broader healthcare delivery and payment landscape. In fact, fee-for-service Medicare spending has trended down in markets with high MA plan participation, indicating that doctors and other medical professionals operating in markets with high MA penetration adapt their practice patterns in alignment with MA plans’ strategies that control spending and use. This, in turn, helps to reduce use and costs for all their patients—including those enrolled in traditional Medicare and commercial/employer-sponsored plans.

MA plan coverage offered by private companies approved by Medicare provide all Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) coverage.

Optimizing the MA Plan Opportunity

An effective MA plan that significantly improves outcomes takes a whole patient approach and applies an end-to-end solution designed to enhance care coordination using analytics, in-home care, retrospective solutions and care management.

Value-based contracting generates cost efficiencies and improves clinical outcomes in MA. The challenge is to design MA plans and risk-bearing entities to remain sustainable. This requires innovative quality and risk adjustment programs to meet the growing demand for effective care strategies. For instance, MA plans can gain clinical insight into risk-adjusting conditions to enhance their traditional analytical platforms.

Understanding a Risk Adjustment Model

Risk adjustment is an actuarial tool used to calibrate payments to health plans based on the relative health of the at-risk populations. If insurers are limited in the extent to which premiums can vary by health status or other factors that are associated with health spending, risk adjustment ensures that health plans are appropriately compensated for the risks they enroll.

Keep in mind that most claims in fee-for-service Medicare are paid using procedure codes, which offer little incentive for providers to record more diagnosis codes than necessary to justify ordering a procedure. In contrast, MA plans have a built-in financial incentive since the current risk adjustment model was introduced that prompts providers to record all possible diagnoses. This is important because higher enrollee risk scores result in higher payments to the plan.

Consider MA plans that rely upon Physician Record Review (PRR), a two-stage retrospective chart review process from a 1) certified coder and 2) board-certified physician. These same plans also use Prospective Health Assessments (PHA) to gain a robust view of members and their care needs. Providers also rely on PHAs to lay the groundwork for developing more accurate reporting documentation, improving patient engagement and compliance, enhancing disease management, and reducing utilization.

This kind of full-spectrum, end-to-end approach to care helps providers identify gaps in care and manage plan members more productively. It also helps health plans that are serving as intermediaries, executing solutions and assuming risk. Fortunately, plan members gain the most form this approach because they are guided toward more preventive care and self-management early in the care process.

Risk-Based Contracting on the Rise

Medicare beneficiaries in fee-for-service Medicare are normally required to pay multiple premiums and deductibles and face a confusing array of cost-sharing arrangements for benefits and services from physicians, pharmacies, and hospitals.

In contrast, when a Medicare beneficiary enrolls in a MA plan it is usually a comprehensive, integrated health plan that includes richer benefits and solid catastrophic coverage. Unburdened of siloed benefits and payments, MA beneficiaries’ plan structure is simpler, and they are able to receive more coordinated care.

The value-based world is enlarging to the benefit of MA patients. In a recent move, CMS expanded its definition of “primarily health-related” benefits that private insurers are allowed to include in their MA policies. These extras include, for instance, air conditioners for people with asthma, healthy food, rides to medical appointments and home-delivered meals. This means MA beneficiaries will have more supplemental benefits and be better able to lead healthier, more independent lives.

Jay Baker

Jay Baker is the senior vice president of quality and risk adjustment solutions at Advantmed, LLC. He was most recently responsible for the ACA risk adjustment strategy and execution for UnitedHealth Group’s Optum division. His accomplishments included standing up an end-to-end service offering and exceeding revenue goals for the first two years of the program. As one of the founders of Dynamic Healthcare Systems, he was responsible for the original design for each of their 10 Medicare Advantage software modules. He is an ACA and Medicare Advantage industry leader and expert in policy, compliance, systems and plans operations.

Advantmed recently developed a white paper that discusses federal policy and the economics of Medicare. Advantmed, LLC is a healthcare solutions company dedicated to partnering with health plans, provider groups and risk-bearing entities to optimize risk adjustment and quality improvement programs. Our integrated and technology-enabled solutions improve health plan financial results and offer insights on health plan members. For more information on Advantmed’s solutions visit www.advantmed.com.

Infographic: Grading the Medicare Advantage Shopping Experience

August 3rd, 2018 by Melanie Matthews

With (on average) 20 Medicare plans to choose from, consumers have high expectations and little patience for friction in health plan interactions, according to a new infographic by NTT DATA.

The infographic examines the leaders and the laggards in the online shopping process for Medicare Advantage options and who is at the top performance level.

UnityPoint Health has moved from a siloed approach to improving the patient experience at each of its locations to a system-wide approach that encompasses a consistent, baseline experience while still allowing for each institution to address its specific needs.

Armed with data from its Press Ganey and CAHPS® Hospital Survey scores, UnityPoint’s patient experience team developed a front-line staff-driven improvement action plan.

Improving the Patient Experience: Engaging Front-line Staff for a System-Wide Action Plan, a 45-minute webinar on July 27th, now available for replay, Paige Moore, director, patient experience at UnityPoint Health—Des Moines, shares how the organization switched from a top-down, leadership-driven patient experience improvement approach to one that engages front-line staff to own the process.

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Infographic: Medicare Home Health Beneficiaries

January 29th, 2018 by Melanie Matthews

Home healthcare patients are among the poorest, sickest and most vulnerable beneficiaries in the Medicare program, according to a new infographic by the Partnership for Quality Home Healthcare.

The infographic compares a traditional Medicare beneficiary with a Medicare home health beneficiary and factors that demonstrate why Medicare home health beneficiaries are financially vulnerable.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI A care transitions management program operated by Sun Health since 2011 has significantly reduced hospital readmissions for nearly 12,000 Medicare patients, resulting in $14.8 million in savings to the Medicare program. Using home visits as a core strategy, the Sun Health Care Transitions program was a top performer in CMS’s recently concluded Community-Based Care Transitions (CBCT) demonstration project, which was launched in 2012 to explore new solutions for reducing hospital readmissions, improving quality and achieving measurable savings for Medicare.

The Science of Successful Care Transition Management: Leveraging Home Visits to Improve Readmissions and ROI explores the critical five pillars of the Arizona non-profit’s leading care transitions management initiative, adapted from the Coleman Care Transitions Intervention®.

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Guest Post: Patient Engagement Technology Tool for Preventing Hospital Readmissions in Chronic Patients

January 23rd, 2018 by Allison Hart, Vice President of Marketing, TeleVox Solutions at West

While almost all chronic care patients say they need help managing their disease, less than one-third receive regular check-ins from healthcare providers.

During the past decade, the Centers for Medicare and Medicaid Services have increased the pressure on hospitals to prevent readmissions. In response to that pressure, many hospitals made changes that have led to declines in readmission rates. However, even with more measures in place to prevent readmissions than ever before, the risk of being readmitted to the hospital is still high for patients with chronic illnesses.

Studies have shown that the risk of adverse health effects increases with each hospitalization. Unfortunately, it can be difficult to keep chronic patients from readmitting once they have been hospitalized. Because of this, it is important that healthcare teams prioritize chronic disease management, and work to engage and support chronic patients. One tool that can help with this is the patient engagement technology many healthcare teams already have in place.

Survey responses indicate that chronic patients welcome efforts from their healthcare team that are aimed at managing disease and preventing hospital admissions and readmissions. A West survey found that 91 percent of chronic patients say they need help managing their disease, and at least 70 percent would like more resources or clarity on how to manage their condition. Additionally, 75 percent of chronic patients want their healthcare provider to touch base with them regularly so they can be alerted of potential issues.

Although patients with chronic conditions have expressed that they desire more assistance from their healthcare providers, they are not necessarily receiving it. For example, more than half (54 percent) of patients feel a weekly or twice-weekly check-in from their provider would be valuable, yet only 30 percent of patients report receiving regular check-ins. This shows that, in some cases, providers could be doing much more to offer ongoing chronic disease management support.

Providers seem to be underestimating patients’ interest in chronic care and their desire to receive support. Patients have suggested that they not only want assistance with managing chronic conditions, they would also be willing to pay for that extra support. Many providers are unaware that their patients feel this way. When asked if their patients would agree to pay 10 dollars per month for additional chronic care support, just over half (53 percent) of providers answered “yes.” However, two-thirds of patients say they would be willing to pay a nominal amount for chronic care support. The eye-opening response from patients confirms that chronic disease management is in demand—more so than providers realize. It also suggests that some providers may need to do more to offer ongoing chronic disease management support.

Chronic Care Management Enrollment

One way healthcare teams can better serve chronic patients and potentially prevent readmissions is by enrolling patients in chronic disease management programs. Chronic care programs, like Medicare’s Chronic Care Management program, require a lot of communication on the part of the healthcare team. Automating some of the communication and outreach makes it easier for providers to offer ongoing chronic care support. Healthcare teams can use their patient engagement technology to:

  • Send patients messages to invite them to enroll in a chronic care program. Using information from electronic health records, healthcare teams can identify patients that are eligible for chronic care management programs. (Patients must have two or more chronic conditions to enroll in Medicare’s Chronic Care Management program.) Then, they can use their patient engagement technology to send patients automated messages with information about the benefits of participating in a chronic care program, and instructions or links for patients to enroll or get further information.
  • Schedule disease-specific preventive screenings and tests. The Chronic Care Management program mandates that patients receive recommended preventive services. Care managers can schedule and send patients automated text messages, emails or voice messages to notify them when they are due for preventive screenings and tests. Patients with diabetes, for example, would automatically receive messages when they are due for an A1C test, foot exam or eye exam.
  • Send medication reminders and messages. Providers are required to manage and reconcile medications for patients enrolled in the Chronic Care Management program. Providers can assign medication reminders and send automated messages to ensure patients know how and when to take their medication, and that they don’t forget to take it.

Communication that engages chronic patients and aids them in disease management can result in better health outcomes and fewer readmissions. Engagement communications can be easily automated, meaning outreach does not require excessive time or resources. Hospitals and healthcare providers have incentives to reduce readmissions, and in many cases, they have the technology in place to make chronic disease management efficient and effective.

About the Author: Allison Hart is a regularly published advocate for utilizing technology-enabled communications to engage and activate patients beyond the clinical setting. She leads thought leadership efforts for West’s TeleVox Solutions, promoting the idea that engaging with patients between healthcare appointments in meaningful ways will encourage and inspire them to follow and embrace treatment plans – and that activating these positive behaviors ultimately leads to better outcomes for both healthcare organizations and patients. Hart currently serves as Vice President of Marketing for TeleVox Solutions at West, where the healthcare mission is to help organizations harness communications to expand the boundaries of where, when, and how healthcare is delivered.

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: Advancing Medicare and Medicaid Integration

December 18th, 2017 by Melanie Matthews

There are more than 11 million individuals who receive services from both Medicare and Medicaid. State policymakers and their federal and health plan partners are increasingly seeking opportunities to improve Medicare-Medicaid integration for these dually eligible beneficiaries, according to a new infographic by the Center for Health Care Strategies.

The infographic explores the reasons to integrate care for dually-eligible individuals; features of effective programs; and factors influencing state investment in integrated care.

Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid PopulationTo locate, stratify and engage dual eligibles, Health Care Services Corporation (HCSC) takes a creative approach, employing everything from home visits to ‘street case management’ to coordinate care for Medicare-Medicaid beneficiaries.

Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population describes HCSC’s innovative tactics to engage this largely older adult and disabled population in population health management with support from a range of community partners and services.

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Infographic: Medicare Costs

December 6th, 2017 by Melanie Matthews

Beneficiaries in Original Medicare spent an average of $5,680 on healthcare in 2013. Half of all beneficiaries spent at least 17 percent of their income on their health, according to a new infographic by the AARP.

The infographic breaks down where Medicare beneficiaries spend their healthcare dollars and how age and health status impact spending.

Medicare Chronic Care Management Billing: Evidence-Based Workflows to Maximize CCM RevenueSince 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: Physician Appointment Wait Times; Medicare and Medicaid Acceptance Rates

May 5th, 2017 by Melanie Matthews

The average wait time for a physician appointment in 15 mid-sized metropolitan areas was nearly 8 days longer than in l5 major metropolitan areas, according to a new infographic by Merritt Hawkins.

The infographic also examined rates of Medicare and Medicaid acceptance by physicians in these markets.

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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