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 Can it actually be repealed?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insured lives in the US[2] including about 20 million covered under Obamacare.[3] Even if the ACA was to be fully repealed, there are nearly three hundred million lives for whom the fundamentals of economics and quality of care necessitate the move towards value based care.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

Moving Towards Automated Provisioning and Identity Management


Post by Mark Pilarski


Vice President and General Manager, Caradigm

I recently read this interesting article by Robert C. Covington on the IT security talent shortage. He cites a telling statistic that virtually all companies (92 percent) that planned to hire information security professionals expected to have trouble doing so.[1] Relief may be coming in the future as Covington believes that there’s a wave of future security professionals entering college programs that will join the workforce in a few years. However, with the amount of daily due diligence needed to combat today’s security threats, organizations need a strategy to compensate for the talent shortage in the meantime.

Covington cautions against falling into the temptation of buying security tools that require multiple IT staff to manage. His point is that rather than improve security, they can actually compound the talent shortage problem. On the other hand, he does recommend investing in tools that can automate routine processes such as log monitoring. I think he makes an interesting point about what types of security tools to invest in, which I would like to explore further.

While the profile of security within healthcare is rapidly rising, the ability to secure budgetary funding is very competitive with other health system initiatives. This is why a compelling business case is typically needed to get approval to purchase new security applications. One of the strongest rationales for a new security tool is if it brings broader value to your IT organization on top of reducing your vulnerability profile. Security solutions that can increase the overall productivity of your team and free them up to take on other projects are worth a closer look. Automated log monitoring is one example of this, but there are others.

For example, some larger organizations are spending thousands of IT hours annually on manual provisioning and deprovisioning processes. Consolidations in the healthcare industry will continue to occur, and if your organization has gone through a merger or acquisition, you know what an enormous commitment of IT resources that provisioning related processes entail given the quantity of applications in your portfolio. Manual provisioning and deprovisioning processes should also be a red flag for your security team because there’s too many moving targets (i.e. shifting roles, new employees, non-employed clinicians) and too many applications to effectively manage through manual processes.

That’s just one example. Consider manual entitlement attestation processes. Do you think that inefficiencies in those processes could cause your organization some serious challenges in the event of an audit? It definitely can. Consider the investigation of potential threats related to improper access and the remediation of those threats. Do you think your organization would be better off being able to automate as much of those processes as possible to remediate threats faster? The answer is obviously yes. Did you know you could have those benefits while also freeing up chunks of IT and Security resource hours for other projects?

There’s a growing awareness that automating provisioning and identity management processes is a strong investment because it brings high value from both a security and IT efficiency point of view. It also supports broader security governance programs and has synergies with existing investments in single-sign on solutions, which integrate into provisioning and identity management solutions. To learn more about how you can automate provisioning and identity management processes, you can download our whitepaper on the topic here.

[1] 2015 Global Cybersecurity Status Report. ISACA. Published http://www.isaca.org/cyber/Documents/2015-Global-Cybersecurity-Status-Report-Data-Sheet_mkt_Eng_0115.pdf

MACRA: Reporting for Quality’s Sake


Post by Brad Miller


Vice-President of Clinical Solutions, Caradigm

Now that we’ve had some time to think about the Medicare Access and CHIP Reauthorization Act (MACRA) and digest the details, a few high-level points stick out. First, it does away with Medicare’s Sustainable Growth Rate (SGR), which few physicians were in favor of due to the detrimental impact on services fees. Second, it consolidates and simplifies current reporting programs that were viewed by some as reporting for reporting’s sake– Physician Quality Reporting System (PQRS), Value-based Purchasing (VBP) and Meaningful Use (MU). For example, in the Merit-Based Incentive Payment System (MIPS) track of MACRA, providers only have to report on six measures, instead of the nine required in PQRS, and they also have greater flexibility in choosing what those six measures are. Third, and most importantly, 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. CMS believes that based on its conversations with thousands of clinicians and patients, most providers have yet to acquire the right set of technology tools to make care and reporting more effective and coordinated.

Andy Slavitt, Acting Administrator for the CMS describes one the main drivers of MACRA:

“With many hours of observations, what became clear was that the combination of technology, regulation and measurement took time away from patients and provided nothing or little back in return. Among other things, physicians are baffled by what feels like the ‘physician data paradox.’ They are overloaded on data entry and yet rampantly under-informed. And physicians don’t understand why their computer at work doesn’t allow them to track what happens when they refer a patient to a specialist when their computer at home connects them everywhere.”[1]

So, how should providers start preparing for MACRA? The first thing they need to determine is whether they will qualify for the MIPS or Alternative Payment Model (APM) track. It can be a complicated determination because some organizations could be considering entering into programs (e.g. NextGen ACO) that would impact which track they will qualify for in the future. Next, they should assess their current ability to succeed in all of their value-based programs, including how they will meet the MIPS or APM reporting requirements in order to qualify for bonus payments. Although it feels like the proposed rule was just announced, providers should begin strategizing for MACRA now because the performance period scoring for MACRA begins in 2017.

At Caradigm, we are already working to stay ahead of MACRA. This includes evaluating and prioritizing the proposed measures in advance of the final rule. We are also collaborating with customers to understand their specific requirements and to determine if there are any synergies with their other initiatives and applications. Our overall approach is to build a data aggregation and analytic foundation that can be used to support multiple initiatives and reporting requirements. That foundation has to be robust yet nimble and efficient so organizations can scale programs and evolve rapidly to meet future iterations of requirements. We have architected our technical solutions to help technology support, rather than be a burden, on the progress of providers.

MACRA is a broad topic with lots of areas to explore and many implications for providers, so we will be discussing different parts of it regularly on this blog. If you’re interested in speaking about your quality reporting and MACRA needs further, then please send us a note here.

[1] Slavitt, Andy. “Datapalooza: MACRA, HER Reform and Working with Doctors – Not Against Them.” The Health Care Blog. May 12, 2016. Originally published: http://thehealthcareblog.com/blog/2016/05/12/datapalooza-macra-reforming-meaningful-use-and-working-with-doctors-not-against-them/

Filling The Care Management Tool Box


Post by Vicki Harter, BA, RRT


Vice President, Care Transformation

As I talk to many providers across the country about how to transform to value-based care, the conversation inevitably turns to the need for care coordination and care management. With many Centers for Medicare and Medicaid Services (CMS) initiatives including the recently announced Comprehensive Primary Care Plus program emphasizing the need for better care coordination, many providers have concluded that they need to evolve how they deliver care for high risk or at risk patients. This is both exciting and a little bit scary. The hard part is figuring out the right way to go about it given that there is no single blueprint that works for all providers.

One of the best written articles on care coordination that I’ve seen was this one written by Patti Oliver, RN, BSN and Susan Bacheller, BA.[1] I could not agree more with Oliver and Bacheller when they say there is a growing movement toward greater care coordination, as more health systems realize there are better ways to deliver care:

“From our combined experience, we both know how critically important it is to have good care coordination in any healthcare system or arrangement, including ACOs. Care coordination helps providers to form a complete picture of a patient’s overall heath and it also allows them to be able to better communicate with the patient, their family, and with each other. Care coordination also requires constant prioritization and re-prioritization of patients for effective panel management; it means applying art and science to split attention between patients with immediate needs and those ripe for preventive measures or patients we regard as healthy working adults”

Oliver and Bacheller then explored the essential functionality that care coordination software should deliver naming the following five features:

  1. Care coordination tools should be tailored to your patient population.
  2. Care coordination tools should have a single place the care coordinator can visit to get the full picture at the panel and patient levels.
  3. Care coordination tools must allow for convenient use of clinical pathways and be flexible for the care coordinator.
  4. Care coordination tools need to have strong communication features among providers to facilitate care hand-offs and to involve family/caregivers when appropriate.
  5. Care coordination tools should integrate with other systems—or at least be straightforward about their ability to do so.

These five items are solid foundational features to seek when it comes to care coordination and care management tools. Having worked closely with providers to identify their requirements for success in coordinating care across the continuum, I would also respectfully highlight a few other key areas.

Workflow automation – as most organizations are looking to scale their population health initiatives, one of the biggest challenges is how to manage large populations given constrained resources. One of the key components to look for in software is the ability to automate time-consuming manual workflows so that the care team can work more efficiently and also at top-of-license. Care management software should be able to auto-generate care plans and assign tasks based on patient answers to assessments.

Evidence-based guidelines – While flexible clinical pathways are important, so is the need to ensure consistency of care. This is especially true for more complex, co-morbid patients who often require care from a larger care team. Care management solutions should help reduce variation of care by embedding evidenced-based guidelines directly into care workflows to guide action. Tools should also be able to help identify best practices so that they can be shared throughout the care team.

Support for multiple programs – Care management technology requirements vary by program. For example, in the CMS Chronic Care Management program, providers must be able to track and report on time spent per month on core care management processes. For the Bundled Payments For Care Improvement (BPCI) program, providers need to be able to transition and track patients to post-acute care. Look for flexible care management solutions designed to support multiple programs so that you can maximize your return on investment.

As Oliver and Bacheller noted in their article, many new technology solutions for care managers are starting to appear. It can certainly be confusing given the broad range of features and different classes available (i.e. enterprise to basic). Ultimately, identifying the right solution will depend on your organization’s specific goals and the scope of what you are trying to achieve with population health. I look forward to having more conversations with providers this year about how they want to transform care.

 

 

[1] Patti Oliver, RN, BSN; and Susan Bacheller, BA. ACOs: What Every Care Coordinator Needs in Their Tool Box. American Journal of Managed Care. 9.24.15.