GE Healthcare Camden Group Insights Blog

The Great Risk Shift: A Strategic Road Map for Providers

Posted by Matthew Smith on Apr 13, 2016 2:47:41 PM

By William Ringwood, Manager, GE Healthcare Camden Group

When assuming financial risk for healthcare delivery, a provider has many options to choose from and a broad range of internal and market-based factors to consider to be able to choose the right option for its specific circumstances.

An unprecedented shift of financial risk from payers to providers is occurring within the healthcare delivery system as a result of reform efforts. Healthcare providers have many important strategic decisions to make in preparation for this shift that will have a profound impact on their future success. Foremost among these decisions is choosing from the broad range of risk options available to providers, including quality incentive and penalty programs, Medicare accountable care organization (ACO) models with various degrees of risk and requirements, commercial shared savings, bundled payments, cobranding, and partial/full capitation or percentage of-premium models. It is clear that government and private payers, as well as employers and the general public, are pushing to improve overall healthcare value by increasing providers’ degree of risk.

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Risk, Providers

Topics: ACO, Medicare, Risk-Based Contracting, Healthcare Delivery, Risk, William Ringwood

Are You Ready for Medicare’s Payment for Value? Do You Know Your Value Modifier Score?

Posted by Matthew Smith on Nov 16, 2015 2:58:18 PM

By Cami Hawkins, MHA, Manager, GE Healthcare Camden Group

The Affordable Care Act established the Value Based Payment Modifier (“VBPM”) to begin moving Medicare payments toward physician reimbursement that rewards value over volume. While it began with medical groups with more than 100 eligible providers (“EP”), all practices, regardless of practice size, are subject to payment adjustments in 2017 as a result of their performance in calendar year 2015. The Value Modifier (“VM”) adjusts the Medicare Physician Fee Schedule (“PFS”) payment based on the quality and cost of care provided(1).

Given the potential for future financial penalties, it is important to understand what your VM is and how you are performing as reported in the 2014 Annual Quality Resource Use Report (“QRUR”), which was released to all physicians by tax identifier numbers on September 9, 2015. The QRUR provides a snapshot of whether your practice is scoring in the acceptable range to avoid a penalty or exceeding the target and eligible for an incentive. Groups with ten or more EPs are subject to penalties in 2016 based on 2014 performance (those participating inMedicare Shared Savings Program ACOs, the Pioneer ACO Program, or the Comprehensive Primary Care Initiative are excluded) and should quickly review their QRUR report. 

If you are not performing within the acceptable range, there is still time to impact your VM and Medicare payments for 2017. Because the QRUR report provides a view into how a practice performs under a fee-for-value model, it is a valuable data source to use in identifying gaps in care and operations. You can use the data to facilitate your efforts to transform your practice to improve your quality of care, streamline resource use, optimize technology, and identify opportunities for care coordination.

Here are four ways your QRUR can help you on your path to success under fee-for-value:
  1. Use QRUR data to stratify your Medicare patients into the four chronic disease categories (diabetes, chronic obstructive pulmonary disease, coronary artery disease, and chronic heart failure) being measured to identify opportunities for care improvement. CMS is measuring this data to determine per capita costs(2). Perform an analysis of current workflows, physician and staff responsibilities, and practice resources to identify gaps in addressing care needs of these patients and develop an implementation plan to strengthen the practice’s care coordination capabilities. Implement a care management program using a team-based care model and use disease registries to track these patients to ensure they are receiving the care they need. Work with your hospitals to develop effective care transition planning.
  2. Review the last hospital admission data and date of last claim filed supplied in the QRUR to identify opportunities for follow-up visits after hospital admission and hospital admissions that could have been prevented. Develop and/or refine processes to ensure effective care transitions and follow-up of recently discharged patients. Create processes to stay in touch with your sickest patients who are at risk of hospitalization and implement interventions to prevent hospitalization.
  3. To ensure that your data accurately attributes the providers in your practice, review “Providers associated with TIN.” Check provider participation and specialty and confirm accuracy against Provider Enrollment, Chain, and Ownership System (“PECOS”).
  4. Non-participation in Physician Quality Reporting System (“PQRS”) will impact your score in VBPM because it relies on PQRS participation for the purposes of reporting quality. While closely connected to PQRS, the VBPM levies penalties separate from PQRS for non-participation. VBPM adjustments are made in addition to the PQRS penalties that EPs may receive for not successfully reporting in that program. Your PQRS scores as compared to benchmarks is another valuable tool in assisting practices in identifying gaps in care.

The move to fee-for-value has started, and your practice can’t afford to be left behind. Both the QRUR and PQRS reports provide practices and physicians with data to use in transforming their practices for success under value-based payment. It is time to start the journey to practice transformation now.

(1) Claims data is used to measure both quality and cost. Quality measures included in the QRUR report are the 30-day All Cause Hospital Readmission, Acute Ambulatory Care-Sensitive Condition (ACSC) Composite, and Chronic ACSC Composite measures. The cost measures included are Per Capita Costs for All Attributed Beneficiaries, Per Capita Costs for Beneficiaries with Diabetes, Per Capita Costs for Beneficiaries with Chronic Obstructive Pulmonary Disease (COPD), Per Capita Costs for Beneficiaries with Coronary Artery Disease (CAD), Per Capita Costs for Beneficiaries with Heart Failure, and Medicare Spending per Beneficiary (MSPB).
(2) For detailed CMS guidelines to evaluate and improve performance, refer to for more information.

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, and hospital/physician integrations. She may be reached at or 512-792-5600.

Topics: Medicare, CMS, Payment Reform, Value Modifier, Cami Hawkins

Medicare Now Reimburses Physicians for Chronic Care Management

Posted by Matthew Smith on May 28, 2015 2:31:00 PM

Care coordination is a cornerstone of value-based healthcare. It is especially important for patients with chronic diseases, who require complex health services and careful tracking.

Under healthcare reform, physicians have increasingly been expected to provide better care coordination. The problem is that they have received no payment for coordination services not delivered face-to-face. That is now changing thanks to a recent Centers for Medicare and Medicaid ("CMS") decision.

As of January 1, 2015, Medicare pays physicians separately for chronic care management ("CCM") services. This is a potential game-changer for provider organizations transitioning to value-based care. The new policy will help medical practices fund the resources needed to provide care coordination. It can also let organizations leverage quality to strengthen bottom-line income.

Implementing Care Management

In the 2015 Medicare Physician Fee Schedule, CCM services are billable under CPT code 99490. Reimbursement is approximately $43 per patient per month. To be eligible for the payment, services must meet several conditions:

  • Patients: Patients eligible for CCM services must have 2 or more chronic conditions expected to last at least 12 months. These conditions must place the patient at “significant risk of death, acute exacerbation/decompensation, or functional decline.” Patients must provide written consent for CCM services.
  • Parameters: Patient CCM services must take at least 20 minutes of clinical staff time per calendar month. Staff must establish, implement, revise, and monitor a comprehensive care plan. Patients must have 24/7 access to care management staff.
  • Providers: CCM services must be performed by a physician, a non-physician practitioner, or another clinical staff member supervised by a qualified health care professional (under Medicare’s “incident to” rules).

Significant Revenue Opportunity

According to the Centers for Disease Control, two-thirds of Medicare beneficiaries have two or more chronic conditions. As a result, healthcare organizations of every size stand to benefit from the new payment policy.

Consider a solo physician with 500 Medicare patients. Statistically, about 333 of these patients will have multiple chronic diseases. Depending on how many patients qualify for CCM and agree to receive these services, the physician could generate $100,000 or more in additional annual reimbursement.

To realize the full potential reimbursement, providers must meet several requirements. Patients must first agree in writing to receive CCM services. In addition, the practice must meet all documentation requirements, including documentation of staff time.

Care management can create additional costs, including staffing and IT costs and other general expenses. That is why this new payment policy is a great opportunity for organizations that have already built a care management program, such as many acountable care organizations, integrated delivery networks and even some larger medical groups.

For example, consider a health system that already provides care management services for select patient populations. The system has 100 employed physicians who manage patients with chronic conditions. With modest changes to comply with service and documentation requirements, the system could be eligible for several million dollars in new reimbursement for CCM services.

The opportunity for all healthcare organizations is to strengthen the bottom line while providing better care. CCM services can help lower complication and readmission rates, which will ultimately lower the cost of care for patients and payers. 

Careful Planning Needed

To successfully implement CCM, provider organizations need to focus on three priorities:

  • Hiring and organizing clinical staff to orchestrate patient care and manage patient populations.
  • Implementing technology that enables the sharing of patient data among providers, tracking clinical quality measures, and maintaining electronic care plans.
  • Developing effective processes for coordinating care, reconciling medications, managing care transitions, and attaining other CCM goals.

Achieving these goals requires careful planning. But qualifying for CCM reimbursement can help many healthcare organizations transition successfully to value-based care.

Topics: Medicare, Reimbursement, Lucy Zielinski, Chronic Care Management

Value-Based Purchasing in 2015: Bonuses Up / Penalties Down

Posted by Matthew Smith on Dec 19, 2014 10:03:00 AM

Value-Based Purchasing, More hospitals will see a payment bump than a penalty in the coming year under Medicare's value-based purchasing program, according to newly released federal data for more than 3,000 U.S. facilities.

A total of 1,698 hospitals will have their Medicare payments boosted in 2015, 467 more than in 2014, according to a Modern Healthcare analysis of data the CMS posted Wednesday. The posted adjustments, however, range between 0.01% and 2.09%, which suggests there could be some anomalies in the data. Under the structure of the program, payments should adjust up or down as much as 1.5% for fiscal 2015. Modern Healthcare has reached out to CMS about why bonuses for more than 40 hospitals in the CMS data surpass that maximum. 

A total of 1,360 U.S. hospitals will have their Medicare payments docked next year. The cuts will range from 0.01% to 1.24%. The number of hospitals facing cuts represents only a slight improvement over last year, when 1,400 hospitals were penalized under the program. The average penalty for 2015 is negative 0.30%. That's higher than the minus 0.26% in 2014 and minus 0.21% adjustments in 2013.

The CMS launched the value-based purchasing program in October 2012 in a major effort under the Patient Protection and Affordable Care Act to reimburse hospitals for quality that marked a shift from pay-for-reporting initiatives such as the Hospital Inpatient Quality Reporting Program. 

The program is budget-neutral because it draws its funds from an across-the-board reduction in base operating DRG payments. For 2015, that cut increased to 1.5% from 1.25% in 2014 and it will grow incrementally each year until reaching 2% in 2017. The 1.5% reduction produced a pool of $1.4 billion. 

The current adjustments are based on hospitals' performance across 26 measures of clinical processes; patient satisfaction; and outcomes, including use of preoperative antibiotics, doctor-patient communication and mortality rates. They include 12 clinical process-of-care measures; eight patient-experience dimensions; five outcome measures; and one efficiency measure on spending per beneficiary.

Health policy leaders at the American Hospital Association are reviewing the data but say upon initial review the findings are positive. “There's nothing surprising here,” said Nancy Foster, the AHA's vice president for quality and patient safety policy. “We see that hospitals continue to improve on their performance on these measures, and some measures are getting to the point where we've achieved such high levels that there's very little room for additional improvement.”

Topics: Medicare, CMS, Value-Based Purchasing

New EHR Attestation Deadline for Eligible Hospitals: 12/31/14

Posted by Matthew Smith on Nov 24, 2014 3:01:00 PM
Courtesy of Centers for Medicare & Medicaid Services 

CMS, EHR, Meaningful UseCMS is extending the deadline for eligible hospitals and Critical Access Hospitals (CAHs) to attest to meaningful use for the Medicare Electronic Health Record (EHR) Incentive Program 2014 reporting year from 11:59 pm EST on November 30, 2014 to 11:59 pm EST on December 31, 2014.

This extension will allow more time for hospitals to submit their meaningful use data and receive an incentive payment for the 2014 program year, as well as avoid the 2016 Medicare payment adjustment.

CMS is also extending the deadline for eligible hospitals and CAHs that are electronically submitting clinical quality measures (CQMs) to meet that requirement of meaningful use and the Hospital Inpatient Quality Reporting (IQR) program. Hospitals now have until December 31, 2014 to submit their eCQM data via Quality Net.

Note: This extension does not impact the deadlines for the Medicaid EHR Incentive Program.

How to attest?
Medicare eligible hospitals and CAHs will use the Registration and Attestation System to submit their attestation for meaningful use for the 2014 reporting year. The system is open and fully operational, and includes the 2014 Certified EHR Technology (CEHRT) Flexibility Rule options. Medicare eligible hospitals and CAHs can attest any time to 2014 data until 11:59 pm EST on December 31, 2014 to meet the new 2014 program deadline.

Attestation Tips
Here are some steps to help make the attestation process easier:

  • Consider logging on to use the attestation system during non-peak hours, such as evenings and weekends
  • Log on to the registration and attestation system now and ensure that your information is up to date and begin entering your 2014 data  
  • If you experience attestation problems, call the EHR Incentive Program Help Desk and report the problem

Reminder: Medicare eligible hospitals must attest to demonstrating meaningful use every year to receive an incentive and avoid a payment adjustment.

2016 Payment Adjustments
Payment adjustments will be applied at the beginning of FY 2016 (October 1, 2015) for Medicare eligible hospitals that have not successfully demonstrated meaningful use in 2014. Read the eligible hospital payment adjustment tipsheet to learn more.

Note:  CAHs have a different payment adjustment schedule than Medicare eligible hospitals. Review the CAH Payment Adjustment and Hardship Exception Tipsheet.

The EHR Information Center is open to assist you with all of your registration and attestation system inquiries. Please call, 1-888-734-6433 (primary number) or 888-734-6563 (TTY number). The EHR Information Center is open Monday through Friday from 7:30 a.m. – 6:30 p.m. (Central Time), except federal holidays.

Attestation resources are available on the Educational Resources webpage of the EHR Incentives Programs website.

Topics: EHR, EMR, Meaningful Use, Medicare, CMS, Medicaid, Attestation

Medicaid Reform: Are You Ready?

Posted by Matthew Smith on Nov 19, 2014 1:11:00 PM
By Gregory Shufelt, Adam Medlin, Patricia A. Hines
The Camden Group

The Camden Group, ACA, Affordable Care Act, Medicaid, Healthcare Reform, In an article for HFMA's HFM Magazine, our colleagues at The Camden Group urge health system leaders to view any steps they take to prepare for their state's Medicaid reform initiatives as integral to their organization's evolution toward value-based care and population health.

Hospitals and health systems should follow a four-step process to evaluate their state’s Medicaid initiatives and to develop new care models to better manage the Medicaid patient populations they serve:

  • Perform an initial assessment
  • Identify opportunities and risks
  • Develop a business plan
  • Implement the plan

More than 72 million Americans receive healthcare coverage from Medicaid, including children, nondisabled adults, pregnant women, individuals with disabilities, and seniors with both Medicare and Medicaid coverage (known as dual eligibles). This number is expected to grow to 93 million by 2024.a New reports are showing that even in states where Medicaid expansion under the Affordable Care Act (ACA) was rejected or put on hold, Medicaid enrollment is still expanding due to the “woodwork effect,” whereby people previously eligible for Medicaid are just now signing up, due in large part to the outreach and educational efforts associated with the ACA. Regardless of their state’s decision to expand Medicaid, healthcare leaders should prepare for potentially drastic changes in how states manage their Medicaid programs.

To read the full version of this article, please click the button, below:

Medicaid Reform, Affordable Care Act, ACA, Population Health

Topics: Medicare, ACA, Affordable Care Act

Hardship Exception Applications to Avoid the 2015 Medicare Payment Adjustment Due 11/30/14

Posted by Matthew Smith on Oct 7, 2014 3:46:00 PM

CMS, Meaningful UseCMS is announcing its intent to reopen the submission period for hardship exception applications for eligible professionals and eligible hospitals to avoid the 2015 Medicare payment adjustments for not demonstrating meaningful use of Certified Electronic Health Record Technology (CEHRT). The new deadline will be November 30, 2014. Previously, the hardship exception application deadline was April 1, 2014 for eligible hospitals and July 1, 2014 for eligible professionals.

As part of the American Recovery and Reinvestment Act of 2009 (Recovery Act), Congress mandated payment adjustments under Medicare for eligible hospitals, critical access hospitals, and eligible professionals that are not meaningful users of CEHRT. The Recovery Act allows the Secretary to consider, on a case-by-case basis, hardship exceptions for eligible hospitals, critical access hospitals, and eligible professionals to avoid the payment adjustments.

This reopened hardship exception application submission period is for eligible professionals and eligible hospitals that:

  • Have been unable to fully implement 2014 Edition CEHRT due to delays in 2014 Edition CEHRT availability; AND
  • Eligible professionals who were unable to attest by October 1, 2014 and eligible hospitals that were unable to attest by July 1, 2014 using the flexibility options provided in the CMS 2014 CEHRT Flexibility Rule.  

These are the only circumstances that will be considered for this reopened hardship exception application submission period. Applications must be submitted by 11:59 PM EST November 30, 2014.

More Information
More information about the application process will be shared soon. We intend to address this issue in upcoming rulemaking. Visit the Payment Adjustments and Hardship Exceptions webpage for more information about Medicare EHR Incentive Program payment adjustments.

Topics: Meaningful Use, Medicare, CMS, CEHRT

October 3 is Last Day for 1st-year Medicare EPs to Begin a 2014 Reporting Period

Posted by Matthew Smith on Sep 16, 2014 11:58:00 AM

Deadline, EHR, EMR, The last day to begin a 2014 reporting period for first-year Medicare eligible professionals is October 3rd.

Here are a few key points eligible professionals who have not yet started participation in the Medicare EHR Incentive Program should know.

Earning Incentives

  • October 3rd is the last day to start the 90-day reporting period in 2014 for the Medicare EHR Incentive Program. 
  • If you start participation by October 3, you will have the opportunity to receive an incentive for 2014, and if you continue to achieve meaningful use, can earn incentive payments for 2015 and 2016 participation.  
  • If you wait and start participation in 2015, you will not be eligible to receive incentive payments, but can avoid payment adjustments.

Avoiding Adjustments

  • You will not avoid the payment adjustment in 2015, as you will not be able to attest to 90 days of data by October 1, 2014.
  • If you applied for a 2015 hardship exception by July 1, 2014, you may avoid the payment adjustment.
  • If you attest to 2014 data by February 28, 2015, you will avoid the 2016 payment adjustment.

Medicare eligible professionals must attest to demonstrating meaningful use every year to receive an incentive and avoid a payment adjustment.

For More Information

To learn more about other eHealth events and National Health IT Week, visit the CMS Events page on the eHealth website. For more information about the EHR Incentive Programs, visit the CMS EHR website.

Topics: EHR, EMR, Electronic Health Records, Medicare, CMS, HIT, Health IT

Infographic: A Look at the Emerging Nashville EHR Market

Posted by Matthew Smith on Aug 12, 2014 2:47:00 PM

Nashville, EHR, EMR, Meaningful Use, HCAAs one of the fastest growing healthcare markets in the United States, Nashville is home to the Hospital Corporation of America (HCA) with has 194,000 global employees and $34 billion in annual revenue. Technology Advice surveyed over 250 Nashville practices to look for EHR trends in this emerging market.

Some of the most interesting findings iinclude:

  • Epic, the number one national electronic health record vendor, does not rank among the top five vendors in Nashville
  • Nashville healthcare providers are significantly more satisfied with their EHR programs than providers nationwide
  • 16% of providers in Nashville have already switched EHRs
  • Adoption rate among certain specialties is significantly higher than national averages
  • Cost appears to be the number one consideration for Nashville EHR buyers

They also put out the Nashville EHR market infographic below. Most interesting is the percentages and how the EHR market is still very diverse. 

Nashville EHR Market Infographic resized 600


Topics: EHR, EMR, Meaningful Use, Electronic Health Records, Medicare, CMS, Nashville

Expert Panel Recommends Sweeping Changes To Doctor Training System

Posted by Matthew Smith on Aug 1, 2014 9:51:00 AM
Courtesy of Kaiser Health News

Physician Training, HospitalsAn expert panel recommended Tuesday completely overhauling the way government pays for the training of doctors, saying the current $15 billion system is failing to produce the medical workforce the nation needs.

“We recognize we are recommending substantial change,” said health economist and former Medicare Administrator Gail Wilensky, co-chairwoman of the nonpartisanInstitute of Medicine panel that produced the report. “We think it’s key to justifying the continued use of public funds.”

The federal government, mostly via the Medicare program, currently provides more than $11 billion per year in payments to support the training of doctors who have graduated medical school. Most of that goes to the hospitals that sponsor interns and residents. States, through the Medicaid program, contribute nearly another $4 billion annually.

“The scale of government support for this phase of physician education is unlike that given to any other profession in the nation,” said the report, which was funded by a dozen foundations with the support of a bipartisan group of members of Congress.

But there are little data on how those funds are spent and how well they contribute to the preparation of a medical workforce needed for the 21st century. Despite a growing public investment in graduate medical education (GME) support, there are persistent problems with uneven geographic distribution of physicians, too many specialists and not enough primary care providers, and a lack of cultural diversity in the physician workforce, the report found.

Not only that, the authors note, “a variety of surveys indicate that recently trained physicians in some specialties cannot perform simple procedures often required in office-based practice and lack sufficient training and experience in care coordination, team-based care, and quality improvement.”

All of the changes proposed in the report would have to be made by Congress, because government support for graduate medical education is written into Medicare and other laws. The politics, however, are unclear because the changes would produce winners and losers among those programs currently training interns and residents. 

The Association of American Medical Colleges was sharply critical of the report. Its recommendations would “threaten the world’s best training programs for health professionals and jeopardize patients, particularly those who are the most medically vulnerable,” said AAMC President Darrell G. Kirch, whose group represents the nation’s top teaching hospitals.

“By proposing as much as a 35 percent reduction in payments to teaching hospitals, the IOM’s recommendations will slash funding for vital care and services available almost exclusively at teaching hospitals, including Level 1 trauma centers, pediatric intensive care units, burn centers, and access to clinical trials,” Kirch said. “In addition to hurting patient care, these cuts will limit critical training settings for future physicians, nurses, and other health professionals.”

The committee proposes a sweeping overhaul of the entire financing program for graduate medical education, with the goal of shifting the program “to a performance-based system,” rather than one that merely funnels money to any facility with an accredited training program.

The current Medicare medical education payment system would be phased out over 10 years. At the end of the phase-out, policymakers would reassess whether Medicare should continue to subsidize doctor training at all, and if so, to what extent.

The panel calls for spending the same overall funding from Medicare over the decade, adjusted for inflation. But it would be distributed much differently, with a declining share providing direct subsidies to teaching programs. An increasing share would go instead to a “GME transformation fund” that would finance new ways to provide and pay for training and fund training positions “in priority disciplines and geographic areas.”

The funds would still be distributed through the Medicare program, but a new “GME Policy Council” would be created under the office of the Secretary of Health and Human Services to oversee workforce issues and commission research on how well the federal dollars are being spent. The committee recommended that states impose similar requirements for Medicaid training funds.

Among those that would be most immediately affected are major teaching hospitals in the Northeast, which currently account for a disproportionate amount of Medicare medical education funding and number of doctors-in-training. The panel called for an end to the current system of payments that favor those hospitals, and instead for Medicare to make a flat “per resident” payment to training sponsors based on the national per-resident amount, adjusted for geography.

It’s time to close the open checkbook for teaching hospitals, the panel said. “The statutes governing Medicare’s GME financing were developed at a time when hospitals were the central – if not exclusive – site for physician training,” the report said. But by doing that, “the Medicare payment system discourages physician training outside the hospital, in clinical settings where most health care is delivered.”

Members stopped short, however, of recommending that Medicare stop funding graduate medical education altogether, at least for the near future.

The rapid evolution of the health care sector, said Wilensky, “was an important rationale for potentially using the leverage provided by government funding  to try to train the health care workforce we needed for a 21st century delivery system.”

But the panel also did not recommend lifting the current cap on the number of residencies that Medicare currently supports. That cap was imposed in the 1997 Balanced Budget Act.

“Increasing the number of physicians per se is not likely to solve important workforce issues,” Wilensky said, “particularly with regard to specialty distribution or geography.”

Topics: Medicare, Hospitals, Physician Training, Teaching Hospitals

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