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MACRA: How the New Merit-Based Incentive Payment System Will Impact Physician Practices

Posted by Matthew Smith on Jul 14, 2016 4:15:34 PM

By Lucy Zielinski, Vice President, and Nidhi Chaudhary, Consultant, GE Healthcare Camden Group

MACRA_Image.pngHealthcare delivery and its corresponding costs are changing due to recent industry trends. Value-based programs reimburse healthcare providers for the quality of care they provide to patients. To support this, the Medicare Access & CHIP Reauthorization Act of 2015 (“MACRA”) intends to reform Medicare payments to physicians over the next several years. MACRA has two pathways:

  1. The Merit-Based Incentive Payment System (“MIPS”)
  2. Alternate Payment Models (“APMs”), which will take effect starting in 2017.

In order for practices to survive and compete in this value-based environment, specific initiatives must be deployed this year. 

MACRA1.png

Transitioning to the MACRA MIPS model

There are currently multiple quality and value programs for Medicare providers: Physician Quality Reporting Program ("PQRS"); Value-Based Payment Modifier; and the CMS EHR Incentive Program. 

MACRA streamlines those programs into MIPS and adds a fourth category called Clinical Practice Improvement Activities. Below is an example of MIPS Scoring for Year 1:

MIPS1.png

Challenges Faced by Physicians:

  • Uncertainties surrounding the shift from volume-to-value
  • Potential reduced reimbursement for services
  • Tracking of quality and cost management
  • Optimizing electronic health record (“EHR”)/registry use

Key MACRA questions for medical groups:

  • What does the current Quality and Resource Use Report (“QRUR”) tell you?
  • What is the implementation plan for 2016 and 2017?
  • What are the right measures that should be tracked and reported? Are workflow changes required?
  • What clinical practice improvement activities will be added?
  • How will the current infrastructure support the initiatives?
  • Is additional technology required?
  • How will the composite score be optimized?
  • Do we have adequate resources and education opportunities to be successful?

How can GE Healthcare Camden Group help organizations create and navigate a MACRA roadmap for 2017?

We help organizations:

  • Identify gaps and priorities by performing a MACRA readiness assessment
  • Help groups form and facilitate a steering committee with a shared vision
  • Integrate change management methodologies to ensure success
  • Create education and communication plans
  • Develop a tactical MACRA roadmap focusing on strategic and operational objectives   
See our sample work plan and timeline below:

MACRA_Roadmap.png

If you want to get started with your own, personalized MACRA roadmap, click the button below and a GE Healthcare Camden Group MACRA expert will be in touch to start you on your way.

MACRA


ZielinskiL.jpgMs. Zielinski is a vice president with GE Healthcare Camden Group, with over 20 years of experience in the healthcare industry. She specializes in helping private and hospital-owned medical practices achieve top financial performance by guiding physicians through practice development, strategic planning, coding and revenue cycle process optimization, and electronic health record system implementation. In her health system leadership roles, she has successfully managed the revenue cycle for over 2,000 physicians. Additionally, Lucy has led engagements with physician billing companies that involved restructuring operations and development of dashboard reports. She may be reached at lucia.zielinski@ge.com.

ChaudharyN.jpgMs. Chaudhary is a consultant with GE Healthcare CamdenGroup specializing in delivering strategies, working to provide more efficient and lean processes as well as coaching leaders and management. Ms. Chaudhary joined GE Healthcare in 2007 and has extensive experience in Regulatory Affairs and Quality Engineering pertaining to both medical and pharmaceutical devices. Ms.Chaudhary has provided support for strategic and business planning while working within the business and with the medical staff at multiple hospitals. She may be reached at Nidhi.Chaudhary@ge.com.

 

 

 

 

Topics: Value-Based Care, Payment Reform, Value-Based Contracting, Lucy Zielinski, Payment Models, MACRA, MIPS, Nidhi Chaudhary

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

Payment for ValueThe 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 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/Downloads/2014-Understanding-Your-QRUR.pdf 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 chawkins@thecamdengroup.com or 512-792-5600.

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

Bundled Payments and the Breakthrough Power of Partnerships

Posted by Matthew Smith on Jul 30, 2015 1:00:19 PM

By Kimberly Hartsfield, MPA, Vice President, The Camden Group

Bundled Payments, PartnershipsAs bundled payment programs are expanding across specialties, payers, and sites of care, it is becoming increasingly clear that the path to success can be summarized in one word: partnerships.

Who is your Apple?

Consider the successful partnership between Nike and Apple. Although they are in different industries, their commonality lies in their customers. As a result of their partnership, both companies have experienced enhanced brand recognition, in addition to significant market and sales growth. Nike CEO, Mark Parker said about their partnership with Apple, “As I look ahead at what's possible with Nike and Apple...technologically we can do things together that we couldn't do independently. So yeah, that's part of our plan, is to expand the whole digital frontier and go from...25 million Nike+ users to hundreds of millions (theverge.com).”[1] Who is that perfect partner that you had not previously considered, and what can you accomplish together?

Why it Matters

How do these strategic partnership examples apply to healthcare? The same patient that has an inpatient stay and is discharged to a post acute care facility has one goal: to get home pain-free as fast as they can. Bundled payment arrangements are holding both providers accountable very differently than the traditional fee-for-service model. How can potential partners leverage one another to expand their existing capabilities and utilize resources in innovative ways? All provider organizations are facing demand destruction pressures, and partnering may help both parties retain much needed volumes and revenues, while continuing to provide excellent patient quality.

New relationships between providers, and between payers and providers, are being forged to advance payment transformation efforts through bundled payments. Providers are looking beyond their four walls, obtaining, analyzing, and sharing data, and partnering across the care continuum to enable patient-centric care delivery with a new focus on value and total cost of care.

Identifying the right partner organizations is paramount to a successful bundled payment program. Providers should consider partnerships with organizations that are innovative, philosophically aligned around value-based care, cost-efficient, and high performing in their markets. Today’s strategic partnership evaluations require a willingness to look beyond the closest geographic provider or the provider organization that has historically been the preferred referral choice. Publically available data from sources such as The Centers for Medicare and Medicaid Services ("CMS") Hospital Compare, Nursing Home Compare, Home Health Compare, Physician Compare, and Dialysis Facility Compare enable providers to proactively evaluate and identify potential candidates for partnership.

The Right Sandbox

Bundled payments are the perfect testing ground for partnerships where gainsharing programs can be established to strengthen provider engagement and evaluate potential for long-term strategic alignment. This allows participants to demonstrate their ability to eliminate unnecessary variation in care and meet the agreed upon goals of the program without assuming risk that providers may not be prepared to manage. Bundled payment programs and accountable care organization initiatives can be very complementary, and many organizations are choosing to pursue both simultaneously.

The ability to expand the external focus and consider the full continuum of care requires very different commitment and communication between providers. Partners must develop innovative solutions and continue to make information technology investments to overcome the frequent inability of electronic medical records to transmit data between different platforms and providers. They must also be willing to collaborate clinically through the standardization of care protocols and/or seamless coordination across care settings. Perhaps more importantly, they must be willing to demonstrate mutual accountability for patient outcomes and the total cost of care.


[1] http://www.theverge.com/2014/10/23/7044999/nike-apple-wearables-partnership

Kimberly Hartsfield, Bundled Payment, Payment Reform, The Camden GroupMs. Hartsfield is a vice president with The Camden Group. She specializes in payment transformation strategies with a focus on designing and implementing Medicare and commercial bundled payments. She frequently presents on a variety of topics including value-based payment models and provider engagement. She may be reached at khartsfield@thecamdengroup.com or 501.940.2526. 

 
 

 

Topics: Payment Reform, Bundled Payment, Deirdre Baggot, Kimberly Hartsfield, Payment Models

Top 10 Considerations When Transitioning Physicians to Payment-for-Value

Posted by Matthew Smith on Mar 5, 2015 10:35:00 AM

By Tawnya Bosko, MHA, MSHL, MS, Senior Manager, The Camden Group

change-ahead-signWith increased focus on payment based on value, physician practices and those involved with physician practices need to plan for how to transition to new reimbursement models. Here are the top considerations to keep in mind when implementing value-based structures:

1. How do you define value? 

For all the talk of compensating physicians based on value as opposed to volume, there is no consistent methodology for measuring “value.” Often, payers define value in different ways, making it difficult for physician practices to understand what is required of them in order to meet criteria. Leadership should define what value means to the practice with insight from key payers. Typically, initial steps in measuring value are based on compliance with designated measures from the Healthcare Effectiveness Data and Information Set, but depending on the program, different criteria may be used. Further, the practice may include measures that it has identified as needing improvement, such as patient access, completing notes, meeting meaningful use, or responding to lab results in a timely manner.

2. How do you report on value?

Once the practice has determined the clinical measures or other criteria that will define value, it must proactively assess information system readiness for reporting on these measures. Historically, many payers have tracked these values based on claims data. Practices must be able to monitor, track, and report on performance related to value metrics. Assess the system, and ensure that necessary data can be extracted efficiently and accurately for reporting. Build custom fields within the electronic health record (“EHR”), or consider an add-on reporting tool if needed.

3. How do you document value?

Just as important as determining how to generate reports to measure the value metrics, practices must determine how physicians and other providers should document their work within the EHR in order to ensure their results are captured. Often, EHRs have several ways and areas in which documentation of a certain procedure or services can be documented. Best practice is determining the field or area to document each measure so that it is clearly communicated to physicians and easily reported on, retrospectively.

4. Incentive program - carrot or stick?

Once the metrics to measure value have been determined, what is the incentive (carrot) or penalty (stick) for meeting or failing to meet value as defined by the group? There must be enough incentive to gain buy-in so that physicians do not feel as though extra work is being added without additional benefit. And, there must be enough penalty at stake for the program to be taken seriously. It is about finding the right balance. Is it a withhold on revenues with the opportunity to earn X times the withhold in return if measures are met? Is there a “direct” line of sight between the incentive earned by physicians and the impact on their compensation? There are many models that could be implemented to meet the practice’s needs.

5. Educate, educate, educate.

This point cannot be emphasized enough. Often, healthcare leaders think the difficulty is in defining value, measuring value, and designing the incentive program. While those can be complex, educating the physicians on the measures, model, and how to document them is a very important step and could make or break your program. Remember that these situations often involve changing the way a physician has practiced and/or documented and that it takes time, education, and re-education. Ensure the appropriate processes and tools are in place to communicate and educate effectively.

6. Living in a grey world/burden of value.

Understand that during this transition to payment-for-value, physicians are living in a grey zone. They are expected to take extra steps to meet value criteria, but the majority of reimbursement may still be based on a fee-for-service or volume-based methodology. Essentially, they are asked to spend extra time with patients and on documentation in order to meet quality measures but also to continue to meet their productivity targets in order to sustain the viability of the practice. Typically, the burden of many of the value-based measures falls hardest on primary care physicians. Be aware of this when designing incentive models. Do not do too much at once and overwhelm physicians to the point where they give up.

7. Transparency of data.

Physicians, rightfully so, are often skeptical of performance-related data. They have questions...make sure tyou have answers. Be transparent with data. If a physician asks for the names of patients where they failed on a certain measure, ensure the information is provided. It is important to not only be transparent with data but to build confidence in results.

8. Timeliness of results.

Be timely with reporting. Provide information to physicians in a timely and regular manner so that they are able to improve any deficiencies in the measurement period. Do not wait until the point where it is too late to correct issues for the current performance year. It is in the practice’s interest to improve each physician’s performance. Use the data and reporting to provide feedback and to help them be successful in the program.

9. Impact on total compensation.

Understand the impact that the design of the incentive program has on total compensation. What percentage of total compensation does the incentive (or withhold) represent? Does the physician employment agreement need to be revised to incorporate the incentive model? If physicians are on salary guarantees, how is that addressed so that the incentive/penalty falls on them and not the employer?

10. Engage payer partners.

Work with payer partners and do it early. Discuss their needs when measuring value and pursue discussions on how they can support the transition. Make it a collective effort where initiatives are streamlined and convergent. It is not practical for practices to have multiple different models for multiple different payers; be open with major payers, and develop a program that is supported uniformly.

As medical groups and hospitals that own medical groups look for ways to be more efficient and seek stability in a quickly changing marketplace, embracing a transition to value-based reimbursement is necessary. The focus should be on managing the care of a population, and incentive models should be designed with the end goal in mind.

bosko_headshotMs. Bosko is senior manager with The Camden Group and specializes in designing and implementing clinical integration, high growth medical service operations (“MSO”) and finance, physician hospital organization (“PHO”) and MSO development, managed care strategy, and physician alignment. She may be reached at tbosko@thecamdengroup.com or 310-320-3990.

Topics: Payment Reform, Payment Models, Tawnya Bosko, PFV, Payment-for-Value

The Payment Reform Mash-Up: Top 10 Smart Leadership Strategies for Managing in an Era of “Fusion” Reimbursement Models

Posted by Matthew Smith on Feb 3, 2015 10:16:00 AM
By Deirdre Baggot, MBA, Ph.D., Senior Vice President, The Camden Group and Kimberly Hartsfield, MPA, Vice President, The Camden Group

Bundled Payment, Payment Reform, Clinical IntegrationFew would argue that this may be one of the most exciting times in healthcare – volatile and disruptive, yet also transformative and empowering for those organizations and innovative leaders who are able to move markets by embracing “fusion” reimbursement models. While not all leaders have relished these challenges, many of their more adaptable and failure tolerant counterparts are at the forefront of payment transformation and reconceiving their payer strategy today. Now is the time to for true transformation, and those innovators who meet the changes head-on are far more likely to succeed than their overly cautious counterparts, who may well find themselves left behind. Here are the top ten strategies of transformational leaders who are taking the healthcare “bull by the horns” and redesigning their business model to seize the inherent opportunity of payment transformation.

1.  Have great timing

In an era of payment transformation, building value is not enough. Moving from building value to extracting and trading value requires appropriate timing. The inherent threat of demand destruction that both bundled payments and ACOs drive require many providers to reconceive their business model. The key is to time new payer arrangements with the redesign of the care models. The transformation is already well underway, and the clock is ticking for those who have not embraced this as their future.

2.  Risk is your friend

Risk is described as the gap between opportunity and success. Without it, the greatest opportunities an organization holds will not have the possibility to develop. Organizations are charting new territory, and creating success in the future is contingent upon leadership’s willingness to “run to risk.” Keeping an open mind and viewing the future from a broad perspective will allow an organization to identify opportunities for risk that make sense. Risk tolerance goes hand in hand with failure tolerance (see number 7).

3.  Think like Google

In industry transformation, talent becomes the linchpin asset. Identifying all-stars and empowering them in a way never done before may mean beginning to build teams that look more like a group of Google interns. Ask them what unproductive activities are they wasting their time on each day? Who are the creative thinkers within the organization, and how much time are they spending envisioning the future? An organization must continually innovate to stay ahead of competitors, while recognizing both its market and the healthcare industry are in a rapid state of flux. A wait and see approach will not cut it. The experience people (both customers/patients as well as internal audiences) have within a system must be described as prompt/quick, high value, high quality, responsive, and personalized. These core principles must permeate everyday culture.

4.  Execution matters...a lot

The ability to execute is not inherent among all leaders. When it comes to payment transformation and complex change, it is often assumed that that a critical change can be “assigned” – and that is flawed thinking. Masterful execution requires process, project, and conflict management, as well as sharp communication skills, and most importantly, the ability to influence others. Time and again, seemingly good ideas are lost on poor execution. Payment reform becomes the impetus for care delivery reform which is a heavy lift. Simplifying the plan and managing the execution process will keep you on path to smart execution and foster the commitment to change.

5.  The imperative to adopt new payment models

Bundled payments are a natural introduction to value-based care delivery as the entry point is low, the investment is lower than ACOs by comparison, and the yield can be high. Certain other shared savings models with payers as your partner can also yield results in a relative “safe” environment. Bundled payment programs are moving out of the pilot stage and are becoming an integral part of healthcare finance in many markets. Many of the pilot initiatives focused on inpatient hospital stays and physicians performing procedures in high cost, high volume specialties like orthopedics and cardiology. Bundles are expanding across the care continuum into both the outpatient and post-acute arenas. Also, we are seeing many new joint venture arrangements with payers to facilitate population health management experience in commercial, Medicare, and Medicaid markets. The point is, successful leaders are pursuing new payment models rather than shying away.

6.  The next “dream deal" (Hint: It’s not a volume play)

No healthcare provider or setting is an island. The kind of thinking that connects cross-setting care delivery will change the world of healthcare in the United States. The next dream deal can be summarized in one word: Partnership. Successfully managing risk under the evolving reimbursement structures requires organizations to look beyond their four walls for partners to complete the care continuum, provide new capabilities, and live up to the goal of delivering patient-centered care. Partnership evaluation efforts across multiple healthcare stakeholders must be fact-based through a comprehensive market assessment. In a perfect world, who do you see as your long-term partners? What partnerships have you not considered that you should? Are you philosophically aligned with this potential partner? Are their practitioners and executive staff well aligned with yours? How do they perform on cost, quality, and customer satisfaction metrics, as well as key metrics like readmission rates, compared to their peers? Asking the key questions early will prevent the dream deal from becoming a nightmare.

7.  Failure tolerance as a leadership best practice

Managing “fusion” reimbursement models requires an understanding that innovation is the hardest work to do, and failure is not failure at all--rather, it is just a data point on the journey to transformation. Failure cannot be personalized, and future leaders understand the need to “roll with it” and move quickly through tests of change. Tomorrow’s healthcare leaders are “disruptive innovators” who do not subscribe to a “culture of nice,” are not afraid to fail, and are not constrained by the political implications of killing a bad project. These leaders view failure as merely new information and are already on to the next innovation. In order to effectively compete in a time of industry transformation, the really great leaders, those capable of transforming organizations, will demonstrate a high degree of failure tolerance.

8.  The courage imperative

The healthcare leaders who will survive understand that courage and bravery shape the kind of thinking needed to spur payment transformation. Transforming the way care is delivered is not an overnight exercise and requires extraordinary courage. This includes saying “no” to unsustainable cost structures, but not through slash-and-burn tactics, which are largely short-term fixes. Success with bundled payments or any risk-based reimbursement model requires the courage to speak truth to waste and duplication and resulting behaviors of fee-for-service.

9.  Proximity

Assumptions underlying collaboration and innovation are changing. The collaboration and innovation necessary to thrive during the payment reform mash-up do not happen over conference calls or in cubicles. Chance cafeteria encounters and hallway conversations are strategic opportunities to break down silos and achieve break-through care transformation. There is a natural rhythm to collaboration that is rooted in trust and transparency. Smart leaders are asking themselves how to best foster, enable, and invest in proximity. Face-to-face connections, often occurring on the front-lines, are communication tools, and innovation sessions must be promoted.

Cross-discipline, cross-setting collaboration is the vehicle that enables innovation. Tomorrow’s successful leaders demonstrate a unique ability to collaborate, even when it means partnering with their “frenemies.” It is not personal, nor is it about burying the competition. It is about promoting and achieving health in the community. That said, collaboration done poorly can lead to endless meetings and costly delays. Being open, intuitive, and deliberate about how and when to collaborate has never been more critical for healthcare executives.

10.  Payment reform best practices are still evolving

“First Generation” transformation is not the end game; however this does not give an organization a “pass” to do nothing. The devil is in the details. Methodologies are being refined and improved. Care patterns are being altered. Transparency in healthcare is increasing exponentially. Payers and providers alike want an industry standard defining the “new normal” that outlines those best practices and makes this transition straightforward with clear timelines. Those organizations that choose to embrace payment reform now have the ability to help lead and shape the future of what those best practices look like.

As we have seen in other industries, such as the rise and fall of the dotcom era, true leaders must accept nothing less than breakthrough innovation and must understand that technology will never replace the importance of high-quality relationships grounded in trust, courage, collaboration, and innovation. Actively, energetically, yet thoughtfully pursuing new payment models, such as bundled payments, offers current leaders a wonderful sandbox to implement innovative strategies today that will enable them to thrive tomorrow.

Bundled Payments, Payment Reform, Deirdre Baggot, The Camden Group




Ms. Baggot
is a senior vice president at The Camden Group. baggot_headshotShe is a nationally recognized thought leader in bundled payments and was selected by CMS and the Innovation Center to serve as an expert panelist in Models 2 and 3 application reviews for the Bundled Payments for Care Improvement initiative. She may be reached at dbaggot@thecamdengroup.com or 303.335.7047.

hartsfield_headshotMs. Hartsfield
is a vice president with The Camden Group. She specializes in payment transformation strategies with a focus on designing and implementing Medicare and commercial bundled payments. She frequently presents on a variety of topics including value-based payment models and provider engagement. She may be reached at khartsfield@thecamdengroup.com or 501.940.2526. 
 
 

Topics: Payment Reform, Bundled Payment, Deirdre Baggot, Kimberly Hartsfield, Payment Models

3 Drivers of Accountable Care that Challenge CIOs to Re-Think Health IT

Posted by Matthew Smith on Mar 10, 2013 8:40:00 PM

By Daniel J. Marino, President & CEO, Health Directions

Part 1 of a 3-Part Series

ACO, Accountable Care OrganizationTrustees, CEOs, finance directors and others are increasingly turning to hospital IT leaders with a simple request: Build us the infrastructure for accountable care.

The challenges are many—system options, interface design, staffing, budgets, timelines, etc. One of the biggest problems, however, is that accountable care is pushing CIOs to master new ways of thinking about healthcare IT.

Traditionally, hospital IT decisions are based on department needs, system functionality and cost. CIOs focus on issues like system selection, implementation and ongoing maintenance. Starting now, accountable care is taking the IT decision making process to a new level. To create a viable accountable care infrastructure, CIOs need to understand and weigh factors like industry trends, system interoperability, evolving regulations, organizational strategy and more.

Drawing the interface design scope is not enough. CIOs need to create a design strategy focused on results-oriented information that supports the hospital’s unique accountable care model. The key to moving forward is to understand the fundamental goals of accountable care and how they dovetail with the organization’s overall business strategy.

Basic Drivers and Key Developments
The push for accountable care can be boiled down to three basic drivers.

  1. The need for cost control. U.S. per capita spending on healthcare is significantly above that of other developed nations, and healthcare economists expect costs to swell as the population ages.
  2. The demand for better quality. While the U.S. compares favorably to other nations on many quality measures, it appears to lag in important ways, including preventive care and patient safety. Healthcare leaders see a pressing need to improve care processes and outcomes in these and other areas.
  3. Expanded use of health information technology. Both providers and payers see an opportunity to address cost and quality challenges by taking advantage of health IT to capture more information, increase information sharing, standardize care and improve processes.

These basic drivers are shaping the concept of an accountable care enterprise: a group of providers and provider organizations that use technological tools and clinical integration strategies to assume collective responsibility for the quality and cost of healthcare for a defined group of patients. In turn, this basic concept is being shaped and modified by a handful of key developments.

The first development is payment reform. Experts blame high healthcare costs on fee-for-service reimbursement, the traditional payment system that rewards physicians and hospitals for the number of services performed, with little regard for quality or efficiency. Both government and commercial payers hope that making provider organizations responsible for costs and quality will help cut waste, control spending and improve care. Medicare’s new Value-Based Purchasing (VBP) program is a good example. Under the VBP program, DRG payments are tied to hospital performance on specific quality and patient satisfaction measures.

The second development is the focus on clinical integration. The government is requiring providers that want to function as a Medicare Accountable Care Organization (ACO) to demonstrate that they are collaborating to improve patient care, not just creating negotiation leverage. The key is to show that providers are organizing a clinically integrated delivery system around evidence-based standards, with the consequence that providers who do not achieve these standards are ineligible to share in ACO payments. While clinical integration is a Medicare requirement, the concept applies to all providers who are pursuing any kind of accountable care opportunity.

The third development is the evolution of government Meaningful Use (MU) standards.MU is currently focused on electronic medical record (EMR) reporting requirements and process improvement in the form of chronic disease management and e-prescribing. However, MU requirements will develop toward clinical outcomes improvement, and in the near future accountable care performance goals will merge with MU standards.

Next Blog Post: 5 Functional Requirements of ACOs

Electronic Health Records EHR Assessment

Topics: Meaningful Use, Accountable Care, ACO, Clinical Integration, Payment Reform, Drivers, CIO, Health IT

3 Drivers of Accountable Care that Challenge CIOs to Re-Think H.I.T.

Posted by Matthew Smith on Jul 23, 2012 6:09:00 PM

By Daniel J. Marino, President & CEO, Health Directions

Part 1 of a 3-Part Series

Understand the fundamental goals of accountable care and how they fit with the organization’s overall business strategy.Trustees, CEOs, finance directors and others are increasingly turning to hospital IT leaders with a simple request: Build us the infrastructure for accountable care.

The challenges are many—system options, interface design, staffing, budgets, timelines, etc. One of the biggest problems, however, is that accountable care is pushing CIOs to master new ways of thinking about healthcare IT.

Traditionally, hospital IT decisions are based on department needs, system functionality and cost. CIOs focus on issues like system selection, implementation and ongoing maintenance. Starting now, accountable care is taking the IT decision making process to a new level. To create a viable accountable care infrastructure, CIOs need to understand and weigh factors like industry trends, system interoperability, evolving regulations, organizational strategy and more.

Drawing the interface design scope is not enough. CIOs need to create a design strategy focused on results-oriented information that supports the hospital’s unique accountable care model. The key to moving forward is to understand the fundamental goals of accountable care and how they dovetail with the organization’s overall business strategy.

Basic Drivers and Key Developments
The push for accountable care can be boiled down to three basic drivers.

  1. The need for cost control. U.S. per capita spending on healthcare is significantly above that of other developed nations, and healthcare economists expect costs to swell as the population ages.
  2. The demand for better quality. While the U.S. compares favorably to other nations on many quality measures, it appears to lag in important ways, including preventive care and patient safety. Healthcare leaders see a pressing need to improve care processes and outcomes in these and other areas.
  3. Expanded use of health information technology. Both providers and payers see an opportunity to address cost and quality challenges by taking advantage of health IT to capture more information, increase information sharing, standardize care and improve processes.

These basic drivers are shaping the concept of an accountable care enterprise: a group of providers and provider organizations that use technological tools and clinical integration strategies to assume collective responsibility for the quality and cost of healthcare for a defined group of patients. In turn, this basic concept is being shaped and modified by a handful of key developments.

The first development is payment reform. Experts blame high healthcare costs on fee-for-service reimbursement, the traditional payment system that rewards physicians and hospitals for the number of services performed, with little regard for quality or efficiency. Both government and commercial payers hope that making provider organizations responsible for costs and quality will help cut waste, control spending and improve care. Medicare’s new Value-Based Purchasing (VBP) program is a good example. Under the VBP program, DRG payments are tied to hospital performance on specific quality and patient satisfaction measures.

The second development is the focus on clinical integration. The government is requiring providers that want to function as a Medicare Accountable Care Organization (ACO) to demonstrate that they are collaborating to improve patient care, not just creating negotiation leverage. The key is to show that providers are organizing a clinically integrated delivery system around evidence-based standards, with the consequence that providers who do not achieve these standards are ineligible to share in ACO payments. While clinical integration is a Medicare requirement, the concept applies to all providers who are pursuing any kind of accountable care opportunity.

The third development is the evolution of government Meaningful Use (MU) standards. MU is currently focused on electronic medical record (EMR) reporting requirements and process improvement in the form of chronic disease management and e-prescribing. However, MU requirements will develop toward clinical outcomes improvement, and in the near future accountable care performance goals will merge with MU standards.

Next Blog Post: 5 Functional Requirements of ACOs

Topics: Meaningful Use, Accountable Care, ACO, Clinical Integration, Payment Reform, Drivers, CIO

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