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


How DPC care can segue to direct-to-employer care

Change is generally a challenge, particularly in the workplace. Employees who are told they must change their healthcare plan may not always react positively. In fact, employers may not want to change their company healthcare plan, at least not all at once. One option is to segue to a new plan in small steps, especially when it entails a new concept, as is the case with direct primary care (DPC).

DPC practices are a relatively new breed but are growing in popularity. The DPC model involves patient membership fees rather than insurance reimbursements, as well as more direct involvement by the independent physician. The DPC practice harkens back to the day of the family doctor. House calls, after hours communications, and personalized care are among the benefits cited by DPC physicians and their patients.

Employers have moved slowly toward the DPC trend but are still somewhat hesitant to forego traditional healthcare coverage completely. One option is to offer employees the choice of a health insurance plan such as a PPO product in addition to the DPC practice. That’s exactly what one company – a large healthcare provider itself – has done for its employees.

CHI Health is the Catholic Health Initiatives (CHI) division for Nebraska and southwest Iowa. In 2017, CHI Health launched its own DPC practice to augment its traditional healthcare services. The DPC was designed to care for CHI Health’s own employees primarily. CHI Health employees are given the option of enrolling in traditional PPO coverage or participating in the DPC. Approximately 1,130 of the organization’s 20,000 employees and beneficiaries opted into the DPC model during the first quarter of 2018.

Employees were reassured that if they needed care beyond the basic primary care services provided by the DPC that they could seek out specialty providers and other catastrophic services such as hospitalization for the same deductible costs as the PPO-covered employees. However, according to HealthLeaders, “early results suggest DPC participants use these more-expensive options less.”

In fact, the costs were significantly lower for DPC-covered employees during the first quarter of 2018. Facility and specialist claims were 20% less for those employees in the DPC practice than for those employees enrolled in the traditional PPO plan.

Employers can test the waters by segueing employees to a DPC practice, offering the choice for those who do not readily accept the change. After demonstrating both cost savings and improved outcomes, the DPC may be seen as the preferred choice for all going forward.

Nick Dealtry
January 22, 2019


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


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


Employer health clinics and value-based care

Employers are constantly looking for ways to reduce costs. In the prevailing move toward value-based care, those employers are also searching for innovative strategies to help their employees become healthier and maintain their health. On-site and near-site clinics have been shown to be a viable solution for both challenges.

A report from the Duke-Margolis Center for Health Policy and the Robert Wood Johnson Foundation cited the connection between population health management and workplace clinics, stating that, in particular, the employer programs help manage employees’ chronic conditions. Approximately 90 percent of US healthcare costs are related to chronic conditions such as diabetes or high blood pressure.

The report states that “Employers have targeted this issue in a number of ways. 62 percent of large employers and 38 percent of small employers offer health risk assessments, with an even larger percentage providing programs like smoking cessation, lifestyle coaching, and weight-loss management. In another survey, 20 percent of employers report having opened onsite clinics, and 8 percent have near-site or multi-employer clinics, with a larger percentage of employers considering it.”

Larger companies such as SAS, National Public Radio (NPR), USAA, Goldman Sachs, and Capital One Financial offer their employees basic primary care services through on-site or near-site healthcare clinics. Additionally, companies such as Apple, Amazon, Berkshire Hathaway, and JPMorgan & Chase have announced plans for internal healthcare ventures that will provide health and wellness services to their employees.

The Duke-Margolis Center report details the importance of offerings such as employer health clinics as they relate to value-based care. “Employer-sponsored health insurance coverage accounts for 49 percent of insured Americans. If the U.S. health system is to be transformed into one that rewards value, then employers must not only participate in the transition, but play a leading role.” The report continues to explain that “Employers have an interest in the value of care not only because they help pay for their employees’ health insurance coverage, but also because better employee health means fewer missed days of work and better productivity.”

Employers need healthy employees to help reduce their own costs, to maintain a quality level of productivity, and to reduce absenteeism. In general, the current transition to value-based care is welcome news to most employers, with its focus on quality care at the physician’s office and cost containment for both employer and employee.

Roy Steiner
December 14, 2018


The benefit of direct care for on-site and near-site employer health clinics

Employers are as concerned about healthcare costs as their employees and, as such, search for alternatives to traditional healthcare plans for those employees. The direct care model has been proven to offer benefits as the provider of employee healthcare at on-site and near-site employer health clinics.

One company, in particular, that recognized the potential for those benefits conducted a case study of a group of its employees before offering on-site direct care as a company-wide employee healthcare plan. DigitalGlobe, based in Colorado, conducted its study from June to December 2015 by offering the direct model to its Colorado employees. The company also has employees in Tampa, Florida, and Herndon, Virginia.

Company leaders had reviewed information about the direct care model and recognized that it saved businesses and their employees a significant amount of money while providing high quality healthcare. DigitalGlobe searched for a direct care provider and conducted their study with three goals in mind:

  1. Improve the overall health of employees.
  2. Provide employees a more positive healthcare experience.
  3. Reduce healthcare costs for the employees and the company (a self-insured entity).

Employees, in general, realized a number of benefits from their direct care healthcare. The ability to communicate directly with their provider by phone, text, and email was particularly valuable to them. In addition, they were appreciative that they did not have to wait long when they visited the doctor and did not feel rushed during the appointment.

Another benefit came about because of the closer relationship and the focused nature of the provider visit in the direct care on-site model. The company’s report on their study indicated that “there were several instances in which serious health issues (specifically, pre-cancerous conditions, pre-diabetes, and early stage liver cirrhosis) were discovered during a routine checkup or an unrelated treatment—healthcare encounters that the participants readily admit might have been postponed or neglected in the past.”

In addition, the direct care on-site physicians were able to focus on more personal challenges with the company’s employees, such as stress management, dermatological concerns, and weight loss. Many employees “reported that the added level of accountability … was a significant factor in achieving health and wellness successes in those and other areas.”

The company also realized cost savings during the very brief study period. For example, the company estimated “a diversion of costs averaging $54.31 per-member per-month and additional care prevention of $99.99 per-member per-month, for a total savings of $221,442 over the seven months.”

Roy Steiner
December 10, 2018


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


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


How to integrate a cost-benefit analysis with value-based care

The move toward value-based care has caused independent physicians to move from a fee-per-visit model to payments based on quality healthcare outcomes for their patients. The trend has created a situation for many independent practices in which they need to be more efficient, particularly in regard to costs for treatment that may not be immediately reimbursed. A cost-benefit analysis integrated with the physician’s value-based care model may help in that area.

Research recently published by Joel Tsevat, MD, MPH, professor of medicine at UT Health San Antonio, calls for a “convergence” of cost-benefit analysis and value-based healthcare. Tsevat has identified the key differences in the two as being time, perspective, and the ability to maximize outcomes.

While value-based care focuses on shorter timeframes, such as a 30-day plan of care, cost-effectiveness analysis tends to look at the longer term, often as long as a patient’s lifetime. Cost-effectiveness analysis, viewed from a more societal or health care sector perspective, can actually benefit from “drawing on value-based healthcare’s patient-centered approach,” Tsevat says. Conversely, “value-based healthcare could benefit from the capability of cost-effectiveness analysis to gauge tradeoffs—the costs for the benefit.”

In the research report, Tsevat states that “Value-based health care focuses on maximizing outcomes achieved per dollar spent. As such, it bears many similarities to a well-established method, cost-effectiveness analysis (CEA), which provides a framework for comparing the relative value of different diagnostic or treatment interventions.”

Understanding the cost-effectiveness analysis could become a critical component of efficiency and financial stability for the independent practice. Value-based care will be rewarded, but the independent physician must gauge the costs and weigh them against the returns. As Tsevat emphasizes, “value-based payment has emerged as a visible component of VBHC (value-based healthcare) and is gaining a foothold in the United States in various forms, particularly bundled payments and accountable care organizations, in an effort to reward high-value care and disincentivize low-value care.”

Nick Dealtry
November 14, 2018


The core tenets of a care management system

In the move to value-based healthcare, care management is gaining traction as a way to effectively and cost-efficiently manage the health of the independent physician’s population of patients. The renewed focus on what has been termed the “Triple Aim,” that is, sustainable costs, better health outcomes, and improved patient experience, has led to the need to implement a care management system for managing patients and their plan of care.

A brief published by the Agency for Healthcare Research and Quality (AHRQ), “Care Management: Implications for Medical Practice, Health Policy, and Health Services Research,” defines care management as a “team-based, patient-centered approach” to helping a population of patients and their support systems to manage their medical conditions more effectively. Care management also “encompasses those care coordination activities needed to help manage chronic illness.”

Care management systems should incorporate data analysis capabilities as well as practical aspects of patient engagement and care coordination. The system should also define “patients beyond their diseases,” according to Ron Geraty, MD, writing for HIMSS. Dr. Geraty states that “care plans that are based solely on disease can be ineffective, contribute to resource waste, and fail to deliver appropriate interventions.”

Patient segmentation is an integral part of a care management system as well. As Dr. Geraty explains, “Segmentation zeroes in on clear steps to advance the Triple Aim across a spectrum of clinical conditions, and interventions are delivered with precision to those who need them the most.”

The three strategies for an enhanced and effective care management system highlighted in the AHRQ brief are to “1) identify population(s) with modifiable risks; (2) align CM services to the needs of the population(s); and (3) identify, prepare, and integrate appropriate personnel to deliver the needed services.”

In a theme similar to Dr. Geraty’s, AHRQ recommends that a care management system should first identify and develop “risk-based approaches to identify patients most in need of care management (CM) services. As part of the process in developing an effective care management system aligned to the specific needs of the patients, AHRQ also recommends using electronic health records (EHRs) “to facilitate care coordination and effective communication with patients and outreach to them.”

Nick Dealtry
November 12, 2018