The movement around independent physician associations

Independent physicians who want the advantages of belonging to a larger organization while at the same time retaining their autonomy are choosing to join independent physician associations (IPAs). An IPA is, according to the AAFP, “a business entity organized and owned by a network of independent physician practices for the purpose of reducing overhead or pursuing business ventures such as contracts with employers, accountable care organizations (ACO) and/or managed care organizations (MCOs).”

IPAs are growing, as more independent physicians recognize that they need collaborative power when negotiating contracts or navigating complex reporting requirements. In fact, the IPA Association of America (TIPAAA) says that it represents over 300,000 physicians who are associated with IPAs.

Independent physicians find that they are able to focus more on their patients and less on administrative tasks when they are part of an IPA. One study, conducted of 1164 practices that had 20 or fewer physicians, has shown that “physicians participating in IPAs provided about three times as many care management services for their patients with more than one chronic conditions as compared to non-participating practices: 10.45% over 3.85%.”

When asked about the movement around IPAs, Scott Kronlund, MD, MS, the President and CMO at Northwest Physicians Network in Tacoma, the largest IPA in Washington, confirmed that there is definitely an increased interest in IPAs among independent physicians. Dr. Kronlund noted that “The marketplace is too complex for private practice physicians to survive on their own — they need help synthesizing data and responding; they need support so they can be flexible in this ever-changing environment.”

Dr. Kronlund added that his group began with 375 members and has grown to over 1,000 independent physicians. He attributes the movement around IPAs to the many challenges faced by independent physicians, including clinical integration, administrative burdens, and negotiating power that helps increase revenue. Many independent physicians are not able to participate in shared savings programs due to the economies of scale. IPAs can also benefit independent physicians by playing a key role in the implementation and optimization of healthcare technology, including electronic health records.

Nick Dealtry
March 27, 2019

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Interoperability a focus at HIMSS 2019

Among the many pertinent and educational topics featured at HIMSS19, held in February 2019, was Health Information Exchange, Interoperability, Data Integration & Standards. Participants were encouraged to explore “all aspects of information exchange, interoperability, data integration and standards across technical and administrative strategies that contribute to sustaining the healthcare enterprise and enabling a positive consumer experience.”

HIMSS19 brought together over 45,000 healthcare professionals, including health information and technology professionals, clinicians, executives and market suppliers, featuring the theme “Champions of Health Unite.” Interoperability was a key focus at the conference. In fact, according to an article published by Mobihealth News, interoperability stood out among the extensive list of educational topics presented at the annual conference.

Mobihealth noted that interoperability has been on the conversation and seminar list for several years at the HIMSS conferences, but “this time there was a sense that all the effort that’s gone into creating HL7, FHIR and other data standardization and sharing tools is finally paying off.” The topic of interoperability also included discussion of the new rules proposed by the Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator for Health Information Technology (ONC).

Several sessions featured interoperability and the move to artificial intelligence (AI) in the medical field. Sessions included Style Standards to Improve Data Quality and Interoperability, focused on improved interoperability’s accuracy as well as the overall process. Another session, From Print to Interoperability: Cancer Staging in the EHR, looked at leveraging the EHR for cancer staging and transitioning from print to a truly interoperable electronic format for medical records.

The session, Enabling Data Interoperability Across the Continuum of Care, was presented by leaders from CMS and ONC. Presenters discussed the organizations’ goals around health information technology (HIT) vocabularies and how Fast Healthcare Interoperability Resources (FHIR) can enable data exchange.

The conference also featured an Interoperability Showcase where attendees could see technology solutions and learn more about interoperability topics that may impact them.

Nick Dealtry
March 22, 2019

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CMS proposes new interoperability rules to close care gaps and improve data sharing

In 2018, the Centers for Medicare & Medicaid Services (CMS) announced a new initiative, My HealthEData, that would “empower patients by giving them control of their healthcare data, and allowing it to follow them through their healthcare journey.” The initiative was led by the White House Office of American Innovation and included participation by the Department of Health and Human Services (HHS), CMS, Office of the National Coordinator for Health Information Technology (ONC), and National Institutes of Health (NIH), as well as the Department of Veterans Affairs (VA).

In February 2019, CMS proposed policy changes to support the My HealthEData initiative, including new interoperability rules designed to close care gaps to improve data sharing between physicians and patients. The Interoperability and Patient Access Proposed Rule “outlines opportunities to make patient data more useful and transferable through open, secure, standardized, and machine-readable formats while reducing restrictive burdens on healthcare providers.”

Some of the proposed changes and updates include:

  • Patient Access Through Application Programming Interfaces (APIs)
  • Health Information Exchange and Care Coordination Across Payers
  • API Access to Published Provider Directory Data
  • Care Coordination Through Trusted Exchange Networks
  • Improving the Dual Eligible Experience by Increasing Frequency of Federal-State Data Exchanges
  • Public Reporting and Prevention of Information Blocking
  • Provider Digital Contact Information
  • Revisions to the Conditions of Participation (CoPs) for Hospitals and Critical Access Hospitals
  • Advancing Interoperability in Innovative Models

At the same time, the ONC proposed a rule that “places a strong focus on a patient’s ability to access their health information through a provision requiring that patients can electronically access all of their EHI (structured and/or unstructured) at no cost.” Regarding the CMS proposed rule and the ONC proposed rule, HHS Secretary Alex Azar said, “These proposed rules strive to bring the nation’s healthcare system one step closer to a point where patients and clinicians have the access they need to all of a patient’s health information, helping them in making better choices about care and treatment.”

In addition to the policy proposals, CMS is releasing two Requests for Information (RFIs) to obtain feedback on interoperability and health information technology (health IT) adoption in Post-Acute Care (PAC) settings, and the role of patient matching in interoperability and improved patient care.

CMS will accept comments on the major provisions in this proposed rule and the RFIs (CMS-9115-P) until early April (exact date will be updated upon posting at the Federal Register); it can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.

Nick Dealtry
March 5, 2019

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California payers, providers, and regulators are working together to improve data sharing

Accurate and current data is critical in the healthcare industry. Patient data as well as provider data must be properly maintained to ensure the quality of healthcare services. In particular, physician data has to be easily accessible and has to have the correct information for patients who are searching for a provider and for providers who need to connect with each other when coordinating services.

Unfortunately, given a number of factors, physician data is not always accurate or current. Healthcare payers may change their list of providers who are considered in-network. Physicians may change locations or employers, information that has to be updated with every appropriate healthcare payer. Providers may even venture into a new specialty area. These changes are not always reflected in available provider data. It is estimated that over half of all data found in provider directories is inaccurate.

In California, however, a new centralized online provider directory is changing all of that. Integrated Healthcare Association (IHA) has launched a new service, the Symphony Provider Directory, formerly known as the California Provider Directory Utility (PDU). The new directory, funded by a $50 million grant from Blue Shield of California, will serve “as a platform for plans and providers to exchange and reconcile provider information, resulting in improved data quality and more efficient processes.”

The new service is the result of a “cross-industry collaboration of plans, providers, purchasers and regulators.” The directory “enables health plans to maintain more up-to-date and accurate information such as provider demographics, panel status and health plan product and network details in their consumer-facing directories so that consumers can make informed decisions about their coverage and care.”

Jeffrey Rideout, M.D, President and CEO of IHA, notes that the Symphony Provider Directory is “much more than a complex IT project. This is an industry-wide commitment to improve the healthcare system in California. IHA’s role is to drive alignment and establish an effective and sustainable platform that supports the complex needs of health plans, providers and ultimately healthcare consumers.”

Nick Dealtry
February 6, 2019

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Is case management the same as care coordination?

Coordinating a patient’s care properly can mean the difference in that patient’s healthcare outcomes. The primary care physician, in particular, must be able to coordinate care for patients who are seeing multiple providers, undergoing tests, or staying in healthcare facilities for treatment of chronic or complex illnesses. This type of care coordination is not the same as case management.

The Case Management Society of America (CMSA) defines case management as “provided by healthcare professionals working with people to identify issues and barriers that may prevent them from getting better and uncovering mutually agreed upon solutions to achieve their healthcare goals.”

The Agency for Healthcare Research and Quality (AHRQ) describes care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.” The AHRQ emphasizes that care coordination necessitates communicating the patient’s needs and preferences at “the right time to the right people.” The information must be shared and used in a secure manner and in a way that provides “effective care to the patient.”

Care coordination’s main goal, as the AHRQ defines it, “is to meet patients’ needs and preferences in the delivery of high-quality, high-value health care.” Given the shift toward value-based reimbursement structures, independent physicians are investing in tools that help them more effectively direct their efforts toward the specific and immediate needs of their patients.

Similar to and working with the primary care physician’s care coordination efforts, CMSA states that case management is “a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care, and cost effective outcomes.”

Further, case management “helps identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value” for patient, payer, and provider.

Nick Dealtry
January 28, 2019

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Breaking down the major ACO changes from the MSSP final rule

On December 21, 2018, the Centers for Medicare & Medicaid Services (CMS) published its Medicare Shared Savings Program (MSSP) final rule for accountable care organizations (ACOs). The program is now referred to as Pathways to Success and encourages ACOs “to transition to performance-based risk more quickly and, for eligible ACOs, incrementally, to increase savings for the Trust Funds.”

The final rule does away with the previous tracks (Track 1, 1+, 2, and 3) and offers two participation options: BASIC and ENHANCED. Beginning on July 1, 2019, ACOs will enter into agreements under one of these new tracks for at least 5 years.

  • BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk that, at the highest level, would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program
  • ENHANCED track, based on the program’s existing Track 3, which provides additional tools and flexibility for ACOs that take on the highest level of risk and potential reward.

CMS states that one of the goals of the new structure is “Promoting accountability by accelerating the move to two-sided risk while promoting competition by encouraging participation by low revenue ACOs.” Under the Pathways to Success program, ACOs will be classified as “low revenue” or “high revenue.”

  • Low revenue ACOs identified as experienced with performance-based risk Medicare ACO initiatives, such as ACOs identified as having previously participated in the program under Track 2, Track 3 or the Track 1+ Model, are restricted to participating in either the BASIC track’s highest level of risk and reward or the ENHANCED track.
  • High revenue ACOs determined to be inexperienced with performance-based risk Medicare ACO initiatives would be limited to no more than a single agreement period under the BASIC track. High revenue ACOs determined to be experienced with performance-based risk Medicare ACO initiatives would be restricted to participating in the ENHANCED track.

CMS is offering an application cycle for a one-time new agreement period start date of July 1, 2019, and will resume the usual annual application cycle for agreement periods starting on January 1, 2020, and in subsequent years.

Nick Dealtry
January 22, 2019

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Value-based care and care management

Value-based care, as opposed to fee-for-service care, has been shown to improve the quality of care management, particularly for those patients with one or more chronic conditions. Those are the findings of a recent study conducted and published by Humana, the Value-based Care Report.

Worthe Holt Jr., M.D., M.M.M., Humana V.P., Office of the Chief Medical Officer, writes in the report that “By integrating care at all levels, we can better coordinate prevention and wellness of populations to slow and prevent the advancement of disease. We are rapidly moving from a focus on episodic care to one that addresses the whole person, inside and outside the clinical setting, by practicing value-based care.”

The study, Humana’s fifth annual, found that “Physicians who practice value-based care are achieving higher rates of patient engagement in preventive screenings, medication adherence and management of chronic conditions as measured by HEDIS (Healthcare Effectiveness Data and Information Set).”

Value-based care and care management are connected in that physicians are more focused on the need for preventive care and chronic condition management in a value-based care setting. They are better able to manage care for their patients, particularly those who may face challenges with social determinants of health, such as food insecurity or other socioeconomic factors, and who may also tend to experience more chronic conditions.

In fact, the report stated, that “on average, Americans with five or more chronic conditions spend 14 times more on health services than people with no chronic conditions.” Proper care management, including preventive care and medication management, that is part of a physician’s value-based care plan for the patient can catch these conditions early and enable the physician to properly treat the patient, keeping the patient healthier.

Roy A. Beveridge, M.D., Humana’s Chief Medical Officer, stated that “Practicing value-based care works to address the nation’s chronic disease epidemic by giving physicians the support and data they need to focus more on prevention and reduce acute care episodes. This model allows physicians to focus time and energy on those patients who need the most support to stay well at home, and out of the hospital. Physicians are clearly seeing the benefit of improved patient outcomes and more shared savings.”

Nick Dealtry
January 18, 2019

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Why a patient longitudinal record is important for ACOs

The Accountable Care Organization (ACO) is a Centers for Medicare & Medicaid Services (CMS) Innovation Model. CMS defines ACOs as “groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to the Medicare patients they serve.” Coordinated care is an important aspect of the ACO, as it “helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.”

The Health Information and Management Systems Society (HIMSS) emphasizes that “once an accountable care organization (ACO) or other collaborative care entity has laid the foundation for a robust health data exchange by ensuring the electronic capture of complete clinical and financial information at the individual provider level, the next step is to build the core of the structure – the longitudinal patient record.”

A longitudinal record holistically evaluates patient population with a record that trends vitals and lab values over time. The move toward longitudinal records is key to understanding a patient’s complete medical picture. Access to and use of longitudinal records is particularly important for patients with chronic conditions, as the independent physician can quickly access important clinical data to help manage chronic conditions and easily schedule follow-up appointments to address any potential gaps in care.

Patients with chronic conditions tend to see multiple providers, undergo lab tests, and may require stays in healthcare facilities. Coordinating that care within the ACO relies on the patient longitudinal record being accurate, current, and easily accessed by each provider. HIMSS explains that “in addition to providing support for clinical decisions, longitudinal records included in the ACO’s central data repository enable the organization to monitor compliance with treatment guidelines, meet reporting requirements and identify best practices to improve care.”

Nick Dealtry
December 14, 2018

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Health information exchanges (HIEs) and interoperability

The ability to share patient data is critical for the independent physician to provide value-based care for that patient. When a patient sees specialty providers or undergoes lab tests, the primary care physician must have the visit notes and test results to provide appropriate, effective care. Exchanging information electronically is much more efficient than sharing patient data on paper, either hand delivered or via fax.

Physicians who use electronic health records (EHRs) can take advantage of the electronic sharing of patient information between different EHR systems and healthcare providers, improving the ease with which doctors can provide care to their patients and patients can move in and out of different care facilities. This electronic sharing through EHRs is referred to as interoperability, a vital piece of the accurate and timely transmission of patient data between EHR systems.

Health information exchange (HIE) enables that interoperability to happen. As the Healthcare Information and Management Systems Society (HIMSS) describes it, interoperability involves an exchange of patient data that can be viewed and understood on both ends. Interoperable EHR systems “must be able to exchange data and subsequently present that data such that a user can understand it.  In order to ensure interoperability, the use of standards enable data to be shared across disparate healthcare settings regardless of the application or vendor.” HIE, explains the HIMSS, is a “a dynamic and evolving landscape … critical for successful healthcare reform, enabling interoperability and meaningful use of health information and technology.”

The Office of the National Coordinator for Health Information Technology (ONC Health IT) further explains that HIE “allows health care professionals and patients to appropriately access and securely share a patient’s medical information electronically. There are many health care delivery scenarios driving the technology behind the different forms of health information exchange available today.”

Health IT states that “sharing electronic patient information enables providers to:

  • Access and confidentially share patients’ vital medical history, no matter where patients are receiving care—specialists’ offices, labs, or emergency rooms
  • Provide safer, more effective care tailored to patients’ unique medical needs.”

Interoperability between EHR systems, powered by HIE, would make health care data universally sharable, facilitating patient care, and allowing for seamless referrals and transitions between healthcare providers.

Nick Dealtry
December 10, 2018

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Questions to ask about interoperability during EHR purchasing decision

As the National Academy of Medicine (NAM) has recently published a report on the need to drive interoperability between electronic health records (EHRs), many healthcare providers may be asking how to purchase an EHR solution that enables that critical interoperability. An EHR Intelligence article has outlined a number of questions to be asked during the purchasing decision.

Those questions include:

  • Does the EHR vendor adhere to industry standards?
  • Does the EHR vendor work with interoperability services providers?
  • Does the EHR product’s level of interoperability align with organizational needs?

There are resources available to determine the answers to some of these questions. For example, the Office of the National Coordinator for Health Information Technology (ONC) provides information about vendors that meet the 2015 Edition Health IT Certification Criteria for certified EHR technology (CEHRT). In addition, ONC provides information about which vendors use the Fast Healthcare Interoperability Resources (FHIR), a specification for exchanging clinical and administrative health care data. Healthcare providers can also include these questions in their requests for proposals (RFPs) issued to EHR vendors during the purchasing process.

Interoperability is critical for the exchange of information between healthcare providers and is particularly beneficial to care managers in their work in coordinating care for patients. Care managers have been shown to be effective particularly in the care of patients with complex or chronic conditions. However, a 2016 study on care coordination and interoperability “identified multiple areas where the lack of interoperability leads to inefficient processes and missing data” and found that “significant care coordination gaps exist due to the lack of interoperability across the United States.”

The NAM publication emphasizes that “Digital interoperability across clinicians, care units, facilities, and systems has become more essential because of increasing complexity in health care, the need for more seamless interfaces among clinicians, patients and families, and the growing number of clinicians across disparate specialties that a typical patient sees.”

Asking the right questions during the purchasing process can result in EHR interoperability benefiting the independent physician, the case manager, and most importantly, the patient.

Nick Dealtry
November 29, 2018

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