Posts Tagged ‘Medicare’

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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Infographic: How the Affordable Care Act Is Changing Medicare

June 19th, 2015 by Melanie Matthews

One of the Affordable Care Act's lesser known goals is to improve Medicare's coverage, care and financial outlook, according to a new infographic by the Commonwealth Fund.

The infographic drills down on the impact that the ACA has had on reducing gaps in care, improving chronic care management, emphasizing high-value care and slowing healthcare spending.

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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13 Metrics on Care Transition Management

May 7th, 2015 by Cheryl Miller

Care transitions mandate: Sharpen communication between care sites.


Call it Care Transitions Management 2.0 — enterprising approaches that range from recording patient discharge instructions to enlisting fire departments and pharmacists to conduct home visits and reconcile medications.

To improve 30-day readmissions and avoid costly Medicare penalties, more than one-third of 116 respondents to the 2015 Care Transitions Management survey—34 percent—have designed programs in this area, drawing inspiration from the Coleman Care Transitions Program®, Project BOOST®, Project RED, Guided Care®, and other models.

Whether self-styled or off the shelf, well-managed care transitions enhance both quality of care and utilization metrics, according to this fourth annual Care Transitions survey conducted in February 2015 by the Healthcare Intelligence Network. Seventy-four percent of respondents reported a drop in readmissions; 44 percent saw decreases in lengths of stay; 38 percent saw readmissions penalties drop; and 65 percent said patient compliance improved.

Following are eight more care transition management metrics derived from the survey:

  • The hospital-to-home transition is the most critical transition to manage, say 50 percent of respondents.
  • Heart failure is the top targeted health condition of care transition efforts for 81 percent of respondents.
  • A history of recent hospitalizations is the most glaring indicator of a need for care transitions management, say 81 percent of respondents.
  • Beyond the self-developed approach, the most-modeled program is CMS’ Community-Based Care Transitions Program, say 13 percent of respondents.
  • Eighty percent of respondents engage patients post-discharge via telephonic follow-up.
  • Discharge summary templates are used by 45 percent of respondents.
  • Home visits for recently discharged patients are offered by 49 percent of respondents.
  • Beyond the EHR, information about discharged or transitioning patients is most often transmitted via phone or fax, say 38 percent of respondents.

Source: 2015 Healthcare Benchmarks: Care Transitions Management

Care Transition Management

2015 Healthcare Benchmarks: Care Transitions Management HIN's fourth annual analysis of these cross-continuum initiatives, examines programs, models, protocols and results associated with movement of patients from one care site to another, including the impact of care transitions management on quality metrics and the delivery of value-based care.

Meet Deborah Vermillion: Home Care CEO Aims to Keep Seniors at Home as Long as Possible

March 13th, 2015 by Cheryl Miller

Deborah Vermillion, RN, MSHCA, CSA, CDE, President/Owner of ComForcare Homecare, a non-medical home care business.

This month we provide an inside look at a healthcare case manager, the choices she made on the road to success and the challenges ahead.

HIN: Tell us a little about yourself and your credentials.

(Deborah Vermillion) I have been in the healthcare workforce for 36 years. I am a registered nurse. I have a master's degree in health care administration. I am a certified senior advisor. I am also certified in diabetic education.

What was your first job out of college and how did you get into case management?

My first job out of college was in an intensive care unit (ICU)/coronary care unit (CCU) at Allegheny General Hospital in Pittsburgh as a staff nurse. After four years as a staff nurse and supervisor, I entered medical sales in the home care equipment and infusion industry. During that time it was very important to manage discharge planning as it related to the items we were providing. That was the beginning of my entry into case management.

Has there been a defining moment in your career? Perhaps when you knew you were on the right road?

I always knew that I wanted to be a nurse. My nursing education has led to continued growth and career development, and has been the springboard to all that I have achieved.

In brief, describe your organization.

I own a non-medical home care business. We provide activities of daily living (ADL) and instrumental activities of daily living (IADL) care to seniors in their homes. Our goal is to keep seniors at home for as long as possible. Because I am a nurse we also provide private duty nursing services. We will be expanding this product line through accreditation this year.

What are two or three important concepts or rules that you follow in case management?

  • Follow all cases through to completion.
  • Pay attention to all client details in order to avoid any unforeseen issues.
  • Understand that we are working in their environment, not an institutional environment. Adjust our approach to achieve the best results without being overly invasive.

What is the single most successful thing that your organization is doing now?

Because of our care for each of our clients we have been able to keep readmission rates to a minimum. When we last measured we were at five percent.

Do you see a trend or path that you have to lock onto for 2015?

We need to continue to pay attention to details. We have instituted a more robust quality management program that we hope will bring a stronger platform to our already complete care.

What is the most satisfying thing about being a case manager?

Being able to keep the client at home, aging in place up to their death.

What is the greatest challenge in case management and how are you working to overcome this challenge?

Communication between the various organizations that care for the client in the home. I constantly have to chase the Medicare agencies to ask for cross communication; most of the time they do not call back and obviously do not feel the importance in communicating to support continuity of care.

What is the single most effective workflow, process, tool or form you are using in case management today?

We have a Dementia Wise Training program that certifies our caregivers in dementia care. It is 8.5 hours of training. It has truly raised the bar of care for our clients with dementia, and it makes care much easier for caregivers as well.

Where did you grow up?

Pittsburgh, PA

What college did you attend? Is there a moment from that time that stands out?

University of Pittsburgh. Graduation day stands out. It was a very difficult five-year program and I was extremely proud and happy when I made it through.

Are you married? Do you have children?

I have been happily married for 28 years and I am the proud parent of two great sons — ages 24 and 27.
Yes and yes.

What is your favorite hobby and how did it develop in your life?

Snow skiing. I learned at the age of 22. I have improved every year and have become a relatively good intermediate skiier.

Is there a book you recently read or movie you saw that you would recommend?

American Sniper.

Do you have any additional comments about case management or the industry in general?

I believe that the case management industry needs to employ the very best. They need to be given full knowledge so that they can advise their clients of all their options as accurately as possible.

Leveraging the PHO Model for Bundled Payment Success

February 5th, 2015 by Cheryl Miller

As Medicare begins its ambitious timeline for moving Medicare payments from volume- to value-based models, alternative payment formulas, including bundled payment arrangements for episodes of care, which CMS has tested in a range of pilots in recent years, will come to the forefront. Here, Travis Ansel, senior manager of the Healthcare Strategy Group, explains why the physician-hospital organization (PHO) provides an attractive framework for bundled payment models.

Bundled pricing is appearing in more and more markets across a number of payors. As I’m sure everyone knows, CMS is testing bundled payment pilots across the country. A number of our clients that have been involved with that have had a reasonable amount of success. Overall, the level of success of the bundled pricing pilot program for CMS leaves one to wonder: is that the future of CMS? Is it some combination of accountable care organizations (ACOs) and bundled payments?

Another interesting program for bundled payments is what’s going on in Arkansas with the Healthcare Payment Improvement Initiative. In this program, the state Medicaid program and Blue Cross have actually worked together to create bundled payments for episodes of care based around high volume diagnosis-related groups (DRGs). The responsibilities for hitting the cost targets in this case are assigned to what they refer to as the "principal accountable provider." For example, for DRG 470, major joint, the principal accountable provider is the orthopedic surgeon, but the orthopedic surgeon in this case was being held accountable for what goes on in his or her practice.

What goes on before surgery? What goes on during the hospitalization and the surgery, and then what happens 30-90 days post-acute care? They’re being held accountable for care across the continuum. This is relevant to the PHO model, because as this is phased into a number of DRGs—it started with eight, but now it includes quite a few more—the need for a PHO model will bring these physicians together.

PHO Models
Travis Ansel, MBA, is manager of strategic services with Healthcare Strategy Group, LLC. Ansel’s practice focuses on helping hospitals and health systems with physician alignment issues through strategic planning initiatives, such as hospital strategic planning, employed physician group strategic planning, physician alignment planning, and clinical integration. Mr. Ansel holds a master’s of business administration from Vanderbilt University, and bachelor of science degrees in finance and business management from the University of Tennessee.

Source: Preparing for Value-Based Reimbursement Models: PHO Development for ACOs, Bundled Payments and Direct Contracting

Infographic: Medicare Spending Trends

January 26th, 2015 by Melanie Matthews

In the short term, Medicare spending per person is expected to be lower relative to previous projections and to grow more slowly than private health insurance, according to a "Visualizing Health Policy" infographic by the Henry J. Kaiser Family Foundation.

The infographic also examines long-term predictions for Medicare spending and projections on a Medicare shortfall.

Physician Reimbursement for Chronic Care Management: Identifying New Practice Revenue OpportunitiesStarting this month, Medicare is reimbursing physician practices for select Chronic Care Management (CCM) services not previously eligible for reimbursement, underscoring the vital role of care management in primary care.

Physician Reimbursement for Chronic Care Management: Identifying New Practice Revenue Opportunities offers practical guidance to prepare physician practices to maximize CCM reimbursement in the year ahead.

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Infographic: The Challenge of Serving Dual Eligibles

December 24th, 2014 by Melanie Matthews

Individuals dually eligible for Medicare and Medicaid are among the sickest and poorest individuals covered by healthcare in the United States. They are also likely to have mental health needs and live in nursing homes.

A new infographic by HealthX examines dual eligible healthcare spending, the challenges of serving dual eligibles and strategies for best serving this market.

Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population To 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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CMS Chronic Care Management Medicare Reimbursement: Sizeable Revenue, Health Outcome Opportunities

November 21st, 2014 by Cheryl Miller

Beginning January 2015, Medicare will pay a flat, monthly chronic care management (CCM) fee to providers coordinating care for beneficiaries with more than one chronic condition. This change will expand the current Medicare payment policy to include non face-to-face management services previously included within payments for evaluation and management (EM) services, amount to about $40 a beneficiary, a sizeable new source of revenue for eligible providers.

The targeted population is also substantial; as recent news story reported by the Healthcare Intelligence Network (HIN), 87 percent of U.S. adults ages 65 and older have at least one chronic illness, and 68 percent have two or more, the highest rates in a new 11-country Commonwealth Fund survey.

But healthcare organizations do not have that much time to prepare for the newly released 2015 Medicare Physician Fee schedule, which finalized the CCM reimbursement. Who can bill for CCM, what constitutes a chronic condition, which patients are eligible to receive CCM services, and the scope of services required were among the issues discussed during Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care Coordination, a November 19th webinar, now available for replay. Rick Hindmand, an attorney with McDonald Hopkins, a law firm that advises a nationwide client base extensively on healthcare reimbursement, shared insight on these issues and how to best prepare for this reimbursement opportunity.

Those allowed to bill for CCM reimbursement fall into one of five categories: physicians, advanced practice registered nurses (APRNs), physician assistants (PAs), clinical nurse specialists and certified nurse midwives. If these practitioners are part of a practice entity, that entity can bill for it as well.

Beneficiary requirements are not as clear cut, Mr. Hindman continued. Eligible patients must have at least two chronic conditions that are expected to last at least 12 months or until death, and those conditions need to create a significant risk of death, acute exacerbation/decomposition or functional decline. Specific definitions of conditions can be found at CMS’s Web site.

And because CMS does not want to pay for duplicative services, CCM is not allowed for beneficiaries who receive services for transitional care management, home healthcare supervision, hospice supervision, and various end stage renal disease (ESRD) conditions. Patients attributed under the Multi-payer Advanced Primary Care Practice Demonstration (MAPCP) and the Comprehensive Primary Care (CPC) Initiative are also excluded.

Once these requirements are satisfied, providers must offer and document 20 minutes of CCM services a month, which enhance access and continuity of care, care management, transition management, and coordination, Mr. Hindman continues.

The CCM fee comes to about $40 a beneficiary, a significant revenue source once applied to all patients within a practice. Why the change now? Mr. Hindman speculates that CMS is finally realizing that care management is a crucial component of primary care. But questions and details await future guidance from CMS, and satisfying and documenting compliance with the CCM reimbursement requirements is going to present a challenge for many practices.

But the time and effort is worth it, he says. "With careful structuring, chronic care management can provide the potential to improve the health of their patients, while also providing some significant financial benefits for the practice."

To listen to an interview with Mr. Hindman, click here.

Community Linkages Support HCSC’s Holistic Approach to Duals

September 25th, 2014 by Cheryl Miller

Meeting the holistic needs of the individual, and not treating them as a diagnosis has been key to Health Care Services Corporation's (HCSC) work with dual eligibles. Here, Julie Faulhaber, HCSC’s vice president of enterprise Medicaid, describes the organization's innovative use of community care connections to engage the unique challenges of this largely older adult and disabled population in population health management.

Question: What are some examples of HCSC community connections and how do these linkages benefit Medicare-Medicaid beneficiaries?

Julie Faulhaber: Our community connections are really critical to the success of our program. We work with a number of different community agencies in our state: the community mental health centers, the public health agency, and also with those types of agencies that deliver long term care services or have worked with those with mental health concerns.

We work across the board. All of these agencies catch our members, and we try to have relationships with them in order to gain access to our members, for example to better understand the types of services and support that our members truly need and where to access them. That’s been a key component of our program. We also look for community health workers who have backgrounds in the cultural needs of our members, which helps to engage them initially and maintain engagement.

HIN: What are the most common behavioral health issues your duals face and how has HCSC addressed these issues?

Julie Faulhaber: Our members have the full range of behavioral health issues that one would expect in a dual eligible population. Of course, the majority of individuals are experiencing depression and those types of concerns are often in conjunction with some physical disability. Referring back to the previous question on community linkages, we develop relationships with community agencies that support people with mental illness.

Other behavioral health concerns include those agencies that help people with recovery from addiction. We also worked with an integrated team in our own model of people with behavioral health backgrounds as well as our traditional physical healthcare model. That integration has been important for us in meeting the holistic needs of the individual and not treating them as a diagnosis.

dual eligibles care
Julie Faulhaber, vice president, enterprise Medicaid for Health Care Service Corporation (HCSC), a $52 billion health insurance company with 13.2 million members operating in five states, is responsible for the leadership and oversight of HCSC’s Enterprise Medicaid Business. This includes expansion of Medicaid programs across HCSC’s Blue Cross Blue Shield plans in Illinois, Montana, New Mexico and Texas.

Source: Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population

5 Ways to Reach, Engage Dual Eligibles

May 15th, 2014 by Cheryl Miller

It takes a village — and more — to locate, stratify and engage dual eligibles, says Julie Faulhaber, vice president of enterprise Medicaid at Health Care Service Corporation (HCSC), especially when they can range from school-aged children to elderly Native Americans. Here, she discusses how to best engage the company's diverse population.

Here’s an example of a Centennial Care outreach plan, which includes our dual eligibles. It has our Medicaid adults and children. There are not very many school-based children that are dual eligibles, but there are some, so working with the school-based clinics, the nurses’ association, etc., helps us engage.

In the New Mexico market, working with the Native American community is very important in engagement and sometimes actually for locating our members. Working with the tribal government and their leadership, some of the urban health centers, Indian health organizations, and other community organizations under the Native American groups can be extremely helpful. And some of our populations work with our behavioral health groups so again, those community mental health centers and other community organizations serving those with mental health and behavioral health concerns are of value to us.

We also work with community and public health outreach in this market. Promotoras or community health workers are critical elements for us to not only engage, but then also to maintain our relationship with members. With some of these outside agencies, we often have contractual relationships, and are able to share personal health information back and forth. That makes it much easier for us to locate members, and also have some of the staff in these organizations be part of our interdisciplinary care team.

Excerpted from Dual Eligibles Care and Service Planning: Integrative Approaches for the Medicare-Medicaid Population.