MIPS and the Business of Healthcare


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

At this year’s Healthcare Information and Management Systems Society (HIMSS) conference, representatives from the Centers for Medicare & Medicaid Services (CMS) held multiple sessions where they reinforced the message that the Quality Payment Program and value-based programs are moving forward. Jean Moody-Williams, deputy director of the center for clinical standards and quality at CMS said “As we build the program, our goal is to achieve a 90 percent participation rate by all clinicians. That includes small practices as well.”[1] Other CMS officials touted tangible results that value-based care has been delivering, such as a “17 percent reduction in hospital acquired conditions across all measures from 2010 to 2013, to savings of $37 million from providers participating in the advanced ACO Pioneer program.”[2]

As about nine out of ten providers are expected to fall under the Merit-Based Incentive Payment System (MIPS) track of the Medicare Access and CHIP Reauthorization Act (MACRA), many providers are asking themselves whether they should fulfill MIPS’ minimum requirements or strive for more. Said another way, should their organization strive to be a MACRA All-Star? Is it worth it to commit the effort and investment required to max out potential bonuses?

There are four main inputs to consider as you create your data-driven strategy for performing under MIPS. The first is the amount of Part B Reimbursements that you are expecting currently, how much you have received in the past, and how much you expect to receive in the future. That is going to drive your bonus potential as a practicing system, which is the second input to consider. Your bonus potential is going to help you understand the amount of resources that you have available to make the necessary changes in your care team. This third factor is critical in driving your organization’s MIPS strategy as you may decide to change the workflows of your nurses and physicians or add a data analyst to help you take care of the populations that are now transforming your practice. And finally, consider the amount of data analytics you have in your practice. In the past, where have you performed? Where do you stand to gain? How much of a gap do you have to close to become a MACRA All-Star?

Providers should think about these key inputs they will need to evaluate for their MIPS strategy. What is my Medicare Part B Revenue today? What impact does MACRA have on it? Do I need to get ahead of payment rates that will remain basically flat? How many resources will be impacted by MACRA reporting requirements this year, next year, in two years? Can I earn a bonus that makes a difference to my business?

If you’d like to continue the discussion, please send a note here.

[1] http://www.diagnosticimaging.com/articles/cms-seeks-make-macra-manageable-small-practices

[2] http://www.healthcarefinancenews.com/news/despite-some-good-parts-ahip-says-gop-healthcare-bill-concerning-insurers

Have You Adopted Electronic Prescriptions for Controlled Substances?


Post by Jaimin Patel


Vice President IAM Program Management, Caradigm

When regulations for Electronic Prescriptions for Controlled Substances (EPCS) were introduced in 2010, more than 12 million people reported using prescription painkillers non-medically, and the number of painkillers being prescribed could have medicated every American adult for a month straight. [1] In response to the volume of both the abuse and prescribing of controlled substances, the Drug Enforcement Agency (DEA) set several regulatory requirements for healthcare practitioners and organizations that want to prescribe controlled substances by electronic means.

Initially, many providers were concerned about the strict security mandates. To be able to prescribe controlled substances electronically, the DEA requires a secure, auditable chain of trust for the entire process. In addition, the financial and IT resources required to implement the appropriate solutions for EPCS can be challenging for smaller organizations.

With only 1% of e-prescribers being enabled for EPCS as of December 2013, adoption was a concern as prescription abuse remained a prominent societal issue. [2] In 2014, almost 50,000 people died of drug-induced causes in the United States. [3] In 2015, opioids alone killed more than 33,000 people. [4] The unavoidable reality of opioid abuse in society led to additional state laws and regulations following the DEA mandate in 2010, which resulted in broader EPCS adoption. As of September 2016, 20.2% of e-prescribing providers were enabled for EPCS. [5]

Caradigm offers an integrated and comprehensive solution for EPCS workflows that is a seamless extension of our industry-leading Identity and Access Management (IAM) portfolio. Caradigm’s Multi-Factor Authentication (MFA) solution for EPCS offers a variety of integrated authentication options ranging from biometric fingerprints, hard & soft token authentication, as well as mobile authentication. These options allow your organization to implement the best authentication solution to meet your prescribers’ needs.

The DEA requires identity proofing for prescribers that access EPCS controls within an electronic medical record (EMR). Caradigm Provisioning Identity Management ensures that appropriate checks and balances are applied for an organization before granting a prescriber EPCS rights within an EMR. Further, when the prescriber no longer needs EPCS privileges, Caradigm Provisioning Identity Management can seamlessly update these permissions in the EMR while notifying appropriate members in the organization. This integrated solution ensures that no unauthorized access is granted for prescribers.

Caradigm’s EPCS solution has been deployed at number of sites where users are benefiting from integrated Single Sign-On for fast and efficient access into their applications and MFA for EPCS workflows.

Overall, it’s hard to argue that EPCS is anything but a positive for the healthcare industry, and any organizations that have not adopted a solution for EPCS should act now. E-prescribing is a tool that increases efficiency, prevents the likelihood of fraud, and reduces the risk of controlled prescription errors. For additional information, please visit our EPCS page.

[1] http://www.cdc.gov/VitalSigns/PainkillerOverdoses/index.html

[2] http://www.ajmc.com/journals/issue/2014/2014-11-vol20-sp/adoption-of-electronic-prescribing-for-controlled-substances-among-providers-and-pharmacies

[3] https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_04.pdf

[4] https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

[5] https://www.healthit.gov/opioids/epcs

 

Embedding Evidence-Based Medicine into Transitions of Care


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

Population health is a journey over time and provider organizations understand they must begin with the most impactful programs. Providers have to prioritize and focus initial efforts to quickly bend the needle on patient outcomes such as reducing readmissions. When organizations ask me where others are seeing tangible initial success, I often tell the following story.

An outpatient care manager at one of Caradigm’s existing customers shared with me that the value of population health technology became clear for her after getting a real-time alert one day that one of her patients was in the ED. She called the ED and was told that the patient’s blood glucose levels were extremely high, and the ED nurse thought the patient should be admitted. However, the care manager informed the nurse that the patient’s numbers were actually the patient’s baseline, and recommended that the patient did not have to be admitted, which saved an unnecessary admission. The outpatient care manager was able to devise and implement an effective plan of care to address a variety of contributing barriers to care, and the patient outcome was improved.

This story is about taking the right action, in the right time frame, in the right care setting. In other words, how do you embed best practices into workflows to reduce variation in care? How do you help patients move through a confusing and disjointed healthcare system that can be overwhelming to navigate? Transitions of care is an area central to population health that for many organizations is an excellent place to focus your population health efforts. The following are a few best practices to think about as you develop your strategy.

Facilitate access to primary care

Coordinated care is a proven value for high-risk patients, however, it is often a challenge for patients to access primary care soon after being discharged. Some organizations have found it effective to enroll high-risk patients into a Patient Centered Medical Home (PCMH) as a standard practice to get them better connected to primary care, a care coordinator and other community resources. Another approach is to partner closely with primary care clinics and even embed a care manager, a transition focused mid-level practitioner or social worker into the clinic to specifically serve high risk transitions patients. Even offering telephonic transitions of care support to coordinate scheduling for patient can help.

Standardize interdisciplinary care

When multiple levels of clinicians partner effectively with defined pathways and shared information, it’s amazing to see the impact. For example, psychiatrists and social workers going to a PCP’s office to speak to patients. Pharmacists calling physicians to say a prescription ordered is far more expensive than other options. Home health that directs patients back to lower acuity centers if needed, and works with patients to prevent unnecessary ED stays. Some provider organizations have had success identifying non-employed physicians interested in adding home visits as an additional revenue opportunity. Population health is truly a team sport and technology can help support transparency and care traffic control, making patients more confident in a team based delivery model.

Embed practices into workflows

After establishing your care protocols and pathways, care management tools can help ensure they’re followed consistently. Intelligent plans of care can have pathways embedded in the patient care plan, assuring that steps aren’t missed. Role-based tasking can help a team of clinicians take the right steps, in the right sequence, all while working at top-of-license. As mentioned in the story earlier, alerts can let the appropriate care team member know when a patient has a change in status, whether an ED visit, observation stay or inpatient admission. Lastly, as it is common for patients to be managed in multiple EMRs, technology can play a big role in streamlining medication review and in overall information sharing by aggregating data from multiple EMRs. Performing standardized readmissions assessments can help determine root cause, support an automated plan of care to mitigate barriers and perhaps even identify patterns or discharge practices of care that require change.

Improving transitions of care, supports long term success in advancing quality, patient experience of care as well as managing the cost of care. Organizations should be thinking about strategies for scaling, risk stratification, solving for social determinants and reducing variations in care. Wherever your organization is today, if you focus on meeting patients where they’re at and guiding them through what is a complex healthcare system, you will have succeeded in a foundational strategy for long term success.

What a Trump Presidency Could Mean for Population Health


Post by Neal Singh


Chief Executive Officer, Caradigm

Based on President-elect Trump’s campaign promises, the healthcare industry could experience significant changes. His commitment to “repeal and replace” the Affordable Care Act (ACA) is at the center of the conversation, and raises a number of questions. Can it actually be repealed? What is the impact for value-based programs currently underway such as the Medicare Shared Savings Program, bundled payments and MACRA? What should healthcare providers do now? This post will address these questions and my opinion on what it means for the future of population health.

1) A complete repeal of the ACA faces challenges

President-elect Trump has indicated[1] that he supports some parts of the ACA such as forcing insurers to cover people with pre-existing health conditions and allowing parents to cover children on their plans into their mid-20s, so it is hard to determine this early the full extent of the changes to come. In addition, Republicans support some aspects of value-based innovations. There are about 283 million insured lives in the US[2] including about 20 million covered under Obamacare.[3] Even if the ACA was to be fully repealed, there are nearly three hundred million lives for whom the fundamentals of economics and quality of care necessitate the move towards value based care.

2) Value-based healthcare will continue because it has bi-partisan support

MACRA passed with overwhelming bi-partisan support in both the House of Representatives (392-37) and the Senate (92-8).[4] Bundled payments[5] and ACOs[6] also have bi-partisan support. The reason for this is that both sides of the aisle recognize the clear need for healthcare payment reform. Amongst all the contentious legislative arguments that exist today, there is no debate around the fact that healthcare costs are on an unsustainable growth trajectory. There is consensus that the government has to continue making providers more accountable for reducing costs, improving quality and increasing patient engagement and satisfaction.

3) Expect some changes to the mechanics of value-based programs

While the top-level themes in healthcare payment reform are unchanged, I do think we can expect changes in the mechanics of some value-based programs. Republicans, including President-elect Trump’s nominee to head Health and Human Services, Rep. Tom Price (R-Ga), have expressed concerns about the power and budget controlled by The Center for Medicare & Medicaid Innovation (CMMI)[7], so CMMI’s role could be impacted. Specific programs like the MSSP ACO program could be structured differently in the future although that would have to take place after current three-year contracts with the government expire. Republicans could push for new Medicare and Medicaid reform, which would impact beneficiaries and could drive more formation of Medicare Advantage plans or lead to Medicaid ACOs. No one today knows exactly how current programs are going to evolve, but the reality is that programs must evolve to address cost and quality concerns.

4) “No regrets” strategies for healthcare

Although healthcare faces uncertainty, there are certain priorities for organizations that will apply. So-called “no regrets” strategies for healthcare include driving more consistent, efficient and coordinated care, integrating IT systems, accurately forecasting patient risk, lowering your cost structure, and building deeper relationships and loyalty with patients. Everyone needs to operationalize these capabilities now so they can manage large scale Medicare and Medicaid populations effectively in the future. These are capabilities that take years to refine, which is why some healthcare organizations view the building of these best practices as market differentiators that will ensure their long-term success against regional competition.

Population health is already making a difference for patients. Our customers are seeing tangible improvements in patient outcomes and cost reduction through lower utilization while developing deeper relationships with their patients. They’re even benefiting financially through the generation of significant shared savings. This is an incredible time of innovation in healthcare that I believe is going to accelerate even more as healthcare organizations build off their early successes and learnings.

 

[1] http://www.nytimes.com/2016/11/12/business/insurers-unprepared-for-obamacare-repeal.html?_r=0

[2] http://www.census.gov/content/dam/Census/library/publications/2015/demo/p60-253.pdf

[3] http://talkingpointsmemo.com/dc/nejm-obamacare-progress-report

[4] http://www.entnet.org/content/permanent-repeal-sgr-formula

[5] https://www.premierinc.com/premier-lauds-introduction-of-bipartisan-bundled-payment-legislation/

[6] https://www.brookings.edu/blog/health360/2015/03/23/how-early-accountable-care-efforts-shaped-payment-reform-in-the-aca-and-bipartisan-reform-ever-since/

[7] http://www.jdsupra.com/legalnews/will-republicans-embrace-cmmi-s-11849/

What Are The Key Population Health Management Capabilities?


Post by Michelle Vislosky


Senior Population Health Market Executive, Caradigm

Like a Rubik’s Cube, the functionality and performance metrics for population health management can be difficult to define, align, and deploy. The Institute for Healthcare Improvement Triple Aim for healthcare proposes three linked goals for population health management: 1) Improving the individual experience of care 2) Reducing per capita cost of care and 3) Improving the health of populations. However, with legislation and payment models still evolving, so too are the requirements to perform population health management. It’s challenging to determine what are the key population health management capabilities required to achieve the Triple Aim.

The health care industry has a number of population health management models, but they are often defined by the current capabilities of providers, payers, and vendors, rather than what is needed. Additionally, the models do not easily translate to the required business models required by the various value based payment arrangements and their combinations. Further complicating matters is the overlapping responsibility for the overall health improvement of individual patients and populations by both the public and private sector, including payers, providers, and community organizations.

The HIMSS Clinical & Business Intelligence (CB&I) Committee creates practical and unbiased tools and resources to help healthcare organizations use clinical and business intelligence to execute population health management initiatives. In 2017, the CB&I Committee’s Population Health Task Force will create a HIMSS population health management model that identifies the various population health domains and their capabilities and map these to the payment arrangements. The payment arrangements will include the current payment models from CMS, commercial payers, employer-based, and provider owned health plans. The model would be the fifth dimension to the HIMSS Healthcare Value suite: http://www.himss.org/ValueSuite.

Once finalized, the HIMSS population health management model will contain a set of resources with content relative to each population health management domain available on the HIMSS website. Like a Rubik’s Cube, it will be able to define the population health capabilities required if deploying a specific payment model or combination. These population health management model resources will include domain summaries such as sharing of “best practices” via blogs and white papers, ROI templates and examples, sample RFP language, and Lunch n’ Learn sessions, (short 20 minute recorded webinars). The model will help to develop education resources and pathways for career development. It could also be used in the future as a means of highlighting and mapping the vendors at the annual HIMSS meeting that offer those population health management capabilities. HIMSS will also share and collaborate with affiliates and the industry at large to further refine the population health management model as the requirements of the Accountable Care Act evolve.

If you are interested in learning more or participating in the development of the HIMSS population health model, you can sign up at www.himss.org/ClinBusIntelCommunity.

Compliance Isn’t Enough: Improving Governance, Risk Management, Compliance


Post by Jaimin Patel


Vice President IAM Program Management, Caradigm

Change is the new normal in healthcare, which can come in many forms. Mergers and acquisitions, the formation of accountable care organizations and clinically integrated networks, having new groups of physicians arrive at a teaching hospital, or even the replacement of an EMR are just a few examples. From an IT perspective, the impact is that you constantly have new clinicians needing access as quickly as possible because it impacts patient care. IT and security professionals also understand that access has to be granted and managed in a manner compliant with the HIPAA Security Rule. However, with the increase in motivated and persistent security threats, healthcare as an industry has to move beyond the notion that our goal is only HIPAA compliance.

I recently heard Mac McMillan, CEO of CynergisTek, talk about this at the Caradigm Customer Summit where he stressed that compliance with HIPAA does not equal security. McMillan explained that HIPAA was designed to protect the privacy and security of certain health information. It was not intended to cover all forms of information or to be a complete standard for data protection.

A major part of the problem is that the HIPAA Security Rule, initially conceived in 2001, pre-dates many of today’s technology advancements. It did not envision cloud computing, mobile devices, networked medical devices, wearables, population health applications and many other advancements seen since that time. It also pre-dates many of today’s evolving threats such as cyber-extortion (e.g. ransomware), cyber-espionage, hacktivism, and specific threats such as phishing and zero day attacks. Consequently, if healthcare organizations are focused solely on compliance, then their security is inadequate.

McMillan called on healthcare organizations to think and act differently when it comes to data security and privacy. It’s about greater due diligence, day in and day out and aligning with your organization’s broader Governance, Risk Management and Compliance strategy. For identity and access management risk, greater security can involve improvements such as the following:

  • Employing a role-based security model to enable more precise granting of access
  • Automating provisioning and deprovisioning so that role changes are made efficiently and accurately
  • Using analytics to proactively search for potential risk such as orphaned accounts or mismatched entitlements
  • Streamlining workflows to evaluate and remediate threats faster across many applications
  • Performing audits more efficiently by empowering managers to review and attest to their direct reports’ entitlements

When I speak to healthcare organizations, I recommend that they consider getting the tools in place now so they can be prepared for when change hits their organization. It’s going to happen eventually. Having the right tools not only makes your organization more secure, it makes your staff far more efficient, and will deliver to your clinicians timely and accurate access. There’s not many IT projects that can claim this trifecta of wins for your organization. If you’d like to learn more about the value provisioning and identity management tools can bring to your organization, please download this whitepaper here.

How Bundled Payments is Driving Care Transformation and Patient Engagement


Post by David Lee


Product Marketing Manager, Caradigm

Bundled payments was one of the most discussed topics at the recent Caradigm Customer Summit, our annual gathering of industry leaders to share best practices in population health and information security. Matt Stevens, Senior Director with The Advisory Board highlighted bundled payments in his presentation as a program that CMS believes will push the needle in reducing cost variability while improving outcomes for high volumes of patients. He said more mandatory bundles (e.g. cardiac, expansion of Comprehensive Care for Joint Replacement) could be coming and that the intersection between bundled payments and MACRA is only likely to grow as it could become tied to the Advanced Alternative Payment Model (APM) track in the future. Matt recommended that hospital systems prepare to deliver both a broad clinically integrated network as well as excellence in individual bundles that can be decoupled and offered to patients in ways that offers them greater value.

We also heard a number of provider organizations (St. Luke’s University Health Network, United Surgical Partners International, Genesis HealthCare and Greenville Health System) explain why bundled payments is one of the most important pieces of their overall value-based strategy. The bundled payment program drives operational learning and experimentation so that expertise and care process improvements can be built, which then trickles down to other parts of the organization and to multiple populations of patients (e.g. Medicare, commercial populations). As that expertise grows, workflows improve and patient quality metrics improve (e.g. reduced readmissions, lower utilization), Our customers said this helped them gain confidence to scale their programs and also engage in additional value-based initiatives.

Another key aspect of bundled payments discussed was that it pushes providers to develop a high-touch patient engagement model. We heard from everyone that developing patient relationships is not easy, and that they take time. Not only is it a major change for patients to communicate more frequently with providers, the conversations are also different. For example, providers are now discussing with patients why it could be beneficial in certain situations to recover in their own homes rather than stay in a skilled nursing facility. We also heard one customer say that patients often hang up on them during a follow-up call thinking it’s a solicitation call. In this shifting dynamic, providers are trying to establish the groundwork for deeper patient relationships earlier in the care process so they can set the right expectations ahead of time.

Overall, it was exciting to hear that the bundled payments program is having a meaningful impact on patient outcomes and is helping organizations achieve financial success in value-based initiatives. We heard throughout the Caradigm Customer Summit that population health is where healthcare has to go to improve the health of the highest-risk patients. Bundled payments is a key program that will help healthcare providers advance down the path to population health. If you’d like to learn more about how Caradigm is supporting bundled payment initiatives through its enterprise care coordination software, then please send us a note here.

MACRA Final Rule: Empowering Physicians and Health IT


Post by Corinne Stroum (Pascale)


Director, Program Management – Healthcare Analytics, Caradigm

It’s the moment that Medicare Part B clinicians and healthcare administrators have been waiting for. The final release of the MACRA Quality Payment Program! Health & Human Services released the rule amidst much publicity, a response to thousands of comments and industry feedback throughout the year.

I would summarize the theme of the final ruling as, “Empowering physicians to achieve the Triple Aim through choice and health IT”.  My colleague Dr. Brad Miller, who contributed to the ideas in this post, also said it well in this recent blog post: “CMS’ ultimate goal with MACRA is to move healthcare further to a system based on quality, and to accelerate the shift in how providers use technology to improve patient care and outcomes.” Here are some of our key takeaways on the final release:

  • Per the earlier “Pick your Pace” communique from acting CMS administrator Andy Slavitt, clinicians can still choose one of three participation pathways for Performance Year 2017:

      – Submit minimum data by March 2018 to avoid a negative payment adjustment

      – Submit partial data to earn neutral or minimal positive payment adjustment

      – Submit complete data to earn a moderate payment adjustment

  • Clinicians will not be scored on the Resource Use category until 2018. In the absence of Resource Use, the Quality category raises to 60% of the MIPS composite score for PY2017.

– Overall, while choosing which quality measures to choose will remain a challenge, by pushing out the Resource Use category until 2018, CMS is giving providers more time to analyze their data and intelligence to drive the necessary practice changes for improved Resource Use performance.  Identifying these areas for RU and enacting change represents a significant practice and workflow re-design effort for providers and this extra year represents a more realistic timeframe under which providers can adapt.

  • Clinical Practice Improvement Activities have been renamed to the simpler, “Improvement Activities” category.
  • CMS has provided much clearer guidance on how existing alternative payment models (APMs) will qualify for different categories:

 – As previously assumed, CMS established the quality reporting requirements for Medicare Shared Savings Plan (MSSP) Track 1 as sufficient for the Quality category.

– Medical Homes, and advanced APMs, will earn full credit for the Improvement Activities category; MSSP Track 1 and Oncology Care will receive points based solely on their APM participation.

  • Advancing Care Information requirements differ based on EHR edition:

– Patient-generated health data is an opportunity for those reporting prior to the 2017 edition to start learning from the copious amount of wearable and patient-reported data now in the marketplace.

  • CMS has supplied the healthcare public with fantastic, easy-to-use resources on the new CMS Quality Payment Program (QPP) site.  Users can select and export their a la carte activities or measures for easy tracking.

Taken together, these changes reflect the ability of healthcare organizations to choose how they adopt MACRA.  First, providers have been given a little more breathing room to gather their understanding and strategy for MACRA overall.  This helps with the widespread sentiment that providers were overwhelmed on how and what to report in the first year.  Second, there is a more gradual focus of scoring on smart fiscal skills and slowed rollout of large downward payment adjustments which aims to decrease overall MACRA performance and financial anxiety.  Finally, CMS motivates providers to get ahead of the rule by supplying incentive bonuses for underrepresented types of quality measures or for demonstrating advanced registry usage.

2017 represents a time for providers to get educated on MACRA’s subtleties, gather needed data and intelligence and develop go-forward strategies to effectively evolve with MARCA.  This includes the hefty task of experimenting and training their practitioners, support staff and their tools like software solutions needed to succeed in future years.  This means organizations now have an opportunity to get ahead of the requirements by creating a MACRA strategy in the remaining 2016 and beginning of 2017 to establish a flexible foundation for MACRA success.  More directly and simply, CMS has listened to providers and given them more space and time to develop practice responses and strategies to adapt to this brave new MACRA world.

 

 

 

Can MACRA and MIPS Move the Needle for Healthcare Analytics?


Post by Corinne Stroum (Pascale)


Director, Program Management – Healthcare Analytics, Caradigm

The Medicare and CHIP Reauthorization Act (MACRA) draft has become a novel I can’t put down. Its 962 digital pages tell a compelling story on the future of healthcare metrics. One narrative I follow in particular, is the next generation of quality measurement that shifts the focus of healthcare analytics to the reporting of patient outcomes.

In MACRA’s first year, most Medicare Part B clinicians will be eligible for the Merit-based Incentive Payment System (MIPS). MIPS will unify existing process-based quality measurement systems into one that promotes diversity of measure types and encourages providers to report on measures which it deems to have more impact.

Here are some examples of measure types that form the performance standards in MIPS:

    • Process measures – These are the most simple measures to report on such as whether a provider successfully completed something, such as an evidence-based best practice. This might take the form of an annual influenza vaccination for an at-risk patient. While process measures formed the meat of early healthcare quality metrics, they don’t tell the whole story.
    • Outcome measures – These measures get to the heart of clinical care by measuring how providers have influenced patient’s health. For example, has the patient’s depression index score gone down over a six-month period? Did an intervention prevent complications? Did a patient attain cancer remission?
    • Intermediate outcome measures – Some outcome measures look at the long term, which may take years to measure performance. Intermediate outcome measures are an important part of the story because they identify other clinical markers to indicate progress along the way. One example is the reduction of fasting blood glucose as part of a larger diabetes management plan.
    • Patient-reported outcome measures (PROs or PROMs) – Championed by organizations like PCORI, these measures are the window into the perspective of the patient: how does the patient feel about his/her health (such as the PROMIS survey) or how does the patient report the outcome of treatment?
    • Patient experience measures Cousins to PROMs, patient experience measures ask patients and caregivers about their perception of their care. The Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are well known experience measures.

The MIPS quality performance category offers opportunities to achieve bonus payments as well as prevent penalties. CMS will allocate points for quality measure performance depending on a “benchmark decile” – assigning providers level of achievement based on thresholds set during a baseline period. These deciles determine the points that the provider will receive. For measures already with overall high performance – those which CMS deems to be “topped-out” – it will be more difficult to obtain full points, incentivizing providers to explore new healthcare quality measures in which they can demonstrate excellence.

MIPS will require one outcome and high-priority measure as part of a standard submission. CMS deems high-priority quality measures as those which track appropriate use, efficiency, care coordination, or patient safety.   Additionally, CMS will score two bonus points for each additional outcome and patient experience measure and one point for each extra high-priority measure that a physician or group elects to report on.

In the first two years of MIPS, the Quality Performance score makes up about half of the performance score. In the following years, the Quality Performance score will balance out with the Resource Use score and clinicians should move from MIPS to advanced APMs. For the next two to three years, however, MIPS will move the needle on quality measurement. It will incentivize providers to report on impactful measures and measures that have not already “topped out”, and to store and transmit quality performance data electronically. This electronic data sets the stage for future victories in healthcare analytics: more data to work with, and more meaningful data.

I highly recommend beginning the process now to develop your MIPS strategy before the performance period begins in 2017. You shouldn’t underestimate the time needed to implement MIPS data and reporting requirements, identify the measures you can be successful in, and plan for how you will drive improved performance in those measures. If you’d like to talk about how Caradigm can help you with your MIPS Quality Measurement strategy, then please leave us a note here.

What are Bundled Payments Really About?


Post by Neal Singh


Chief Executive Officer, Caradigm

It wasn’t that long ago that the healthcare industry was trying to agree upon a definition of population health and you’d see articles like this one that tried to explain it. It’s actually pretty remarkable how in a short period of time, provider organizations have made great strides in adopting strategies and building technology infrastructure to adapt to value-based reimbursement models. We’re now entering the next phase of population health where the industry can apply learnings and iterate to hone in on the strategies that will actually yield better value for patients – improved outcomes at a lower cost. One of the most important programs that many providers are adopting is the Bundled Payment for Care Improvement (BPCI) program. Let’s explore the topic further.

Why do we fundamentally need bundled payments? Patient outcomes and costs have to be viewed holistically. The care of patients and payment of services for a single course of treatment often requires multiple providers in multiple care settings, but has historically been siloed. For example, a patient needing a hip replacement requires care from a host of clinicians including a surgeon, anesthesiologist, radiologist, care manager, physical therapist, home health aide, pharmacist, etc. In a fragmented health system, care is not coordinated between providers, which leads to inefficiencies and variability. In order to incentivize coordinated and standardized care, The Centers for Medicare and Medicaid Services (CMS) will now pay a single payment for all of the services performed to treat a specific episode of care in the BPCI program in four models, as well as will hold providers more accountable for patient outcomes such as readmissions. Bundled healthcare services are also making waves globally as they are being applied successfully in multiple countries including Germany and the Netherlands.[1]

I believe this is a significant step towards delivering better value to patients. Approaching the delivery of healthcare as an episode that takes place across the continuum increases visibility and accountability for both outcomes and costs. When measuring outcomes, if providers look beyond what they directly control to the full cycle of care, they will be able to identify new areas of improvement. The beauty of BPCI is that improving outcomes (e.g. speeding up time to begin treatment, reducing complications such as infections that lead to readmissions), often leads to lower costs. Likewise, by looking holistically at costs, providers will be able to determine new areas of improvement such as how quality care can be delivered by the appropriate and most cost-efficient clinician in the appropriate and most cost-efficient facility.

In the short-term, there could be shared savings opportunities as waste and inefficiency are removed. In the long term, repeatability and continuous refinement will lead to excellence in specific episodes of care that can help secure additional contracts. Providers will also be able to apply the improvements in care outside of the Medicare population so that other populations can benefit. As providers become domain experts in their areas of strength, they will set the benchmark for clinical outcomes and cost reduction for the rest of the industry. That’s healthcare transformation.

BPCI does however create some new challenges for healthcare providers. It links specialists, primary care and post-acute care services in a way that will force providers across the continuum to collaborate and change existing practices and workflows. Providers will need to integrate care and thus share data from health IT systems across sites within their health system and with external providers to improve the coordination of patients moving between different settings. These are significant barriers given that legacy health IT systems were not designed to support these types of integrated workflows. Innovation in health IT is required such as the sharing of patient data (e.g. lab results, care plans) in real-time across multi-EMR environments and streamlined workflows (e.g. automated role-based tasking, tracking of patients across the continuum, secure messaging).

I firmly believe that BPCI will expand rapidly and that it will become one of the key levers helping providers effectively transform healthcare delivery and drive better outcomes for patients. It’s a provider and patient friendly program because it is not focused on reducing utilization, but focused on improving efficiency and accountability for quality and costs. It also supports the CMS goal of interoperability and the broader direction of accountable care organizations and clinically integrated networks. Stay tuned for future blog posts where other members of the Caradigm team will explore bundled payments in more detail including how Caradigm’s award-winning care coordination solution supports BPCI workflows.

[1] Bundling Payments to Promote Integration and Efficiency. The Commonwealth Fund. Originally published: http://www.commonwealthfund.org/publications/international-innovation/apr/bundled-payments-to-promote-integration-and-efficiency