Accountable Care

After years of dwelling in the shadows of healthcare, the long-term and post-acute care industry may finally be ready to join its hospital colleagues in the IT spotlight.  

McKesson and Blue Cross Blue Shield of Arizona are partnering to create a new service that helps physician practices that may not be part of a value-based network take on risk as traditional accountable care organizations do. The service, dubbed ACO Partner, is not an accountable care organization. But don't call it a product either, said John Wallace, ACO Partner's new president and chief operating officer. Wallace is McKesson's national vice president and general manager of accountable care services. "It's more of support structure," Wallace said, for the physician practices and providers that need help making the transition to performance reimbursement. It works like this: Physicians and providers sign a shared savings contract with a health plan participating within ACO Partner. Through the services provided, the practice reduces its expenses in medical claims in general, and a percentage of that savings goes back to the provider and insurer, according to Wallace. There is no cost to practices, so they share in the savings without risking payment cuts. "We're making the bet to say, 'Let's do it for them.' We're taking on the responsibility of analytics," Wallace said. So far, only Blue Cross Blue Shield of Arizona has signed on. [See also: McKesson launches venture capital fund.] ACO Partner in marketed to independent physicians who may not have the resources to transition to value-based care, and also to ACOs and clinically integrated networks that may need help accelerating the transition to getting paid for high quality and cost effective healthcare. "Better benefits for lower costs," Wallace said. "It allows them to take more market share, to compete at a higher level." McKesson provides the technology infrastructure and the analytics to support payers as they collaborate with the provider networks. ACO Partner claims to help physicians with the practical components of value-based care, including disease management, care management, population health management and patient engagement. Providers and payers contracting with ACO Partner have access to  strategic management, analytics, population health, technology, network development, physician engagement and care management services. "A lot of ACOs are making heavy investments in services and technology without a clear roadmap for success," Wallace said. A year from now, Wallace wants ACO Partner to have three to five health plans participating in state of Arizona. Beyond Arizona, he envisions the model in multiple other states. For patients, the new entity is intended to strengthen outcomes while helping reduce out-of-pocket expenses, Wallace said. "Providers love it because they have a better patient experience," Wallace said. "Plans love it because they're seeing a higher quality of care delivered. And it extends to a more efficient cost structure." Twitter: @SusanJMorse

The sheer number and variety of providers that patients see after leaving a hospital make medical mistakes and poor transitions in care all too common today. 

On Twitter, former National Coordinator for Health IT Farzad Mostashari, MD, called it the "most substantive change to how healthcare is paid for in a couple of decades." The propsed MACRA rule put forth by the U.S. Department of Health and Human Services on Wednesday also holds some pretty big changes for how health IT can be put to work by physicians to drive quality improvement and cost efficiencies. [Also: MACRA proposed rule published by HHS, streamlining federal programs including meaningful use] "By proposing a flexible, rather than a one-size-fits-all program, we are attempting to reflect how doctors and other clinicians deliver care and give them the opportunity to participate in a way that is best for them, their practice and their patients," said Patrick Conway, MD, chief medical officer at the Centers for Medicare & Medicaid Services, in announcing the rule. "Reducing burden and improving how we measure performance supports clinicians in doing what they do best – caring for their patients." So far, most industry reaction to the notice for proposed rulemaking is positive – recognizing the fact CMS seems to have taken the feedback from more than 6,000 frontline healthcare stakeholders to heart, crafting a rule that's attuned to the needs of physicians. In a statement, HIMSS applauded the "significantly streamlined reporting and the acknowledgement process for MIPS-eligible clinicians" in the new rule. "We are encouraged by CMS's effort to coordinate reporting periods across federal programs and the decision to align with the ONC Interoperability and Certification Programs," HIMSS officials said. "With the first MIPS performance full-year reporting period expected to begin on January 1, 2017, we're further analyzing the MACRA rule to ensure that Medicare providers will be able to meet the proposed requirements." American Medical Association President Steven Stack, MD, meanwhile, said it's "hard to overstate the significance of these proposed regulations for patients and physicians." In particular, he was pleased that CMS has been listening to physicians’ concerns and "has made significant improvements, by recasting the EHR meaningful use program and by reducing quality reporting burdens." American Health Information Management Association CEO Lynne Thomas Gordon released a statement saying AHIMA supports the MIPS progam's "emphasis on interoperability, information exchange and security measures, which we believe are critical to reaching the rule’s stated long-term goal of ‘better care, smarter spending, and healthier people.'" The Premier healthcare alliance was less pleased, however – specifically taking issue with one part of the two-pronged MACRA approach to value-based care: its provisions related to advanced payment models, or APMs. CMS "made a significant mistake in not including any bundled payment or Track 1 Medicare Shared Savings Program ACOs as qualifying advanced payment models under MACRA," said Blair Childs, senior vice president of public affairs at Premier Inc. "Rather than rejecting bundled payment programs, we believe CMS should focus on ways to alter the bundled payment programs to demonstrate use of certified EHR technology and align measures with other Advanced APMs. "We also believe CMS seriously erred in excluding Track 1 MSSP ACOs in the APMs for failing to meet the more than 'nominal risk' financial requirement," said Childs. "As we've learned through members in our Population Health Management Collaborative, these programs require providers to not only forego revenue through a lower volume of services, but also investment millions of dollars in redesigning care through new technologies, data analytics, additional staff, etc.," he said. "We think most businessmen would call that more than nominal risk, yet CMS choses to define it as only cases where there is risk to the government." Elsewhere in the Twitterverse, the response was mostly positive – with some skepticism and a bit of I-told-you-so mixed in. And "Meaningful Use" is going "away" by changing its name to "Advancing Care Information" #MACRA #livetweeting as I read the proposed rule — Joy Rios (@askjoyrios) April 28, 2016 or basically what #MU should have been from day 1 @Travis_Broome — Harold Smith III (@haroldsmith3rd) April 28, 2016 1/Bottom Line #MACRA NPRM Game changer. Lots of great changes, 100's of thoughtful details and decisions. Biggest blind spot can be fixed — Farzad Mostashari (@Farzad_MD) April 27, 2016 Really good YouTube "whiteboard" connecting the dots of our MACRA announcement. Plain English. No acronyms. Wow. https://t.co/qLHSpYnWRX — Andy Slavitt (@ASlavitt) April 27, 2016 A tree died for this #MACRA #MIPS #Medicare pic.twitter.com/YsiSd3R9Mf — Amanda Narod (@AmandaBinDC) April 28, 2016

The U.S. Department of Health and Human Services issued a long-awaited proposed rule for the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, on Wednesday, ushering in some big changes for the ways physicians are assessed for quality of care and use of information technology.    

Here’s the rub: $50 billion might be hyperbole, but $5 billion is still a sizable enough market to drive innovations that health systems can harness to engage patients, better manage populations and ultimately improve care and the bottom line.    

More widespread implementation of gaps in care programs is essential to realizing the value of population health management, according to a new report from the Workgroup for Electronic Data Interchange. In its study, "Closing Gaps in Care through Health Data Exchange," WEDI defines those gaps as the discrepancy between evidence-based best practices and the care that's actually delivered to the patient. At too many providers, that chasm is still too wide, according to the report. Better IT infrastructure – enabling more robust exchange health data, automating identification of information gaps and streamlining care coordination – is needed to bridge it. Toward that end, WEDI offers five key takeaways: 1. Education and communication are essential to making providers aware of the value of identifying and closing gaps in care. "Providers appear to lag behind health plans in implementing gaps in care programs," according to the report. "Challenges include the lack of sufficient resources or education about how to maximize workflow changes and effectively close gaps in care." 2. Gaps in care can adversely affect provider performance. "Surveyed providers are significantly more concerned than health plans that gaps in care pose a threat to their organization by affecting clinical performance, financial performance and the ability to retain patients," according to WEDI. 3. Programs to address gaps in care offer a high return on investment. "Improvements were observed in quality outcomes such as access to behavioral healthcare, pediatric and adolescent check-ups and medication adherence," according to the report. "Reductions in utilization of ambulatory care, hospital admission and hospital readmission were also observed." 4. Better consensus is needed to develop and standardize quality measures and methodologies for data exchange among payers, providers and patients. "The terminology, standardization and scope of gaps in care measures need more clear definition and alignment between health plans and providers before actionable data harmonization can occur," WEDI researchers say. "Best practices need to be disseminated that illustrate stakeholder roles, automation of workflow and quality improvement. The report also points to other barriers such as the "provenance, quality, completeness, timeliness, transparency and accuracy of data." More widespread use of open API and element - based exchange could help address these 5. Fixing care gaps will only grow in importance as value-based models evolve and access to care and coverage expands. "As newly eligible consumers continue to enter the health insurance marketplace and access healthcare, it will be essential for stakeholders to develop effective healthcare communication, prevention and education and intervention strategies to improve the quality of patient-centered care," the report says. "As we increasingly grow fee-for-value arrangements in our nation, it is critical that we look to methods  automate gaps-in-care – to not only ensure that data moves seamlessly between clinical systems and payment systems but that the information is useful and actionable for clinicians and patients," WEDI founder and former HHS Secretary Louis W. Sullivan, MD, said in a statement. Twitter: @MikeMiliardHITN Email the writer: mike.miliard@himssmedia.com Like Healthcare IT News on Facebook and LinkedIn

Revenue cycle management has gone from being a "back office" function to an "end-to-end" system that begins at patient intake or even before, claims specialists say. Advanced technologies, in tandem with improved workflows and better data have resulted in RCM systems that encompass the entire healthcare enterprise. With the right automation tools and revenue cycle support, experts say healthcare providers should be able to improve their cash flows by collecting patient payments up front, determining precise eligibilities and filing clean claims to payers. With the fee-for-service business model changing to prospective payment and value-based care, healthcare organizations are undergoing a cultural shift that dramatically alters their approaches to patient intake, eligibility verification and claims processing. These are issues that providers will have to understand and adjust to accordingly, says Jose' Rivera, vice president of physician solutions development at Santa Rosa, Calif.-based Visiquate. "Fee-for-service is going away and bundled payments will come to fruition," he said. "We will see a resurgence of capitation because it puts the risk back on the provider. Organizations were able to overcome ICD-10, but as the model moves toward quality I think we'll see another resurgence of value proposition payer mixes." As a result, Rivera believes it will be a lot more difficult to get paid. Meeting the challenge means physicians must become educated on tracking quality metrics and reporting them to payers, he says. "This is a formidable task because different payers with different contracts all want slightly different quality metrics," Rivera said. "It's a big question mark in the back of my mind." Emphasizing intake RCM specialists agree that patient intake is a critical part of the revenue cycle process and that if they aren't emphasizing it, they need to do so immediately. Collecting patient deductibles, co-payments and eligibility authorizations is paramount for boosting the organization's cash flow as well as for ensuring clean claims, Rivera said. "That is the front line – they need to capture that information correctly and guide it to the right places," he said. "When it comes to authorizations, we are still in a prehistoric environment where a payer has to be called on the phone and it's a half-hour wait to get the authorization. This process definitely needs to be upgraded." Patient registration is undergoing dramatic change, with intake clerks "being asked to do more and more," says Colleen Wood, vice president for the Eastern U.S. at Jacksonville, Fla.-based Availity. RCM technology at the point of intake should be leveraging technology for patient data capture as well as having credit and debit card readers for upfront payments, she said. And while some providers – especially physicians – have been reluctant to ask for payment upfront, collecting deductibles and co-payments at intake fosters cash flow while informing patients of their obligations. "As patients, they should want to know how much it will cost," she said. "This is an opportunity for them to ask about costs and manage their dollars, which they couldn't do previously." Receiving deductibles and co-payments not only improves cash flow, it also creates a more comprehensive patient profile, Wood said. "It goes deeper than just getting deductibles and co-insurance," she said. "It is the total dollar for the patient and provider experience. Deductibles are part of the equation, but the challenge is that there is a ton of data about patients being eligible for services, but also the benefit level each payer covers and how it is going to be covered. Providers need to realize they need to get the total dollar and understanding of the benefit level for every patient, whether it is in the physician or hospital setting." Illuminating the buckets Although the emphasis is on intake, the back end of the revenue cycle continues to be as vital as always and clean claims remain the key to prompt payment. Still, there are stumbling blocks in the claims filing system, says Jay Deady, CEO of Greenwood Village, Colo.-based Recondo. "On the back end, we need to identify the buckets and reasons why claims aren't adjudicated cleanly," he said. "When we illuminate those buckets, patient ineligibility and lack of authorization are still the main reasons for denials." Electronic data interchange transactions with payers is still the standard for eligibility and authorization data, but Deady's research shows that the information can be wrong up to 25 percent of the time. On the whole, however, the process has improved immensely in the past few years, he said. "We're getting more information earlier, getting more information cleared earlier and more is being done earlier," he said. Many moving parts While the end-to-end revenue cycle system has become more automated, there are "still a lot of moving parts" within the process, noted Mike Nissenbaum, CEO of Dallas-based billing contractor Aprima. "There are so many changes just on what is covered and how much will be paid," he said. "There are constant changes in plans and the payers can modify formularies and delay them up to six months. That is very stressful. If we don't pay attention to all these rules changes, our clients suffer." Twitter: @HealthITNews Like Healthcare IT News on Facebook and LinkedIn

Care coordination, quality measurement, patient engagement and population health management strategies are routinely used by physicians with electronic health records who participate in accountable care organizations or patient-centered medical homes, according to a new study published in the American Journal of Managed Care. Aiming to find out whether doctors using health IT and working within new reimbursement models were actually employing improved care processes, researchers Jennifer King, Vaishali Patel, Eric Jamoom and Catherine DesRoches examined cross-sectional data on office-based physicians from the 2012 National Ambulatory Medical Care Survey Physician Workflow Survey. "Early indicators suggest strong physician participation in initiatives to support health IT adoption and to reform healthcare payment and delivery," they said. "However, evidence on whether provider participation in these initiatives has translated to better care delivery is just beginning to emerge. "Although studies prior to HITECH and the ACA found health IT and external reporting or payment incentives to be associated with a higher likelihood of performing these care processes," they added, "they are performed at low rates even when these factors are in place." [Also: 4 surprising benefits of PCMH] King et al. examined how ACO and PCMH docs used their EHRs for 14 specific processes in four categories: population management, quality measurement, patient communication and care coordination. They found that those factors were independently associated with better processes: "Physicians who were using EHRs in combination with participation in ACO or PCMH initiatives had the highest likelihood of routinely performing the care processes." Indeed, those docs "were between 6 and 22 percentage points more likely to routinely perform the care processes than physicians with EHRs alone." While fewer than half (44 percent) reported routinely doing quality measurement, substantial majorities of docs said they routinely engage in care coordination (89 percent), patient communication (69 percent), and population management (67 percent). "Given the cross-sectional nature of this study, these results do not establish a causal relationship between payment reform, EHR use, and these care processes," researchers said. "Nonetheless, this finding is consistent with other research that shows that healthcare providers are most likely to perform these care processes when practicing in a payment environment that incentivizes and supports such care." Moreover, many U.S. physicians are still "not performing these processes routinely," researchers said. "Our analysis highlights several specific areas – including population management processes that require the aggregation and analysis of individual patient data and communication with patients and other care team members – where additional technology and policy supports may be important to facilitate wider adoption of these activities." Twitter: @MikeMiliardHITN Email the writer: mike.miliard@himssmedia.com Like Healthcare IT News on Facebook and LinkedIn

Starting in 2019, Centers for Medicare & Medicaid Services, will change how they pay physicians in a profound way. Unfortunately, the details are complicated and confusing, and many of the particulars have yet to be worked out, which has led many healthcare leaders to glaze over the details and focus on more immediate concerns.