Four Steps to Value-Based Care Success in 2017 Under the MACRA Final Rule

Guest post by Richard Loomis, MD, chief medical officer and VP of informatics, Practice Fusion.

Richard Loomis, MD
Richard Loomis, MD

If you bill Medicare, changes are coming in 2017 that may affect your reimbursements. Existing programs such as the electronic health record (EHR) Incentive Program (meaningful use) and the Physician Quality Reporting System (PQRS) are being replaced by a new payment system called the Quality Payment Program (QPP), which is a complex, multi-track program that will adjust payments from -9 percent to +37 percent by 2022. The Centers for Medicare & Medicaid Services (CMS) recently released the final rule that will implement the QPP as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

While the 2,300-page final rule outlining the new program is complex, successful participation in 2017 doesn’t have to be. Here are some tips on how to participate in the QPP starting January 1, 2017 to minimize the risk of any negative adjustment to your Medicare Part B payments beginning in 2019.

Step 1: Check if you qualify to participate

CMS has expanded the range of clinicians able to participate in the QPP compared to Meaningful Use (MU). Eligible clinicians now include physicians, physician assistants, nurse practitioners, clinical nurse specialists and certified registered nurse anesthetists. However, you’re excluded from participating in 2017 if:

Step 2: Choose your participation track

Although the QPP will begin January 1, 2017, there will be a ramp-up period with less financial risk for eligible clinicians in at least the first two years of the program. CMS designated 2017 as a transition year to help providers get started in either of the two participation tracks: MIPS or the Advanced Alternative Payment Models (Advanced APMs).

MIPS

MIPS streamlines current Medicare value and quality program measures — PQRS, Value Modifier (VM) Program and MU — into a single MIPS composite performance score that will be used to adjust payments. All eligible clinicians who are not participating in an Advanced APM should report under MIPS in 2017. Conversely, you’re not required to participate in MIPS if you’re participating in an eligible Advanced APM, as described below. Some APMs, by virtue of their structure, are not considered Advanced APMs by CMS. If you participate in an APM that doesn’t qualify as an Advanced APM, it will increase your favorable scoring under the MIPS participation track.

Advanced APMs

APMs are new approaches to paying for medical care through Medicare that provide incentive payments to support high-quality and cost-efficient care. APMs can apply to a specific clinical condition, a care episode, or a population. The main difference between the MIPS and Advanced APM programs are that Advanced APMs require practices to take on more financial and technological risks.

Advanced APMs meet specific criteria from CMS. Those who participate in Advanced APMs, including   the Comprehensive Primary Care Plus (CPC+), may be determined to be qualifying APM participants (QPs), and receive the following benefits:

It’s important to note that if you stop participating in an Advanced APM during 2017, you should make sure you’ve seen enough patients or received enough payments through an Advanced APM to qualify for the five percent bonus. If you haven’t met these thresholds, you may need to participate in MIPS reporting to avoid a negative payment adjustment.

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Upcoming Trends and Innovations in Healthcare IT 2017

Guest post by John Barnett, project coordinator at Iflexion.

With evolving requirements for care value and quality, caregivers turn to technology to handle emerging challenges related to patients’ health outcomes, care costs and CMS reporting. Each year, new tech-driven solutions arise to assist providers in complying with changing circumstances.

The upcoming 2017 will be even more interesting technology-wise, since after Donald Trump was elected the new President, it’s now possible to form a very different perspective on healthcare. With this in mind, let’s look into market analysts’ predictions for growing trends to watch next year.

3D imaging, augmented and virtual reality

Currently, MRIs and CT scans allow viewing patients’ body parts, organs and tissues in 3D. 2017 may uplift care delivery by harnessing 3D imaging and improving it with augmented and virtual reality.

Caregivers can adopt 3D imaging for patient education and engagement, as well as for treating mental health disorders, such as phobias and schizophrenia.

Surgeons, physicians and nurses might use 3D and enabled glasses for further education and training – for example, to simulate complex microsurgeries. Augmented reality can be harnessed during live surgeries as well, allowing more precision to locate organs and blood vessels accurately, reducing possible damage to healthy tissue.

For instance, eye and brain surgeries imply working in limited spaces, using high-powered microscopes, and making cuts sometimes smaller than a millimeter (e.g., in retina surgery). 3D cameras can widen the picture and allow the whole team to see the target area. When 3D view is coupled with enabled glasses, this may also reduce surgeons’ fatigue from constantly looking into a microscope and keeping an uncomfortable posture with bowed heads and strained necks.

Artificial intelligence (AI)

While physicians have remarkable capabilities to analyze patients’ symptoms and make deductions, still humans can process quickly only a limited volume of information. This is where technology comes into play to support experience and proficiency.

Particularly, artificial intelligence software development is anticipated to become one of the widespread trends of 2017, with such headliners as IBM, Google, Amazon and many others.

AI encompassing machine learning and big data analytics evolves to make multiple healthcare processes faster and more effective. Some of the examples of future benefits are:

Many of future solutions will support natural language processing, as big data in healthcare usually comes in big chunks of unstructured information. If surgeons, physicians and nurses are able to input information directly with their voice, this will also reduce time, effort and, ultimately, costs.

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What is Working in Healthcare?

Guest post by Edgar T. Wilson, writer, consultant and analyst.

Edgar Wilson
Edgar Wilson

In virtually every context that question might be asked, we struggle to give an honest, accurate answer.

It Works If You Believe It Works

Is the medication working? Difficult to say–it may be the placebo effect, it may be counteracted by other medications, or we may be monitoring the wrong indicators to recognize any effect. Is “working” the same as “having an effect,” or must it be the desired effect?

Alternative medicine confounds the balance of expectations and outcomes even further. Right at the intersection of evidenced-based medicine and naturopathy, for instance, we have hyperbaric oxygen therapy, or HBOT. These devices are as much in vogue among emergency departments (to treat embolisms, diabetic foot ulcers, and burns) as holistic dream salesmen (to prevent aging and cure autism, if you believe the hype). When the metric being tracked is as fluid as the visible effects of aging, answering whether the treatment is working is about as subjective as you can get.

As though the science of pharmaceuticals and clinical medicine weren’t confounding enough, you can hardly go anywhere in healthcare today without politics getting added to the mix. In the wake of Trump’s victory in the 2016 presidential election, you have observers and stakeholders asking of the Affordable Care Act (ACA): is it working?

There’s Something Happening Here

It is definitely doing something. It is measurably active in our tax policy, for instance: 2016 returns are heavily influenced by the incremental growth of the ACA’s financial provisions. Of course, the point of this tax policy (depending on who you ask) is to influence behavior. As to this point, there are some signs that, again, something is happening: among young people, ER visits in general are down, while emergency stays due to mental health illness are up. We changed how healthcare is insured, and that changed, in turn, how we access our care. But is it working?

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Professional Support Can Be a Ladder to Upgrade Your HCC Revenue Cycle Management

The CMS (Centers for Medicare and Medicaid Services) employs HCC (Hierarchical Condition Category) for determining payment level for Medicare Advantage Plans. The difference in diagnosis of patients and outcome of their health makes for the risk- adjusted payment. Patients suffering multiple chronic conditions are prone to greater risk scores. For physicians practice accurate HCC coding becomes an important element for managing the revenue cycle.

These risk scores are derived by HCC which are annually assigned to the members. HCCs are completely based on claims data which is collected from the providers. This information further gets annually validated through an audit, which is referred as RADV audit (risk adjustment data validation).

For tackling this situation in a better manner, many payers have started education initiatives for guiding their medical staff and physicians to document complete and accurate medical records. Your medical records determine risk scores of all the members. Here we will tell you how professional support can be a holistic approach for reaping greatest benefits and further  upgrading your HCC revenue cycle management:

Let’s begin with have a brief insight into HCC codes:

Under HCC codes, your reimbursement depends on diagnosis of the patients. The risk score is higher with the patient having severe diagnosis. HCC codes are also referred as “payment multipliers” by CMS. All the guidelines are to choose a primary diagnosis under risk adjustment.

Now, let’s start with the importance of professional support in order to upgrade our HCC Revenue Cycle Management:

  1. Staying Updated with Guidelines

We recommend you to look for a partner who have expertise working in the HCC risk adjustment, encounter data submission, preparation of audits(RADV) and can have a retrospective review of records. Regulations which are implemented by ACA can change anytime and that too abruptly. For staying up-to-date, many vendors have established a body of governance, guidance and memoranda. As soon as the changes are announced, this body of governance informs and updates the affected department.

This governance body is liable for evaluating new requirements. Any single department or an individual can’t anticipate the impacts of modified conditions. Expert of each department collectively takes the decision of selecting the best way for responding the new guidelines.

A professional support have its own body of governance for dealing with new guidelines in a better way.

  1. Implementing Audit and Quality Assurance Program

A quality assurance program will lead you to meet RADV audits and improve the accuracy of your data. For reaping the benefits of this you need to hire a third party. Your third party will substantiate the HCCs which are documented and are based on medical records.

The IVA (initial validation audit) has to verify the enrollment which is included in the sample of the member. After this whole process gets completed, a second validation of audit (SVA) is conducted by HCC. This focuses on the sub sample of the member whose evaluation of record is done in the IVA.

In case SVA finds huge amount of errors, HHS will confirm that whether payer is having an effective program for quality assurance. This program focuses to ensure that the data is complete, accurate and formatted properly. A solid assurance quality program is an important defense in the cases of False Claim Act.

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Can EHR’s Survive Cyber Attacks with An Antidote of Machine-Learning, Ambience and Behavioral Analytics?

Guest post by Santosh Varughese, president, Cognetyx.

Santosh Varughese
Santosh Varughese

Since cybersecurity healthcare threats on hospital EHR systems have become a topic of nightly newscasts, no longer is anyone shocked by their scope and veracity. What is shocking is the financial damage the attacks are predicted to cause as they reverberate throughout the economy.

In the 30 days of June 2016, more than 11 million patient EHRs were breached, making it the year’s worst incident according to a study by DataBreaches.net and Prontenus. For comparison, May had less than 700,000 and 2016’s former breach leader (March) topped out at just over 2.5 million.

While traditional security filters like firewalls and reputation lists are good practice, they are no longer enough. Hackers increasingly bypasses perimeter security, enabling cyber thieves to pose as authorized users with access to hospital networks for unlimited periods of time. The problem is not only high-tech, but also low-tech, requiring that providers across the healthcare continuum simply become smarter about data protection and privacy issues.

Healthcare security executives need to pick up where those traditional security tools end and investigate AI cybersecurity digital safety nets. IDC forecasts global spending on cognitive systems will reach nearly $31.3 billion in 2019.

CISOs are recognizing that security shields must be placed where the data resides in the EHR systems as opposed to monitoring data traveling across the network. Cloud deployment directly targeting EHR systems data is needed rather than simply protecting the network or the perimeter.

Pre-cursors to AI are also no longer that reliable. Organizational threats manifest themselves through changing and complex signals that are difficult to detect with traditional signature-based and rule-based monitoring solutions. These threats include external attacks that evade perimeter defenses and internal attacks by malicious insiders or negligent employees.

Along with insufficient threat detection, traditional tools can contribute to “alert fatigue” by excessively warning about activities that may not be indicative of a real security incident. This requires skilled security analysts to identify and investigate these alerts when there is already a shortage of these skilled professionals. Hospital CISOs and CIOs already operate under tight budgets without needing to hire additional cybersecurity guards.

Some cybersecurity sleuths deploy a variety of traps, including identifying an offensive file with a threat intelligence platform using signature-based detection and blacklists that scans a computer for known offenders. This identifies whether those types of files exist in the system which are driven by human decisions.

However, millions of patient and other medical data files need to be uploaded to cloud-based threat-intelligent platforms, scanning a computer for all of them would slow the machine down to a crawl or make it inoperable. But the threats develop so fast that those techniques don’t keep up with the bad guys and also; why wait until you are hacked?

The Mix of Forensics and Machine Learning

Instead of signature and reputation-based detection methods, smart healthcare CSOs and CISOs are moving from post-incident to pre-incident threat intelligence. AI innovations that use machine learning algorithms to drive superior forensics results and deploy pre-incident security are just what the IT doctor should be prescribing.

In the past, humans had to look at large sets of data to try to distinguish the good characteristics from the bad ones. With machine learning, the computer is trained to find those differences, but much faster with multidimensional signatures that detect problems and examine patterns to identify anomalies that trigger a mitigation response.

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The Rise of Trump Care: 7 Ways Trump Could Impact Healthcare Reform

Guest post by Abhinav Shashank, CEO & co-founder, Innovaccer.

Abhinav Shashank
Abhinav Shashank

On Nov. 9, 2016 the United States of America witnessed a major turnaround in the administration. Republican candidate Donald Trump is the 45th president-elect of the United States. Donald Trump plans to bring about numerous changes to “Make America Great Again,” and true to his Republican roots, Trump’s plans for the healthcare focus on some key facets which have always been a concern for the GOP.

Trump has outlined his healthcare plan for America that is centered around mainly the following key facets. A study conducted by the Commonwealth Fund with RAND Corporation using simulation analyzed his plans and came up with probable impacts.

1.) Repeal Affordable Care Act

Donald Trump and the GOP want to fully repeal the ACA and replace it with something new, dubbed “Healthcare Reform to Make America Great Again.” However, the intention is to achieve a better law with some parts of ACA.

Planned changes: Pre-existing condition clause will remain. As the Republican plan “the better way” dated June 22, 2016, Trump plans to continue with it as no American should be denied on the basis of pre-existing medical conditions or demographics. Remove the individual and employer mandate, as no one should be forced to buy health insurance. Reduce the growth rate of Medicare spending and implementation of new taxes and fees.

2.) Use of Health Savings Accounts (HSA)

A Health savings account is a tax-advantaged medical saving account available to the people of US, which allows people to contribute or draw money from for paying off medical expenses, tax-free.

Planned changes: Under Obamacare, HSAs were available to only individuals who were enrolled in “High Deductible Health Plans.” Keeping the basics same, Trump proposes to expand HSAs, allowing all individuals to use HSAs where the contributions would not only be tax-free but will also accumulate over time. Moreover, he would allow HSAs to become a part of a person’s estate and would be passed on to heirs without any penalty.

3.) Making premiums tax deductible

Before ACA came along, there were substantial tax advantages available to people who had their employer cover for them, but that privilege did not extend to people who took up private, individual-market policies not provided by the employer. To solve this disparity, ACA had the provision of means-tested advance premium tax credits, known as APTCs – where the government reduces the cost of insurance by providing APTCs to bridge the gap between the cost of premium and payment limit.

Planned changes: Trump’s plan will allow individuals to fully deduct their premiums from their tax returns under the current tax system, facilitating a free market to provide insurance coverage to companies and individuals. The scheme Trump has will abolish APTCs and let individuals use pre-tax money to purchase individual market insurance.

The aim is to provide people with an incentive to pay for coverage when they are healthy, and not make it mandatory.

4.) Funding Medicaid through block-grants

Under the current law, Medicaid gets join funds by the federal and state government and the federal government contributes 50 percent to 75 percent of the total costs and the rest is borne by the states.

Planned changes: Trump proposes to fund Medicaid all over the country through block grants. Under this, the federal government would give a fixed amount of money to states and let them fund their programs.
The rationale behind this is that state governments know best about their population and should have the sole authority on how the money should be spent and will fare better without federal administration overhead.

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Building Effective Provider-Payer Partnerships

Guest post by Steve Tutewohl, strategic accounts officer, Valence Health.

Steve Tutewohl
Steve Tutewohl

Payers and providers have always had inherent tension. Their business models never provided a true incentive to work together.

However, as the industry moves toward value-based care, providers and payers are now incentivized to focus on improving quality while lowering costs.

When I got into the healthcare business 20 years ago, as an actuary working on the provider side, my clients were taking bold risks with limited information, little analytical support and hardly any data. Today, providers often have more access to data than payers.

Healthcare is at a critical juncture, which creates a great opportunity for different types of professionals, including actuaries. We will continue to find new purposes, new roles and new responsibilities in healthcare, because the need for sophisticated analytics is growing exponentially every year.

One of the first Affordable Care Act challenges actuaries were uniquely prepared to address was the financial impact of risk adjustment transfers when the healthcare exchange opened.

The insurance industry had never seen anything of this magnitude before. It could either be catastrophic or a huge boon for healthcare insurers depending on how it paid out. Insurers are used to dealing with a certain level of uncertainty, but no company is comfortable operating blindly indefinitely. Based on our understanding of the business and our technical know-how, actuaries were able to offer providers and payers:

Effective payer-provider partnerships are formed when both align on a value proposition. They have to see and understand what value the other one brings to the equation.

On the provider side, it’s pretty simple: They are looking to secure their patient base and increase their market share. On the payer side, there are slightly different objectives. If they are going to move towards assigning risk to providers, they need assurances the provider network can bend the cost curve so they, as payers, can focus on selling product.

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3 Health IT Trends for Small Practice Performance, Profitability and Productivity

Guest post by Gaby Loria, analyst for mental health software, Software Advice.

Gaby Loria
Gaby Loria

There are certain factors clinicians are constantly working to improve at their practices, such as:

While these three P’s apply to every health care provider, regardless of practice size or specialty, they are especially important for independent physicians.

Solo and small practice doctors face more challenges than their counterparts in group-owned or hospital-affiliated organizations. They shoulder all the responsibility for:

For all of these reasons, it’s wise for small practices to invest in health IT tools that can give them an edge in a competitive and increasingly data-driven industry. The three tech trends we describe below can help improve performance, increase profitability and impact productivity without breaking tight budgets.

Improve Performance with Population Health Tools

The goal of managing population health is to achieve measurable improvements in the health outcomes of a group of people. In other words, taking steps to help groups of patients get healthier instead of solely focusing on one individual’s treatment plan at a time.

That may sound like a lot of work, but it’s not—if you have the right IT.  Nowadays, there are a number of population health-enabled capabilities that are built into electronic health records (EHR) software systems commonly used by small practices. The breadth and depth of these capabilities vary depending on the system, but here are some examples:

This technology makes it feasible for busy physicians to provide extra attention and care to patient populations that need it most, so they can prevent a worsening condition from developing. Such clinical interventions on a group scale can therefore make it possible to improve the overall health of a practice’s patient base.

Increase Profitability via Telemedicine

Telemedicine is the use of technology to support remote medical services. One of the most lucrative ways small practices can adopt telemedicine is by offering video consultations, which are virtual patient-physician interactions enabled by videoconferencing software. This allows doctors to see more patients per day without adding overhead costs (e.g., office space or staffing).

Interested physicians have two main options to capitalize on this trend:

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The Largest Hospital in Each State

Healthcare jobs are plentiful, and at least through 2024, the demand for healthcare professionals such as nurses, anesthesiologists and physicians will only continue to rise.

The Bureau of Labor Statistics has said that healthcare jobs are “expected to have the fastest employment growth and to add the most jobs between 2014 and 2024.” Given the healthcare industry’s propensity for increased growth, hospitals need to embrace scalable IT—for their own sake and for the sake of their patients.

Fortunately, there are options.

Healthcare organizations increasingly rely on cloud-based IT solutions, and SADA Systems has reported that the number of organizations living in the cloud could be as high as 89 percent. There’s a reason for the high percentage—cloud solutions are safe, scalable, and efficient.

Hospital data safety is no small concern.

In 2008, 9.4 percent of hospitals used EHRs. By 2014, the percentage had skyrocketed to 96.9 percent. The switch to digital records was necessary, but in the rush to modernize, hospitals were left more vulnerable to data theft than other industries that had migrated more slowly.

According to Niam Yaraghi, healthcare systems are left with an additional concern. “Hospitals cannot tolerate the consequences of computer lockdowns,” writes Yaraghi. “If Wal-Mart gets attacked, it will likely shut down for a short period of time and fix the issue…Hospitals on the other hand, are dealing with patients’ lives.”

Cloud-based IT solutions provide both reliable security and almost nonexistent downtime.

Further arguments for cloud IT include the sheer number of patients hospitals see every year. Hospitals treat 136.3 million patients in the emergency room alone, according to cdc.gov, and believe it or not, that number is growing. Cloud IT accommodates growing demand seamlessly.

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The Promise of Tomorrow’s EHR

Guest post by Paul Brient, CEO, PatientKeeper, Inc.

Paul Brient
Paul Brient

Advances in technology have fundamentally altered and inarguably improved the way we drive, shop and travel. Just ask anybody who uses Google Maps, Foodler or Uber.

Sadly, however, information technology has failed to deliver so far in the most crucial service of all – healthcare.  This is at least partly because electronic health records (EHR) systems grew out of the computer systems that run the hospital’s inner workings — patient scheduling, admission and discharge, staff payroll and accounts receivable. For system designers, physicians’ needs were an afterthought, which is problematic because physicians are, after all, the linchpin of the healthcare delivery system.

To begin pulling healthcare IT out of the past, we must first take a look at how it supports physicians. The short answer today is “not well.” In fact, EHRs are creating as much frustration as benefit.  Problems include poor presentation of patient data, fragmented information sources and unwieldy user interfaces that require dozens of mouse clicks or screen taps. It’s no wonder more than half of physicians who responded to a recent survey claimed their EHR system had negative impacts on costs, efficiency and productivity – three things IT should help, not hinder. These issues not only affect physicians’ professional satisfaction, they contribute to the phenomenon of physician burnout, which is a growing concern across healthcare. Studies show some 30 percent of primary-care physicians age 35 to 49 plan to leave medicine, and there’s an expected shortage of 25,000 surgeons by 2025. A Mayo Clinic study released earlier this year directly connected the burnout problem to physicians’ use of EHRs.

Today’s EHRs have done little more than “pave the cow paths.” We’ve gotten rid of paper in the hospital and made processes electronic, which is why EHRs can legitimately claim to have reduced transcription errors. But eliminating paper is just table stakes; the critical next phase is to do for healthcare what Uber has done for transportation: Reinvent the process so it’s optimized for and native to the technology that enables it.

Patients and physicians can and should advocate for such change. Today, patients have access to a vast body of information—the notes a doctor took, quality of care rankings, the level of personalization provided—and it’s only going to increase.  As Lygeia Ricciardi, former director of the Office of Consumer eHealth at ONC said, “Getting access to personal health information is the start of engaging patients to be full partners in their care.”

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