Guest post by Richard Loomis, chief medical officer and VP of informatics, Practice Fusion.
In 2016 the healthcare industry made a number of meaningful strides on the move to value-based care, culminating in October with CMS issuing the final rule for the Quality Payment Program (QPP). As the largest program of its kind, the QPP will replace existing programs such as meaningful use and PQRS and fundamentally change the way providers receive payment for patients with Medicare Part B coverage.
In 2017, this focus on value will begin to shift to the vast value found in restoring the provider-patient relationship that drives individualized care and best outcomes. Healthcare isn’t ultimately about quality programs, big data or population health management — it’s about improving our shared human experience and to live happier, longer, more fulfilling lives. The healthcare industry will start restoring this humanity by unwinding the complexity of care delivery and supporting individualized care through a number of new and exciting ways in the new year. Below are five themes we’re predicting to see in 2017:
The year of EHR usability: EHR usability will become a critical success factor for providers as the burden of quality reporting continues to grow in an increasingly fee-for-value world. Practices already spend $40,000 per doctor per year — $15.4 billion nationwide — on collecting and reporting information about their care to Medicare, payers and others. These costs will increase in 2017 and disproportionately affect small practices. It will be financially impossible to practice medicine without a user-friendly EHR. Given this emphasis in usability, more EHRs will turn to offering cloud-based solutions to stay relevant and cost-effective.
Real world evidence comes of age: Real world evidence (RWE) will increasingly be used to support FDA approval for marketing new drugs, leading to further investigation through one or more RWE studies. Although randomized clinical trials continue to be the gold standard for establishing efficacy and safety, they may not reflect typical patient care or day-to-day experiences. RWE studies can include larger sample sizes and a greater breadth of patient demographics and clinical circumstances, which can help supplement the data derived from clinical trials. The FDA has already signaled their interest in RWE, and in 2017 we will begin to see it come to fruition.
Small practices recognized for their oversized role: Small independent practices are a cornerstone of the healthcare ecosystem: Independent solo and small practices are shown to have a lower average cost per patient, with fewer preventable hospital admissions, and a lower readmission rate among their patient populations. For CMS to drive additional value through the QPP, they will start to recognize and support small practices in 2017.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
The picture of healthcare industry is changing rapidly and still continues to evolve, with technology playing a huge role and the other factor being the government. With a new administration in the White House, the Senate and the House of Representatives, there ought to be numerous changes in healthcare, modifying ACA being one of them. Come January, what will be the effect of the new policies of the GOP have on health IT?
In his victory speech, President-elect Donald Trump emphasized on restoring and improving infrastructure and calling healthcare and hospitals an integral part of that plan. The Trump administration even after a session is less likely to remove its focus from IT investments and developments in healthcare; the Republicans believe in leveraging technology and healthcare experts are confident that healthcare-related initiatives like Cancer Moonshot and Precision Medicine Initiative will continue to speed up.
According to a recent ONC report, 96 percent of hospitals and 78 percent of physician offices were using certified EHRs to maintain patient data.
With digital initiatives developing, the hassle in prescribing medicines, scheduling appointments and access to vital records have reduced.
Making the consumer the center of the healthcare system and empowering them has been favorable. According to a survey conducted on 13,000 users, it was revealed that 28% changed their providers based on data made available online – implying that patients wish to be a part of the decision making.
A substantial number of digital health startups have emerged, and their revenue in 2015 was over $4.5 billion – and continues to grow.
Health IT developments to look ahead
Although Donald Trump has his healthcare plan for the country under the covers, some significant advancements are coming our way and following is a slice of what’s coming:
Value-Based Care: One of the most important thing Trump has asserted on in his plan is that he wants to ensure that “no one slips through the cracks simply because they cannot afford insurance.” With U.S. healthcare accounting for 17.1% of the entire nation’s GDP, it’s important to back this transition towards value-based care.
Advancements in Interoperability: In ONC’s latest report to Congress, interoperability was tagged as an essential priority. There are still a lot of factors getting in the way of free flow of data between providers, topped with the inability on patients’ part to access their medical information freely. There are many initiatives on the block: the Sequoia Project’s Care Quality programs, the development of FHIR standards that will be backed by Trump and will pan out impressively.
Banking on Digitization: In sustaining the momentum of this transformation, digitization would be the cornerstone. The use of data analytics, machine learning, patient-centered technology developments and the Internet of Things will unleash their forces under Trump administration and fuel further developments and investments.
Changing the Dynamics of the Marketplace: Donald Trump plans to allow insurance companies to sell their plans across the state lines which may result in an increase in competition and making their plans value-focused. Allowing a free market for drug import could also prove critical in reducing the cost of healthcare: he said in one of his speeches that Medicare could save as much as $300 billion every year, if drug prices were negotiated.
Health IT will stay because the need is to continue to work on making healthcare industry interoperable. Major value-focused programs on healthcare by federal government, such as MACRA won’t see significant changes. However, there is a possibility that the Quality Payment Program could be “enhanced.”
Guest post by Richard Loomis, MD, chief medical officer and VP of informatics, Practice Fusion.
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:
You’re a clinician enrolling in Medicare for the first time. You’re exempt from reporting on measures and activities for the Merit-Based Incentive Payment System (MIPS) until the 2018 performance year.
Your practice meets the low-volume threshold. This means your Medicare Part B allowed charges ? $30,000 OR you see ? 100 patients covered by Medicare Part B during the 2017 calendar year.
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 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.
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.
They receive a five percent lump sum bonus payments for the years 2019-2024.
They will receive a higher fee schedule update for 2026 and onward.
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.
Guest post by Abhinav Shashank, CEO and c0-founder, Innovaccer.
Former US President Abraham Lincoln once said, “Give me six hours to chop down a tree and I’ll spend four hours sharpening the ax.” After having a look at the efficiency of the US healthcare system, one cannot help but notice the irony. A country spending $10,345 per person on healthcare shouldn’t be on the last spot of OECD rankings for life expectancy at birth!
A report from Commonwealth Fund points how massive is US healthcare budget. Various US governments have left no stone unturned in becoming the highest spender on healthcare, but have equally managed to see most of its money going down the drain!
Here are some highlights from the report:
The US is third when it comes to public spending on health care. The figure is $4,197 per capita, but it covers only 34 percent of its residents. On the other hand, the UK spends only $2,802 per capita and covers 100 percent of the population.
With $1,074, the US has the second highest private spending on healthcare.
In 2013, US allotted 17.1 percent of its GDP to healthcare, which was highest by any OECD country. In terms of money, this was almost 50 percent more than the country on the second spot.
In the year 2013, the number of practicing physicians in the US was 2.6 per 1000 persons, which is less than the OECD median (3.2).
The infant mortality rate in the US was also higher than other OECD nations.
Sixty-eight percent of the population above 65 in the US is suffering from two or more chronic conditions, which is again the highest among OECD nations.
The major cause of these problems is the lack of knowledge about the population trends. The strategies in place will vibrantly work with the law only if they are designed according to the needs of the people.
What is Population Health Management?
Population health management (PHM) might have been mentioned in ACA (2010), but the meaning of it is lost on many. I feel, the definition of population health, given by Richard J. Gilfillan, president and CEO of Trinity Health, is the most suitable one.
“Population health refers to addressing the health status of a defined population. A population can be defined in many different ways, including demographics, clinical diagnoses, geographic location, etc. Population health management is a clinical discipline that develops, implements and continually refines operational activities that improve the measures of health status for defined populations.”
The true realization of population health management (PHM) is to design a care delivery model that provides quality coordinated care in an efficient manner. Efforts in the right direction are being made, but the tools required for it are much more advanced and most providers lack the resources to own them.
If population health management is in place, technology can be leveraged to find out proactive solutions to acute episodes. Based on past episodes and outcomes, better decision could be made.
The concept of health coaches and care managers can actually be implemented. When a patient is being discharged, care managers can confirm the compliance of the health care plans. They can mitigate the possibility of readmission by keeping up with the needs and appointments of patients. Patients could be reminded about their medications. The linked health coaches could be intimated to further reduce the possibility of readmission.
The current plight of America’s healthcare industry is not wholly unprecedented. In fact, it isn’t even unique.
American education — higher education in particular — is going through a parallel period of turmoil and scrutiny. It is really uncanny how closely the two industries actually reflect one another. Consider:
Both are critical industries whose public/private status is up for constant debate
Both serve an essentially captive market: everyone needs education to succeed in the economy, and everyone, sooner or later, will require some form of healthcare
There has been a historical tendency for both to treat the people they serve as customers, rather than as students or patients. It is more than semantics: it is a reflection of an underlying philosophy that can potentially compromise the mission of each type of institution
Both are going through a crisis of accountability, in terms of what standards are used to measure their performance, and to whom they must answer for that performance
Both have been very slow to adopt modern technology, and as a result are going through a rapid, disruptive catch-up period
In the race to modernize and reconcile many of these conflicts of purpose and identity, it appears that higher education as a whole may be slightly ahead. Because of this relative lead on the healthcare industry, behavior within the American college and university system can act as a rough preview for the health sector. So, what do we see upon gazing into this crystal ball?
All for One?
A helpful place to direct this gaze is the recent ASU GSV Summit. The name alone reveals much about what is happening in higher education, and needs to happen in healthcare: Arizona State University, in the interest of promoting innovation, collaboration, and evolution in the higher education sector, joined forces with Global Silicon Valley’s family of companies to create their joint summit.
The summit began in 2009, seven years into the tenure of ASU president Michael Crow, who has become one of the leading voices and actors in higher education’s 21st century evolution. The summit is just one of the many strategic partnerships Crow has helped organize through ASU. Aligning the school with everything from technology startups supporting the development of ASU’s online degree programs, to the Mayo Clinic Medical School to offer future doctors transdisciplinary education in fields like business or engineering, Crow is expanding the reach of America’s largest public university by strategically sharing its resources.
In American medicine, there is a clear need for a similar attitude toward strategic partnerships and mission alignment, especially with technology companies and developers. This need is most acute in terms of EHR interoperability. Despite all the rhetoric, the old mentality of siloes, competition, and proprietary ownership prevail, and information remains immobile.
This symptom has implications that extend into every other facet of healthcare.
Patrick Soon-Shiong, billionaire, surgeon and incorrigible optimist, has set his sights on curing cancer. Much like the Precision Medicine Initiative, Soon-Shiong’s approach to this challenge is a matter of getting more, better data from as many partner institutions as possible.
“Cancer is really a rare disease,” he explains. “Because of the molecular signature, because of the heterogeneity, no single institution will have enough data about any [single] cancer. So you actually need to create a collaborative overarching global connected system.”
The end result — better medicine, better outcomes — is something common to the mission of every clinical organization, and ever caregiver practicing medicine. But the means — large scale collaboration, facilitated by transparency and a suspension of select elements of competition — are seldom realized in the current environment. Reconciling the ends and the means requires organizations to think bigger than themselves, and prioritize the sort of partnerships that bring new perspectives, larger pools of data, and creative solutions where they are desperately needed.
Though many Medicare and private payer reimbursement programs that require practices to begin moving to value-based compensation already have set sail, most small practices are still treading water near the shore when it comes to this new wave of payment models.
While admirable in their care goals, these quality care-based reimbursement programs can pose some insurmountable challenges for small providers. In fact, they require a whole new way of providing care for some practices, as well as creating new documentation of integrated data analysis, development of care coordination with other providers, payer reporting applications, and often times new technologies that can support these new provisions.
What’s more, all this change also can be quite expensive for small practices and wreak havoc on current business practices.
Set the course
No doubt about it, though, the move to value-based care is on. According to the 2015 Physician Compensation Survey, conducted by Physicians Practice magazine, 63 percent of physician compensation is currently tied to productivity; 37 percent to value metrics and 29 percent to patient satisfaction scores.
The Centers for Medicare and Medicaid Services (CMS), however, has expressed its goals of having more providers participating in value-based plans each year, with a goal of 50 percent by 2018. And it has further incentivized physician participation by specifying increasing reductions in payments for non-participation that began in 2013.
So unless they want to start leaving money on the table, practices have no choice but to take the plunge into such new compensation programs.
Lift the Anchor
Before diving in and potentially draining money and resources to participate in such programs, physicians need to look around and assess their current situation to determine how the new reimbursement model might work in their practice. For example, they need to evaluate current technology, vendors, resources and physician support to determine what changes they need to make, as well as what internal infrastructure they can use.