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GE Healthcare Camden Group Insights Blog

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 Nidhi Chaudhary, Consultant, GE Healthcare Camden Group

Healthcare 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. 

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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


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Ms. 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, 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

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 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

As 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 

Topics: Payment Reform, Bundled Payment, 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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