GE Healthcare Camden Group Insights Blog

Stay Focused While Developing Your System Integration Plans

Posted by Matthew Smith on Oct 20, 2016 4:00:21 PM

By Brandon Klar, MHSA, Senior Manager, GE Healthcare Camden Group

3 Pillars.pngAs the healthcare industry continues to experience consolidation and health systems evolve to meet industry challenges, operational integration initiatives present great opportunities to enhance system-wide performance.

Many health systems speak to the integration goals as they design their strategic partnerships, but only a portion develop realistic, achievable, and sustainable integration plans and even fewer accomplish the goals set forth in those plans.

System integration plans fall short and occasionally fail to achieve their desired outcomes most frequently because they lack effective solutions, fail to consider the impact of system operations on the community, and don’t have the necessary support from the workforce. As much as a well-orchestrated integration planning process and an invested leadership team can work to position a system for integration success, a system integration strategy must be grounded in value creation, risk management, and employee engagement to ensure any integration plan to reach its goals.

Value Creation

To achieve success in a value-based world, health systems must actively seek to enhance the value of their clinical services. Defining value as healthcare outcomes per cost, a health system’s pursuit of value creation will involve enhancing the quality of its services while reducing the per unit delivery cost.

Value creation through health system optimization can be achieved through both horizontal and vertical integration strategies. Horizontal integration strategies are focused on reducing unnecessary duplicative resources, enhancing system operational performance, and aligning/optimizing clinical programs and resources. While duplication of select resources and clinical services may be warranted to maintain access in select geographic areas, plans must carefully balance community needs with efficient resource distribution to deliver high-quality cost-effective clinical programs.

Conversely, vertical integration strategies are focused on enhancing the value throughout the continuum of care by effectively positioning access points, redesigning the care model, and promoting information technology and data sharing. As systems form and evolve, seamless handoffs between system providers and multidisciplinary care plans will reduce unnecessary resource utilization and provide for the efficient navigation of patients through the system with high quality and high satisfaction outcomes.

Risk Management

Risk is inherent within every system integration initiative. The term “system integration” can often trigger employment uncertainties and high employee and physician anxiety which heightens the internal challenge to achieve a successful integration. Community resistance or concerns for the planned integration efforts are also possible based upon the drivers that prompted the system to take action. While identified risks may become realities and unanticipated challenges can arise with little warning, effective risk management planning is essential.

Identification and analysis of the integration risks by the system integration leaders and their teams are foundational to the planning process. Balancing the benefits of integration initiatives against the probability of the risk may prompt either the development of preventative and contingency plans, or the abandonment of the integration initiative all together. Regardless, every risk should be thoughtfully analyzed in the context of the benefits of the system integration plan and weighed carefully.

Employee and Physician Engagement

The third pillar to effective health system integration is employee and physician engagement. While system integration planning is overseen and led by senior system leaders, it is imperative that employees and physicians have a voice within the planning process to foster effective integration results.

Solicitation of ideas, involvement in plan development, transparency in the planning process, and frequent communication will provide systems with the best chance for developing an effective integration solution, and fostering acceptance, accountability, and alignment among the stakeholders. This planning approach will also provide the system with the platform to accelerate the change process, and achieve and sustain its integration goals and objectives. While some confidentiality is warranted in the integration planning and implementation process, employee and physician engagement is necessary for success.

As health systems take on their integration planning and implementation process, a focus on the three pillars will provide the foundation to strategically position themselves to be nimble and efficient in a value-driven world.

This is Part 2 in our System Integration blog Series. Part 1 may be found here. Part 3 will examine the 5 steps in a successful system integration planning process.

For more details surrounding health system integration planning, please download our PDF via the button, below:

Health System Integration  

B_Klar.jpgMr. Klar is a senior manager with GE Healthcare Camden Group with over 12 years of experience in healthcare management. Mr. Klar specializes in strategic and business planning advisory services, including service line planning, master facility planning, and transaction work (e.g., mergers, acquisitions, affiliations, joint ventures). He has extensive experience in the creation of strategic partnerships, the facilitation of inaugural health system strategic plan development, as well as the creation and implementation of business plans of operational efficiency, system-wide integration plans, and clinical programmatic alignment plans. He may be reached at brandon.klar@ge.com.

Topics: Business Plan of Operational Efficiency, BPOE, Mergers & Acquisitions, Health System Efficiencies, Brandon Klar, Health System Integration

MACRA Final Rule Released Revealing Changes

Posted by Matthew Smith on Oct 17, 2016 10:09:29 AM

MACRA_Image.pngThis past Friday morning, October 15, 2016, the Department of Health and Human Services released its final rule (with a comment period) on the Quality Payment Program ("QPP"), a part of the Medicare Access and CHIP Reauthorization Act of 2015 ("MACRA").

The QPP has two tracks: the Merit-Based Incentive Payment System ("MIPS") and the Advanced Alternative Payment Model ("APM").

Compared with the proposed rule, the main changes in the final rule include:

  • support for small and independent practices
  • expansion of APM opportunities
  • flexible 2017 reporting options
  • a focus on a unified program that supports clinician-driven quality. 

CMS launched a new Quality Payment Program website where the final rule, along with educational material, can be found. This website will be a great resource for eligible clinicians as they rollout QPP activities in 2017. 

For More Information:

Learn more about the details of the final rule in GE Healthcare Camden Group's webinar: "Chart Your Course for MACRA Success" this Thursday, October 20th. To register for this complimentary webinar, please click the button below.

Webinar, MACRA

Topics: CMS, Final Rule, MACRA, MIPS, QPP, APM

Is Your Care Management Program Delivering Exceptional Results?

Posted by Matthew Smith on Oct 11, 2016 4:19:34 PM

By Court Curneen, RN, MS, CEN, EMTP, Senior Manager, GE Healthcare Camden Group

stethoscope-resized-600-1.jpg“If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions.” – Albert Einstein

Healthcare organizations operate under an ever-changing and complicated set of rules, regulations, laws, and standards. Paul Starr (Harvard University, 1982) is credited with labeling the hospital as “the most complex organizational structure created by man.” It can be a daunting task for healthcare leaders to set priorities and to plan for the future sustainability of their organization. Which of the myriad of regulations will the Congress or the Centers for Medicare and Medicaid Services change in the coming years? What are the two presidential candidates expected to do if elected? Will the Affordable Care Act (ACA) be radically changed, or will it remain largely intact? How can we best position ourselves to negotiate favorable contracts with our payers? What is our population health strategy? And the list of questions continue…

A high-performing care management program is one of the few programs that can help a healthcare organization succeed, regardless of what the answers to these questions turn out to be. Your organization’s strategy on volume versus value and a robust and effective care management program will help you drive towards desired results. Without comprehensive care management throughout the continuum of care, your organization will likely struggle to achieve its strategic goals. Here are 10 questions to ask to help you evaluate your care management program.

1.  Does your care management strategy extend beyond the four walls of the hospital?

“Strategy without tactics is the slowest route to victory; tactics without strategy is the noise before defeat.” – Sun Tsu 

In the past, case management (as it was often called) was a service to be consulted by the inpatient care team, often long after hospital admission, if the team felt the patient might require complex discharge planning, such as placement in a skilled nursing facility, or need durable medical equipment (DME) at home. That is the model of the past.

In today’s demanding healthcare market, your organization must expand the role and responsibility of your care management department to include a strong focus on, and alignment with, your population health strategy. This includes comprehensive discharge planning (both from the inpatient arena as well as the Emergency Department ["ED"), including the scheduling and monitoring of aftercare appointments, ongoing monitoring of patients with a high risk of readmission (such as congestive heart failure), and appropriate short and long-term placement in skilled nursing facilities. These activities are also dependent-upon a strong healthcare information exchange infrastructure that is not limited when communicating clinical information beyond your four walls.

A successful population health strategy must have clearly defined care model principles, aimed at providing clinical effective care in the safest and most cost effective way, thus improving the care of the patient while simultaneously improving the bottom line of your organization. A comprehensive care management program is the vital foundation to this critical strategy. It requires an integrated care management process and communication to assure that patients have one care plan that follows them, rather than reinventing the plan between care venues. Be sure that your ambulatory care managers, who may be embedded in primary care practices or specialty service line venues, and the inpatient care management staff are organized as a seamless care management team for the health system.

2.  Do you have a clearly defined care management model that is the best fit for your unique organization?

“Unless structure follows strategy, inefficiency results.” – Alfred D. Chandler

There are a variety of widely accepted care management models in use across the country. These include the traditional model, dyad model, partially integrated dyad model, integrated dyad model, triad model, hybrid model, etc. Confused yet?

While many have strong opinions about which model is “best,” they all have pros and cons, and it is important to examine each in order to determine the best fit for your particular organization. But far more important than which model your organization employs are two key questions: a) Is the model clearly understood and applied consistently and efficiently and b) Does the model have the full support of both the hospital and physician leadership? If the answer to either of those questions is anything other than an unqualified “yes,” you are unlikely to have a highly successful care management program.

3.  Are you using an established tool and most current practices to perform Utilization Review ("UR")?

“If I had nine hours to chop down a tree, I’d spend the first sharpening my ax.” – Abraham Lincoln

CMS requires that all participating hospitals employ a structure and process to determine if a patient qualifies for inpatient or observation status. Hospitals use a variety of tools to accomplish this UR process. These include commercially available screening products, such as InterQual or Milliman, as well as home-grown solutions. As with the care management model, which UR tool an organization chooses is less important than utilizing that tool correctly and having a clear structure and process in place for the Care Manager (CM) and physician to communicate the output of the initial UR. Often the difference in appropriately classifying a patient as an inpatient, rather than observation, is a small amount of additional documentation by the physician.

4.  Do you have a comprehensive care management dashboard used to drive results?

“Without data you’re just another person with an opinion.” – W. Edwards Deming

In the world of the electronic medical record (EMR), most organizations have access to myriad data points. They can pull reports on almost anything they wish; however, this “data” is often aggregated and unverified for accuracy. Many healthcare leaders complain of “data overload,” where they struggle with what data to focus on in order to drive results.

A comprehensive care management dashboard contains the following elements:

  • 10-15 evidence-based, operational data points
  • All data points have been validated and benchmarked
  • Aggressive but appropriate goals have been set for each metric that is under-performing
  • The dashboard is “pushed” to the end-user, rather than “pulled” by them
  • A clear escalation of accountability, from the individual CM all the way to the C-suite
  • An operational group/committee that is tasked with monitoring the dashboard results and driving improvement
  • Transparency of the data, the goals, and the accountability

5.  Are you staffing appropriately to demand?

“Coming together is a beginning. Keeping together is progress. Working together is success.” – Henry Ford

Many organizations struggle with how to determine if they are staffing appropriately to meet the demands of their patients, while remaining mindful of the bottom line. Whether it is nursing ratios on the inpatient unit or the number of environmental services staff on the evening shift, it is critical to balance operational and financial goals.

Care management programs are staffed in a variety of ways, primary driven by the CM model discussed previously. Depending on the CM model, the makeup of the staff (i.e., nurse, social worker, support staff), the complexity of the patients, and other factors, there is an appropriate staffing plan for your organization. Designing these plans can be complex, because the best plans incorporate a wide variety of variables, but when an organization can harmonize the financial and operational goals simultaneously, they achieve optimal staffing in their care management program.

 6.  How do you measure length-of-stay ("LOS")?

“Measurement is the first step that leads to control and eventually to improvement. If you can’t measure something, you can’t understand it. If you can’t understand it, you can’t control it. If you can’t control it, you can’t improve it.” ― H. James Harrington

As with any data point, evaluating whether your organization is accurately capturing and reporting LOS can be a byzantine task. Here is the first problem – the most accurate and actionable LOS calculation is not the average LOS ("ALOS") that many organizations have been using for decades. Why? It tells you almost nothing that is actionable about your operations. If your ALOS went from 4.1 to 4.6 last fiscal quarter, what does that tell you? Other than your “average” patient spent more time in the hospital, it tells you little else. Also, what does an “average” patient look like? Were they admitted for myocardial infarction, a planned orthopedic surgery, or did they present to the emergency department in septic shock? Were they a readmission?

In order to have the maximum impact on meeting the organization’s LOS goals, the data must be examined far beyond averages. A comprehensive examination of the organization’s LOS data should involve the following elements:

  • ALOS (this is still useful for internal benchmarking)
  • Observed versus expected LOS
  • Case mix index
  • Severity adjust LOS
  • LOS by:
    • Service line
    • Provider
    • Group
    • DRG
    • Unit
  • Benchmarking against peers, using one or more benchmarks, including, but not limited to:
    • UHC and other commercially available databases
    • CMS Geometric Mean LOS

7.  Are service lines/specialties incentivized and or aligned with organizational goals?

“If everyone is moving forward together, then success takes care of itself.” – Henry Ford

If your organization has adequately addressed all of the other questions herein, it’s time to take a hard look at whether there is internal alignment. How does your organization align goals and accountability with your providers, both employed and otherwise?

To maximize goals around care management efforts, not only LOS, but also prevention of readmissions and adequate clinical documentation, the organization must align those goals with the providers. Though incentivizing the providers to drive towards those same goals can be time-consuming and complicated, the benefit of doing so is incalculable.

8.  Is care management supporting the ED to prevent unnecessary admissions/readmissions through shared decision-making at the time of admission?

“Teamwork is the ability to work together toward a common vision. The ability to direct individual accomplishments toward organizational objectives. It is the fuel that allows common people to attain uncommon results.” – Andrew Carnegie 

The ED is, with few exceptions, the portal through which the majority of hospital admissions originate. Although the largest quantity of admissions may come through the ED, they are often admissions with far lower contribution margin than those who enter the organization through a portal such as the OR. They are also sometimes the admissions with little to no value to the patient or the organization.

In a strong care management program, the case managers in the ED should be the front-line of defense in preventing readmissions, “social” admissions, and other inappropriate types of admissions. This may be accomplished by processes such as:

  • Automatic, real-time notification of the ED CM by the EMR upon the arrival in the ED of a potential readmission.
  • Establishing an ED care management committee, led by an ED Case Manager, in order to identify and evaluate ED “Super Users,” and develop an individualized care plan for each of those clients in order to reduce both ED visits and admissions to the hospital.
  • Developing a robust network of up-to-date contacts that the ED Case Manager can call upon to assist them in the development of an appropriate discharge plan and follow-up care following an ED visit.

As noted above, a robust care management program in the ED is invaluable to prevent readmissions and unnecessary admissions, but the program should also be the “tip of the spear” when it comes to the care management process and services for an admitted patient. Ideally, the majority, if not all, admissions from the ED should be screened by a case manager using an appropriate utilization tool, as noted earlier. This requires buy-in from the Emergency Medicine providers, who may see this additional step as something that can have a detrimental effect on ED flow, or simply something that has to do with the inpatient arena. This is a prime opportunity to align service lines with hospital goals, as discussed earlier. The ED must be part of the solution when it comes to patient classification and management across the continuum.

 9.  Do you have a clear escalation and resolution policy to support CM?

“None of us is as smart as all of us.” – Ken Blanchard

What happens when your talented and educated group of case managers runs into a barrier? Whether that barrier be one of your own providers who does not support the case manager’s status evaluation (e.g., inpatient versus observation, etc.), a payer that issues a concurrent denial of care, or perhaps a family member who does not agree with the decision to discharge their loved one, a high performing care management program must have a robust and effective escalation and resolution policy in place. Such an escalation pathway often looks like the following:

Each link in this pathway gives yet another opportunity to achieve a successful outcome for the organization, the patient, and the family. Not only does it continuously bring a fresh perspective and set of skills to bear, when dealing with a payer, oftentimes, repetition, escalation, and documentation can be the key to a favorable outcome.

 10.  Do you have a comprehensive in-house Physician Advisor (PA) program?

“A coach is someone who can give correction without causing resentment.” – John Wooden

In a highly effective care management program, the PA provides counsel to the case management department, clinical documentation improvement (CDI) team, and the hospital leadership on matters regarding physician practice patterns, resource consumption, medical necessity, and compliance with government regulation. The PA also provides coaching and formal education to the medical staff and maintains collaborative relationships with payers. The PA is a member of the organization’s leadership team charged with meeting goals of quality and cost reduction.

Many organizations have one or more PAs in place who deal with and resolve clinical cases, on a case-by-case basis, in a highly effective manner, and consider this be a successful implementation of a PA program. Without the other elements of a PA program, noted above, there is work to be done. One of the most powerful uses of a PA is leveraging them to prevent escalations in the first place. This is accomplished through a robust education program and coaching aimed at their physician peers, so that they may better understand regulations, charting requirements, etc. Ironically, a motivated PA should be working to put themselves out of a job.

Curneed.jpgMr. Curneen is a senior manager in the Care Design and Delivery practice at GE Healthcare Camden Group with over 20 years ofexperience in the pre-hospital and acute care hospital settings. His clinical background comes from roles as a paramedic and a registered nurse, with experience in the emergency department (“ED”), criticalcare, cardiovascular, aeromedical, and emergency medical services environments. Mr. Curneen’s areas of focus include hospital operations and strategy, process improvement, case management, patient experience, and ED operations. He may be reached at court.curneen@ge.com.


Topics: Care Management, Care Design, Hospital Operations, Care Design and Delivery, Court Curneen

Two New Downloads: Analytics-Based Value Model | Health System Integration

Posted by Matthew Smith on Oct 8, 2016 10:16:45 AM

Download_White-resized-600.jpgTwo new downloads from GE Healthcare Camden Group are now available for download. Simply click the button below each description, and you will be taken to the respective download page.

Leveraging an Analytics-Based Value Model to Optimize Healthcare Strategies

Healthcare organizations are faced with the challenge of measuring optimal performance in a complex environment. An analytics-based value model can provide decision-making capabilities to measure performance, risk, and evaluate return on investments.

This new download from GE Healthcare Camden Group details the importance of creating an effective analytics-based value model and focuses on:

  • Key components of an analytics-based value model
  • Key drivers behind value modeling
  • Sample value drivers and KPIs
  • Benefits of leveraging advanced data mining
  • Relationships between trends and outcomes
  • Components of risk stratification
  • Barriers to success

Value Model, Health Analytics

Health System Integration: You Need a Plan!

Health systems fail to achieve full integration due to a lack of effective planning, poor management collaboration, or subpar implementation. Regardless of the reason, a sound integration plan focused on the goals of the system and dedicated true integration will increase the odds of success.  

This new download from GE Healthcare Camden Group details the importance of creating an effective integration plan and focuses on:

  • The increase in the number of hospitals in mergers and acquisitions
  • Health system efficiency imperatives
  • Definition and applications of a business plan of operational efficiencies ("BPOE")
  • Individual hospital vs. system-based savings
  • System integration efficiency strategies

Health System Integration

Topics: Download, Data Analytics, Hospital Integration, Value Model

This is the MACRA Webinar You've Been Waiting For

Posted by Matthew Smith on Oct 6, 2016 12:06:37 PM

webinar_Clouds_icon-resized-600-2.jpgPlease join GE Healthcare Camden Group for a complimentary, 60-minute webinar, Chart Your Course for MACRA Success, on Thursday, October 20, 2016, at 12:00 P.M., ET.


In April 2015, the Medicare Access & CHIP Reauthorization Act of 2015 ("MACRA") was passed, ending the Sustainable Growth Rate ("SGR") formula for determining Medicare payments for healthcare providers’ services. MACRA is intended to accelerate moving care delivery toward quality and value-based reimbursement models through the new Merit-Based Incentive Payment System ("MIPS") and incentive payments for participation in certain Alternative Payment Models ("APMs").

This law has a strict timeline to implement strategy to maximize possible incentive payments, improve care delivery and design, and successfully achieve efficiencies improving cost and quality that will go into effect 2019 based on the 2017 performance reporting period. While the final details of the incentives for the new payment models will not be defined until CMS publishes the final rule in November 2016, there are several things you can begin doing to determine optimum strategy and prepare for 2017.


In this complimentary webinar, members of the GE Healthcare Camden Group consulting team will deliver an overview of the legislative details of the new payment reform law and the implications of MACRA. They will also provide the necessary tools to successfully navigate through the next phase of participation for the Quality Payment Program, MIPS, and APMs.


Thursday, October 20, 12:00 P.M., Eastern

Learning Objectives:

  • Learn the timing and timeline for MACRA implementation
  • Review the two tracks for participation, APMs and MIPs
  • Examine the incentives and penalties associated with MACRA
  • Gain insight on MIPs Composite Score:
  • Understand what it will take to be successful under MACRA
  • Master the steps to take to begin the path to APMs

GE Healthcare Camden Group Presenters:

Burnett_new.jpgSabrina Burnett, Vice President

Ms. Burnett is a vice president with GE Healthcare Camden Group. With more than 20 years of professional experience, Ms. Burnett delivers a wealth of skilled leadership in health management processes and solutions-based planning and execution. She has in-depth knowledge of the post-acute industry and a thorough understanding of the healthcare market, payer reimbursement methodologies, including managed care requirements and strategies, and knowledge of relevant state and federal regulations and actions. Ms. Burnett is recognized for her expertise in contract negotiations, solutions-based planning.

Hawkins_New.jpgCami Hawkins, Manager

Ms. Hawkins is a manager with GE Healthcare Camden Group and has more than 20 years of experience in the healthcare provider sector as a management consultant. She specializes in the areas of practice operations, contract negotiations, benefits administration, reimbursement management, and market development. Ms. Hawkins assists a wide range of provider organizations, healthcare systems, and independent and employed physician groups with addressing issues impacting their overall performance and competitive positioning. Her key areas of expertise include strategic planning, population health strategy.

ZielinskiL.jpgLucy Zielinski, Vice President

Ms. Zielinski is a vice president with GE Healthcare Camden Group. With over 25 years of experience in the healthcare industry, she specializes in helping private and hospital-owned medical groups achieve top financial and operational performance. Such optimization is achieved through physician-hospital alignment—including clinically-integrated networks, strategic planning, practice transformation, coding and revenue cycle improvement, physician compensation plan design, and health information technology, and data analytics optimization.

To Register:

To register, simply click the button below, complete a short registration form, and press the "Cick to Register!" button. We will provide dial-in information and a WebEx link via email the week of the webinar.

Webinar, MACRA Questions?

Please contact Matthew Smith at msmith@ge.com.

Topics: Webinar, Lucy Zielinski, MACRA, Sabrina Burnett, Cami Hawkins, MIPS, APM

MACRA, MIPS, and CPIA GO!: Tips for Success

Posted by Matthew Smith on Oct 5, 2016 12:56:02 PM

By Susan Corneliuson, MHS, FACHE, Senior Manager, GE Healthcare Camden Group 

pkmn.pngPokémon GO!, a sensation in the gaming world, popularized location-based and augmented gaming reality but was initially released with mixed reviews. To some the game is little more than people running around catching virtual critters that appear in their coffee or on their neighbor’s lawn at 2:00 in the morning; to others it is a game of strategy in which they pulverize rival teams by taking control of gyms. In some ways, the Merit-Based Incentive Payment System ("MIPS") is also a game of strategy with physicians pitted against each other to see who will win the most points and take control of the healthcare dollar.

The Clinical Practice Improvement Activities (“CPIA”) performance category is the new addition to the Quality Payment Program under MIPS and with it also came mixed reviews. Adding incentives to improve the clinical practice environment, a category largely missing from past quality reporting programs, was seen as a benefit to the program. However, with over 90 activities to choose from there is concern about the cost to a practice of increasing or adding up to six new activities. 

Regardless of the potential draw-backs how do we become early adopters of CPIA and succeed in this new quality environment? Let’s think of CPIA as a game in which we have to catch three to six Pokémon (activities) out of 90 potential activities to win. In Pokémon Go there is a power hierarchy: those that are found everywhere (Caterpie, Weedle, Meowth) are worth less than those that are rarer (Venusaur, Blastoise, Dragonite). The less powerful Pokémon can be found everywhere so are easier to catch but can evolve into more powerful Pokémon. 

CPIA activities are also arranged in subcategories and assigned a weight of “high” or “medium,” earning 20 or 10 points each, respectively. Full credit achievement for this category is 60 points. Higher weighted activities are aligned with CMS national priorities and programs such as the Quality Innovation Network-Quality Improvement Organization (“QIN/QIO”) or the Comprehensive Primary Care Initiative (“CPCI”).  To be successful, select activities that are:

  • Easy wins such as activities that you are already doing
  • Simple to measure, track and report
  • Easily implemented with minimal effort or cost
  • Choose high-weighted activities for maximum points when possible. To achieve the highest potential score of 100 percent or 60 points, complete 3 high-weighted activities, 6 medium-weighted activities, or a combination thereof.  

Remember, 100 percent achievement on the CPIA category is attainable since measures are selected by the practice and there are no performance thresholds established for comparison. The six proposed subcategories with examples of high and medium weighted activities are show in the table below.

CLIA Sample List of Activities with High and Medium Weightings


Source: Centers for Medicare and Medicaid Services

Examples of activities that are weighted as high include:

  • Population Management: Use of a Qualified Clinical Data Registry (“QCDR”) to access practice patterns and treatment outcomes
  • Care Coordination: Participation in the CMS Transforming Clinical Practice Initiative.

Example of activities that are weighted as medium include:

  • Expanded Practice Access: Collection of patient experience and satisfaction data on access to care and development of an improvement plan
  • Beneficiary Engagement: Access to an enhanced patient portal that provides up to date information related to relevant chronic health conditions with bidirectional communication and interactive features.

There are a few activities that are more evolved than others and therefore earn a higher point value such as a patient-centered medical home (“PCMH”) or alternative payment models (“APM”). Participation in a PCMH model or comparable specialty medical home automatically qualifies for 60 points; full credit under the CPIA category. Participation in an APM that does not quality as an advanced payment model will automatically receive 30 points or 50 percent of the maximum point value. 

There are still a lot of unknowns under MIPS with the final rule expected November 1, 2016; however, preparing early and getting a jump start on your competitors will allow for more success down the road. MIPS is a zero sum game as no additional dollars are added to the budget which means that there will be winners and losers. CMS also anticipates that the first year will be the “easiest” under CPIA, with measures continuing to evolve over time. Just like Pokémon Go!, those that jump in early will be able to evolve more quickly and will have more potential to receive positive payment adjustments down the road. 

Please join GE Healthcare Camden Group on Thursday, October 20th for a complimentary, hour-long MACRA webinar focusing on legislative details as well the necessary tools to successfully navigate through the next phase of participation for the Quality Payment Program, MIPS, and APMs. Please click the button, below, to learn more and register:
Webinar, MACRA

Susan_Corneliuson.pngMs. Corneliuson is a senior manager with GE Healthcare Camden Group and has over 15 years of healthcare management experience. She specializes in physician integration strategies, practice assessments, operational improvement, care and workflow redesign, and compensation arrangements. She is the co-author of The Governance Institute’s signature publication for 2012, Payment Reform, Care Redesign, and the New Healthcare Delivery Organization. She has a strong background in physician practice management with experience in medical foundations, provider-based clinics, and specialty hospital settings. She may be reached at susan.corneliuson@ge.com.


Topics: Webinar, Susan Corneliuson, MACRA, MIPS, CPIA

Utilizing Analytics to Measure Risk and Evaluate ROI in Your Organization's Value-Based Care Initiatives

Posted by Matthew Smith on Oct 4, 2016 2:06:19 PM

By Shaillee Chopra, PMP, Senior Manager, and Daniel J. Marino, MBA, MHA, Executive Vice President, GE Healthcare Camden Group

Data AnalyticsHealthcare organizations transitioning from fee-for-service to value-based models are making substantial investments in building technology and operational infrastructure to drive new services and workflows. Developing an effective and an efficient care delivery system from which to identify and drive profitability under risk arrangements remains of utmost importance. However, developing an analytics framework to support population health management, evaluate potential and expected returns from investment continues to be a struggle for many healthcare organizations.

Creating an analytics-based evaluation model enables healthcare organizations to quantify risks and evaluate viability and value-add of outcomes associated with various decisions. It also allows them to measure and track return on their investments in technology and resources associated with various programs aimed at managing health of populations they serve.

An Analytics-Based Value Model for Population Health

The framework for this model is grounded in measurement of utilization by place of service. It provides near real-time insight into “what works and what does not” in an operational environment. It also serves as a mechanism to ensure an organization’s positive position during re-contracting discussions with payers since it is supported with demonstrable value of delivering the right care to the right patient at optimal cost in the most appropriate setting. It serves as an information-based decision making model that enables the organization to make the transition to pay-for-value while preserving margins and without upsetting the apple cart of existing payer -provider relationships.

The Need for a Value Model Within an Organization’s Population Health Framework

A value model allows your organization to develop a deeper understanding around which variables drive outcomes that impact decisions about investments and resource allocation. For example, high-performing and value-based organizations are committed to improving quality and reducing avoidable utilization and costs. Cost reductions are a byproduct of the reduction in avoidable ER and acute inpatient utilization for individuals with chronic conditions. These costs are offset by an increase in “good utilization” such as increased PCP visits, wellness screenings, and pharmacy costs associated with medication adherence.  An analytics-based value model allows your organization to meaningfully sift through large amounts of data to identify and isolate important variables for future strategic success.

It allows for assessment of returns on investments made in various disease management intervention programs for at-risk, rising-risk and chronically ill population cohorts. It identifies assets and value levers that can be leveraged to prioritize and tweak the operational models for optimal returns.

Finally, it allows your organization to use analytics as a cornerstone for an innovative and data-driven approach to population health management.

Key Questions to Ask Within Your Healthcare Organization

Top performing healthcare organizations that are invested in developing their analytic capabilities begin with the end in mind and work from an analytics roadmap. Below are some of the key questions to consider to ensure you are achieving outcomes you desire without “boiling the ocean” and wasting valuable resources on programs that have minimally aligned outcomes:

  • What are the key questions you want to answer? Do you have 3-5 clearly defined use cases?
  • Accuracy, validity and credibility of your data: Do you know what data is needed? Do you have the right data? Is the data useable, i.e., accurate and credible? What data do you not have? Do you have a data acquisition strategy?
  • Analytics roadmap: Have you established a needs based analytics framework within your organization? Do you have right skillset and adequate tools to conduct analytics? After you perform analytics do you know how to interpret the results and make them actionable?
  • Driving actions: Do you have an actionable strategy for executing on the results? What are the actionable opportunities to execute against? How are you evaluating competing analytic priorities for resources and investment?
  • Monitoring impact and evaluate results: Have you implemented processes to track performance as part of your activation plan? Are you tracking both outcomes and the steps required to achieve the outcomes? Are you leveraging predictive modelling to consider varied “What if” scenarios to continually optimize the focus areas of your operational work plan?

Utilizing an analytics-based value model allows your healthcare organization to optimally invest resources and dollars towards operational programs that generate outcomes and value most alignment with strategic goals.

Value Model, Health Analytics

chopra2-110511-edited-239718-edited.jpgMs. Chopra is a senior manager with GE Healthcare Camden Group and specializes in developing and managing innovative technology portfolios for value-based and clinically integrated healthcare networks. She is highly experienced in leading information technology and consumer experience strategy development, as well as transformations to enable clinical integration, accountable care, and population health management strategies for organizations invested in innovation and transformation of care delivery models. She may be reached at shaillee.chopra@ge.com.


Marino_Dan.jpgMr. Marino is an executive vice president with GE Healthcare Camden Group with more than 25 years of experience in the healthcare field. Mr. Marino specializes in shaping strategic initiatives for healthcare organizations and senior healthcare leaders in key areas such as population health management, clinical integration, physician alignment, and health information technology. With a comprehensive background in all aspects of practice management and hospital/physician alignment, Mr. Marino is a nationally acknowledged innovator in the development of Accountable Care Organizations and clinical integration programs. He may be reached at daniel.marino@ge.com.

Topics: Value-Based Care, Healthcare Analytics, Daniel J. Marino, Data Analytics, Shaillee Chopra, Digital Health Services and Data Analytics, Value Model

Health System Integration: You Need a Plan!

Posted by Matthew Smith on Oct 3, 2016 1:25:10 PM

By Brandon Klar, MHSA, Senior Manager, GE Healthcare Camden Group

Health System Integration PlanSuccess within population health is grounded in a health system’s collective ability to improve the health and wellness of those in its communities, and other patient groups it may serve. With a goal of achieving the Triple Aim, systems are restructuring their operations to strengthen the value proposition of their clinical services. With a desire to enhance access, improve quality, and control costs, many systems are looking towards formal strategic partnerships as a means to attain the necessary scope and scale to be successful.

As systems expand, they have the opportunity to achieve system-oriented efficiencies. Through both horizontal and vertical integration strategies, systems desire to position themselves within the market as high-quality and cost-effective providers to attract patients and payers. While many systems pursue these objectives, some fail to achieve full integration due to a lack of effective planning, poor management collaboration, or subpar implementation. Regardless of the reason, a sound integration plan focused on the goals of the system and dedicated true integration will increase the odds of success.  

System Integration plans can be developed both pre-transaction and post-transaction, as well as by systems that have been operating for some time, but in more of a “loose federation” model than as a truly integrated system. Below, you will find an overview of system integration plans, the critical factors in developing them, and associated benefits and limitations.

Pre-Transaction Integration Plans

The development of pre-transaction integration plans provides the aligning entities a road map to achieve their partnership goals and objectives once the transaction is final. Developed prior to the signing of a definitive agreement, these plans serve to lay the foundation for administrative, support, clinical, and service line integration across the continuum as it relates to the location of services, management and staffing, and the optimization of non-salary resources and contracts.

Pre-transaction integration plans allow the entities to build upon their shared strategic vision and construct a newly integrated operating model by which the two entities can optimize their individual strengths and maximize their collective resources. Recognizing that each entity brings with it their unique resources and capabilities, pre-transaction planning is focused on:

  • Cataloging the collective resources and capabilities of the newly proposed system
  • Understanding the existing operating models and functional area interdependencies
  • Framing a new operating model for the integrated system functions
  • Selecting horizontal and vertical integration strategies to align operations
  • Developing action plans with clearly defined goals, resource requirements, barriers, accountable parties, and quality and cost impact analyses
  • Designing an implementation governance structure to oversee the capture of short-term wins post-transaction while coordinating for long-term integration

In addition to preparing the system for operational integration, pre-transaction integration plans can also serve a role in supporting regulatory approval of the proposed transactions by Departments of Health, Attorneys General, and the Federal Trade Commission. While the burdens of proof and detail required may vary by state and regulatory agency, these plans illustrate that the transacting parties are committed to the transaction, have a roadmap to integrate operations at a systems level, and possess a plan to reduce overall system costs. These plans have been proven helpful in demonstrating the value that can be derived by a transaction for a community, but are limited in their detail as the parties are unable to exchange competitively sensitive information prior to the transaction.

In the preparation of these pre-transaction integration plans, parties have utilized both anti-trust counsel and a system integration consulting firm to prevent undue disclosure of sensitive information and support in the development of a more meaningful integration plan.

Post-Transaction Integration Plans

Post-transaction integration plans seek to enhance the integration of entities with a system both horizontally and vertically outside of the confines and limitations of the transaction process. These plans are developed to support system operational integration at two points in a system’s journey: (1) Immediately following a transaction, and/or (2) Years post transaction to optimize a system’s operational performance.

As systems pursue integration post-transaction, they should build upon their pre-transaction plans or previously completed integration initiatives. As the parties are now able to share competitively sensitive information, the integration plans can be further refined, enhanced, and validated. To efficiently drive system integration planning and implementation, the newly formed system should:

  • Activate a system integration governance structure to oversee operational integration
  • Establish an Integration Management Office (“IMO”) in line with an integration governance structure to manage processes, team collaboration, and track progress
  • Convene functional area integration teams to drive integration plan refinement and implementation
  • Engage employee and physician stakeholders to keep them informed and solicit ideas
  • Construct a community communication plan to highlight benefits and any changes to care design and delivery

Integration plan refinement and implementation immediately following a transaction can both position the system for success, or doom it for failure. While integration planning and implementation will drive efficiency, attention must be paid to cultural alignment. Individual functional plans and strategies should have their benefits objectively weighed against the cultural or political turbulence that could result. This process requires collaboration between the integrated management teams, and will require input from both internal and external system stakeholders if the plans are to successfully drive acceptance, accountability, and alignment within the system.

Many systems fall short of achieving full integration immediately following a transaction, and thus have opportunity to further optimize system performance years later. These systems may have either decided not to pursue specific integration opportunities in fear of cultural turbulence, stakeholder resistance, or a lack of guidance, will-power or resources to do so. Regardless of the reason, systems should reassess their degree of integration at least annually to identify new opportunities that may have arisen or determine if previous barriers to implementation or resistance to change have been mitigated. It is not uncommon for systems to achieve between 5 to 10% in sustainable, operational annual cost savings years after a transaction as a direct result of future integration plans.

As consolidation trends and cost pressures accelerate, the keys to a successful integration initiative are to focus on value creation, risk management, and employee and physician engagement in order to develop a realistic, achievable, and sustainable plan that positons the system for success.  

For more details surrounding health system integration planning, please download our PDF via the button, below:

  Health System Integration

B_Klar.jpgMr. Klar is a senior manager with GE Healthcare Camden Group with over 12 years of experience in healthcare management. Mr. Klar specializes in strategic and business planning advisory services, including service line planning, master facility planning, and transaction work (e.g., mergers, acquisitions, affiliations, joint ventures). He has extensive experience in the creation of strategic partnerships, the facilitation of inaugural health system strategic plan development, as well as the creation and implementation of business plans of operational efficiency, system-wide integration plans, and clinical programmatic alignment plans. He may be reached at brandon.klar@ge.com.

Topics: Business Plan of Operational Efficiency, BPOE, Mergers & Acquisitions, Health System Efficiencies, Brandon Klar, Health System Integration

GE Healthcare Camden Group Welcomes New Senior Leaders to Team

Posted by Matthew Smith on Sep 29, 2016 10:17:00 AM

In response to client needs, particularly around population health and financial operations and transactions, GE Healthcare Camden Group is pleased to announce the addition of several new leaders to the firm:

Robert Green, MBA, FACHE, CHFP

GreenB1.pngMr. Green joins as senior vice president and the practice lead for the Financial Operations and Transactions practice and is based out of the Chicago office. He will be responsible for overseeing the practice and enabling innovative solutions to the complex financial challenges facing clients that are meaningful and impactful in the business of improving the health of individuals and of a popualtion. He has more than 26 years of healthcare experience with 13 years of healthcare consulting experience and 13 years of provider-based financial, operational, and strategic experience among health systems, hospitals, medical groups, management services organizations, and physician hospital organizations. Mr. Green most recently served as PWC’s Managing Director in its Health Industries Advisory practice. He has also held positions at Deloitte & Touche and Ernst & Young. Additionally, Mr. Green served as Senior Vice President, Strategic Financial Services at Baylor Healthcare System from 2010 to 2013 and held a variety of leadership roles with Advocate Healthcare from 1998 to 2010. He may be reached at roberet.t.green@ge.com

David DiLoreto, M.D., MBA

DiLoreto.pngDr. DiLoreto joins as senior vice president in the population health practice and is based in the Chicago office. In his new role, Dr. DiLoreto will serve health systems, accountable care organizations, and clinically integrated networks in creating strategies and solutions for sustainable improvement. He has twenty years of healthcare expertise in population health, accountable care, physician group practice, hospital operations, managed care operations, graduate medical education, quality improvement, and informatics. Prior to joining GE Healthcare Camden Group, Dr. DiLoreto was the CEO of WellPledge, a consumer health IT company. He also previously served as the Chief Clinical Officer at Presence Health and Baptist Health Care where he was responsible for key population health management strategies and the operations of ACOs, clinically integrated networks, physician alignment strategies, and the integration of clinical services across outpatient clinics, hospitals, and post-acute care. He may be reached at david.diloreto@ge.com

Mark Krivopal, M.D., MBA

Krivopal.pngDr. Krivopal joins as a vice president in the population health practice and is based in the Boston office. With more than 15 years of care delivery experience across the continuum throughout the healthcare industry, Dr. Krivopal will be responsible for developing and leading engagements that require innovative, value-based programs addressing client needs in health systems, hospitals, physician practices, and integrated networks. His experience spans not-for-profit and privately held organizations of various sizes as well as the start-up environment in the healthcare IT space.

Prior to joining GE Healthcare Camden Group, Dr. Krivopal served as Vice President of Clinical Programs at Kyruus, Inc., a leading provider of enterprise patient access solutions. He has also previously served as the Vice President and Medical Director of Clinical Integration and Hospitalist Medicine at Steward Health Care, where he implemented provider engagement strategies, clinical integration and healthcare system governance redesign, assured sustainability and operational effectiveness of hospital medicine programs, and served as the senior executive and key advocate for the network with external payers and providers. Prior to that, Dr. Krivopal was the Senior Regional Medical Director at TeamHealth in California, a publicly-held healthcare company specializing in nation-wide outsourcing for hospital medicine, emergency medicine, and anesthesia. Dr. Krivopal’s career as a physician-executive began when he co-founded and then, for many years, led Beth Israel Deaconess HealthCare Hospitalist Services based in Boston, Massachusetts. He may be reached at mark.krivopal@ge.com

In addition to the leadership above, due to its growth, GE Healthcare Camden Group has also added another 10 advisors to the consulting team since this spring. For a look at the full GE Healthcare Camden Group leadership team, please click here.

Topics: Physician Leaders, Mark Krivopal, David DiLoreto, Robert Green, Financial Operations and Transactions

Truth Be Told: What CMS Doesn’t Tell You About the Medicare Shared Savings Program

Posted by Matthew Smith on Sep 28, 2016 11:10:56 AM

By Megan Calhoun, MS, MSW, Manager, and Andy McNerney, Manager, GE Healthcare Camden Group

Secrets.jpgWhen the Centers for Medicare & Medicaid Services ("CMS") launched its Medicare Shared Savings Program ("MSSP") in 2012, CMS leveraged the upside, risk only-design and the opportunity to be a care model redesign champion. It also intended to lead the market in value-based care delivery as a way to entice ACOs to join the program. Four years and 539 accepted MSSP ACOs later, CMS released its most recent set of performance results for the 80 percent of ACOs that have survived the program.

While savings of more than $429 million and overall quality improvement sounds like cause for celebration, the real story begins by acknowledging that program success doesn’t come easily and requires hard and transformative work…just ask the almost 70 percent (n=272) of MSSP participants who failed to achieve a shared savings distribution. Even for those participants that did achieve program savings, it is likely that the set-up and operating costs associated with the ACO program threatened bottom line financial success…today. But care transformation is not just about today’s bottom line, is it? Program veterans, or those who have participated for more than one Performance Year, have shown that it takes years to truly make an impact on cost and quality. The rest of the story will be written by their continued success as they gain a strategic advantage and encourage other providers to invest in their own transformation.


If CMS Isn’t Telling the Whole Story, Define and Measure Your Own Success!

Participation in the MSSP is not only an opportunity to impact select quality metrics and recuperate some dollars lost as a result of reduced unnecessary utilization. It is a long-term strategic play to prepare for the not so distant future when up- and down-side risk taking will be the norm, not the exception. The data provided from CMS through the MSSP program is neither real-time nor risk-adjusted, making it extremely difficult for ACOs to assess their performance. In addition, the influx of participants makes it challenging to track and trend an ever-moving target. Furthermore, performance on quality measures is not released to the ACOs until Quarter 2 of the following performance year.

This leaves the ACO limited time to review performance, establish initiatives, and implement efforts to improve outcomes. ACOs need to develop a mechanism by which they can continuously monitor overall cost of care and performance on the established quality measures so that they are not relying on CMS to report on their progress. Instead, continuous process improvement and measurement needs to be the new normal in preparation for a time when CMS will not be the only value-based contract in place. The amount of shared savings achieved, the level of patient satisfaction, and the quality outcomes delivered at the end of each Performance Year should not be a surprise, but all too often it is!

The Focus On Quality Should Go Beyond MSSP Attributed Lives!

The overall quality improvement shown by the MSSP ACOs indicates a program-wide commitment to improved health outcomes that should be applauded. These measures focus on patient satisfaction, reduction in avoidable utilization, preventive care, and evidence-based protocols for at-risk populations. Successful performance on many of these measures requires substantial data aggregation and analysis and proactive outreach to MSSP ACO patients. Where many ACOs falter is by laser-focusing on only the MSSP population; those beneficiaries assigned to the MSSP receive proactive preventative care while other patients are overlooked.  While this can be a successful short-term strategy (particularly when resources are limited or information systems have not yet have matured), operationalizing it is a challenge and this approach will not position the organization for long-term success.

Quality outcomes initiatives should be inclusive of all patients, regardless of payer, to demonstrate that your model of care can be scaled and to attract similar shared savings arrangements beyond CMS. The bigger problem is that care delivery does not just change for a given population and organizations are realizing that other payers are benefiting from their performance improvement efforts, which causes barriers to engage these providers in value-based contracting because the organization is producing results that are benefiting the payer without the compensation.

In 2015, CMS set a goal of having 50 percent of Medicare payments made through alternative payment models by 2018. Providers have responded through strong participation in programs such as MSSP, Pioneer ACO, and Bundled Payments and indications are that value-based payments will become the standard. If your organization embraces a value-based world, then program participation can be a good step towards building the necessary muscle. But only if you make a full organization wide commitment to the cultural change required to support care model redesign and do so with a customized definition of success; because unsuccessful participation may be even more costly to an organization than no participation at all.

Organizations who don’t take the time to invest in the appropriate care coordination resources will find that they have spent money on ACO staff, slightly reduced inpatient utilization (and therefore revenue), and receive no shared savings distribution to offset these costs. This can be a very frustrating result, leading to dissatisfaction with the program and disillusionment with care coordination. So, jump in! But don’t leave the necessary people, data, or innovation behind. 

Calhoun.jpgMs. Calhoun is a manager with GE Healthcare Camden Group and specializes in the areas of care management strategy and design, strategic and business planning analysis, accountable care organization applications, development and implementation, and the development of clinically integrated organizations. Ms. Calhoun has supported numerous clients with the completion of Medicare Shared Savings Program (“MSSP”) applications and implementation strategy and planning. She may be reached at megan.calhoun@ge.com.


mcnerney.jpgMr. McNerney is a manager with GE Healthcare Camden Group. His primary area of focus is bundled payments strategy, design, and implementation. Mr. McNerney also specializes in system and service line strategic planning and new business development for a variety of healthcare organizations. He may be reached at andrew.mcnerney@ge.com




Topics: MSSP, CMS, MSSP ACO, Megan Calhoun, Andy McNerney

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