Guest post by Ken Perez, vice president of healthcare policy, Omnicell, Inc.
Ken Perez
The recently concluded debate about the American Health Care Act (AHCA), the Republicans’ first attempt at a Patient Protection and Affordable Care Act (ACA) replacement plan, centered largely around issues of insurance coverage and access to care.
The real turning point for the AHCA seemed to be the Congressional Budget Office’s March 13 release of its analysis of the bill, which concluded, among many things, that millions more Americans would be uninsured under the AHCA than under the ACA (14 million in 2018, 21 million in 2020, and 24 million in 2026).
After it became clear that the roughly three-dozen member Republican House Freedom Caucus—which sought a more aggressive piece of legislation that would gut the ACA—would not support the bill, House Speaker Paul Ryan concluded that the Republicans lacked the needed votes. Thus, on March 24, he pulled the AHCA from the floor. Ryan told reporters, “I don’t know what else to say other than Obamacare is the law of the land” and “We’re going to be living with Obamacare for the foreseeable future.”
With the focus mainly on coverage and access issues, a largely unasked question has been, “What will happen to value-based care?” The AHCA did not address this area, though, perhaps the Republicans intended to cover it in phase two or three of their grand plan to repeal and replace the ACA. As originally envisioned by congressional Republicans, phase two will consist of executive branch initiatives (e.g., actions by the Department of Health and Human Services and presidential executive orders), and phase three will include subsequent pieces of legislation addressing other aspects of the ACA.
The fate of value-based care is an important topic because U.S. healthcare costs continue to escalate and outpace general inflation—increasing 5.8 percent and reaching $3.2 trillion in 2015, equal to almost $10,000 per person per year. In addition, the ACA mandated five major healthcare delivery reforms promoting value-based care:
The Hospital Value-Based Purchasing (VBP) Program
The Hospital-Acquired Condition Reduction Program (HACRP)
The Medicare Shared Savings Program (MSSP)
The national pilot program for payment bundling
The Hospital Readmissions Reduction Program (HRRP)
Moreover, the ACA provided funding of $10 billion over 10 years for the Center for Medicare and Medicaid Innovation (CMMI), which was tasked with testing and evaluating various payment and service delivery models involving, in most cases, voluntary provider participation, with only a few models being mandatory.
Guest post by Abhinav Shashank, CEO and co-founder, Innovaccer.
Abhinav Shashank
The way we see healthcare today is very different from what it was a couple of decades ago. Back then, we did not have the technology to capture the best practices. But, today we have the capability to use medical data as a source of innovation and create impact at scale. But the question is are we capitalizing on it? Have we made the lives easier for both patients and care teams? Are we close to the goals we started chasing ten years ago?
When we talk about innovation in healthcare, we stumble across intuition. The intuition of care teams enhanced by data-driven approaches. It is not just limited providing connectivity to healthcare organizations; it is also about providing advanced analytics and reducing the cumbersome, tedious work! Like deep diving for hours on Excel or making quality tracking and reporting easier.
The concept of population health management is a new one. It has evolved from an idea to become a clinical discipline that works on developing and continually refining measures to improve the health status of populations. A successful population health management program thrives on the vision to deliver robust and coordinated care through a well-managed partnership network. This said, there is no one definition of Population Health Management, fifty different CIOs in an interview gave different definitions to this term. It is a broad concept and covers a lot under its umbrella.
What does an ordinary health IT setup lack?
True, the healthcare systems are working on building the skills to interact and develop well-planned health intervention strategies to move away from the traditional fee-for-service model to value-based reimbursements and incorporating value, but they are falling short in many areas:
Limited EHR capability: EHRs played a pivotal role in digitizing health care, but with EHR technology many restrictions came along. Today, only a few are equipped to support the necessary interoperable standards. To deliver better clinical outcomes, it is of paramount importance that we have the data and right analytics to ensure improvements; something healthcare organizations lack even today.
Integrating data sources: A patient who is being relocated to a new state and will have a new PCP and Care Coordinator. Can we say with confidence that the patient’s information will be available to the new PCP? In a large healthcare network, there is labs, pharmacy, clinical, claims, and operational data, but the capability to integrate it into a single source of truth is still a challenge for many! This has limited the potential of care teams and made them communicate in a disconnected ecosystem.
Risk Stratification: 50 percent of expenditure in healthcare is on 5 percent patient population. Wouldn’t it be great if we could find these patients and cure them before any acute episode? Back in 2012, about 117 million Americans had one or more chronic conditions, and account for 86 percent of the entire healthcare spending. The road to population health management will require care teams to recognize at-risk population timely to reduce cost and improve outcomes!
Guest post by Andy Ridinger, director of client experience, MyHealthDirect.
Andrew Ridinger
Despite much of the uncertainty facing the future of the health care industry, the shift to value-based care is not going to go away. Regardless of what new laws may decide, organizations need care coordination tools now more than ever to be successful. Doctors and hospital officials continue to cite care coordination as a key advantage in accountable care models, which seek to more tightly integrate providers and maintain joint financial incentives that deliver better-quality and lower-cost services.
In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Referrals are the crucial link between primary and specialty care. Yet despite this frequency, the referral process itself has been a great frustration for many years. The transformation to value-based healthcare is well underway with a shift away from the quantity of patients to the achievement of better health outcomes.
The current state of the specialty-referral process in the U.S. provides substantial opportunities for improvement, as there are breakdowns and inefficiencies throughout. These are inevitable when the process hinges on a patient following through on a slip of paper. It is no wonder that of the one third of patients that receive referrals, 20 percent never follow through to schedule a visit. Of the referrals that are completed, a host of other challenges often result. Sometimes it is just a disconnect of information between the two providers but can be an incorrect provider altogether. The final outcome is poor for everyone involved; patient, referrer, and target provider alike.
To improve the referral process and care coordination, here are four strategies to facilitate greater convenience in care coordination initiatives:
Make it digital
Just by enabling online booking, referral lead times (time between a PCP and specialist office visit) decrease by up to 36 percent, and show rates improve by 20 percent. Additionally, on the spot booking to a specialist reduces patient leakage for health systems. It can guarantee that care is rendered by the best-suited physicians within your preferred network.
Make it best-fit
The most effective appointment maximizes show rates and minimizes lead times. A provider must select the preferred physician with the earliest availability at a time the patient is likely to show up. Optimized scheduling can yield up to a five times increase in referral completion rates.
Make it measurable
The best way to improve referral completion rates and reduce lead times is to capture the relevant data points in a timely manner so that you can track changes over time. Presenting the data in an easily consumable and actionable format is equally critical.
Connect the docs
To know if patients complete visits, it is critical that all parties share the right information and facilitate two-way communication in real time. A primary care physician making a referral is far better equipped to manage a patient’s health if she receives show status and notes back from the specialist visit as soon as that information is entered into the specialist’s electronic health record.
Guest post by Richard Loomis, chief medical officer and VP of informatics, Practice Fusion.
Richard Loomis
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.
Abhinav Shashank
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?
Healthcare Today
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.
Future Implications
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.
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:
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
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.
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.
Abhinav Shashank
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.
Countless Possibilities
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.
Edgar T. Wilson
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.
