CPC+ and population health management

In 2012, the Centers for Medicare & Medicaid Services (CMS) launched an initiative designed to strengthen primary care. The Comprehensive Primary Care Initiative (CPCI) was designed as a four-year initiative to offer population-based care management fees and shared savings opportunities to participating primary care practices to support the provision of a core set of comprehensive primary care functions. In January 2017, CMS launched Comprehensive Primary Care Plus (CPC+), based on the foundational model of the CPCI.

With a renewed focus on population health, CPC+ is “a national advanced primary care medical home model that aims to strengthen primary care through regionally-based multi-payer payment reform and care delivery transformation. CPC+ includes two primary care practice tracks with incrementally advanced care delivery requirements and payment options to meet the diverse needs of primary care practices in the United States.”

Track 1 is designed for those practices that are ready to build the capabilities they need to deliver comprehensive primary care for their patients. In 2017, 1365 practices participated in Track 1. Track 2 is for those practices that are ready to take the additional step of increasing the breadth and depth of their care, focusing on patients with complex needs. In 2017, 1511 practices participated in Track 2.

Through its CPC+ initiative, CMS “seeks to improve quality, access, and efficiency of primary care.” Payment elements may vary, depending on which track the practice is in, but payment elements include a Care Management Fee, a Performance-Based Incentive Payment, and Payment under the Medicare Physician Fee Schedule.

Participants in CPC+ are expected to make changes in the way they deliver care for their patients. Those changes are centered on key Comprehensive Primary Care Functions: (1) Access and Continuity; (2) Care Management; (3) Comprehensiveness and Coordination; (4) Patient and Caregiver Engagement; and (5) Planned Care and Population Health.

The redesigned CPC+ includes a “robust learning system.” One of the CPC+ strategies is empanelment, which “pairs patients with a practitioner or care team as a foundation for population health management and patient relationships.” The rate of empanelment for practices participating in CPC+ grew steadily throughout 2017. CMS states that the CPC+ initiatives “ensures practices have the infrastructure to deliver better care, resulting in a healthier patient population.”

Greg Miller
March 27, 2019


Suggestions to improve MACRA and MIPs

Administrative burdens that detract from a provider’s ability to focus on patient care are at the heart of challenges independent physicians have with the Quality Payment Plan (QPP) that is part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Providers participating in either of the two QPP payment tracks, the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (Advanced APMs), have raised questions and made suggestions for improvement.

The main theme at a hearing held in July 2018 on how to improve Medicare was to reduce the administrative burdens on providers. Other concerns focused on the quality measures involved in MIPS, particularly whether they were relevant across the board. Healthcare providers participating in the hearing suggested that the reporting process be simplified and that it incorporate more meaningful measures.

Frank Opelka, MD, FACS, ACS’ Medical Director of Quality and Health Policy, noted that for quality reporting that did not impose an administrative burden to physicians, “CMS needs measures that accurately and meaningfully target the episode of care being assessed, providing useful information to physicians and patients. This is not currently the case.”

In addition, as reported by Revcycle Intelligence, “The American Medical Association’s (AMA) immediate past president David O. Barbe, MD, MHA, also provided a list of suggestions for decreasing administrative burden in the Quality Payment Program. His recommendations included:

  • Reducing the number of measures a physician must report for the MIPS Quality performance category
  • Permitting providers to report for a minimum of 90 days in all MIPS performance categories
  • Expanding facility-based definition to include providers in all settings, such as post-acute care and long-term care facilities.”

Physicians are urging the Centers for Medicare & Medicaid Services (CMS) to make improvements to MIPS to encourage more healthcare providers to participate. Those who are currently participating do not feel they are being rewarded adequately for meeting the quality measure requirements. Smaller, independent physicians should be assisted with participating, perhaps with the option of an alternative MIPS pathway.

Greg Miller
March 22, 2019


What industry leaders think about the new proposed interoperability rules

Rules proposed by the Centers for Medicare & Medicaid Services (CMS) and by the Office of the National Coordinator for Health IT (ONC) in February 2019 focus on interoperability of electronic health records (EHRs) to make patient data more useful and transferrable. CMS proposed the Interoperability and Patient Access Proposed Rule, which includes policy changes to support its My HealthEData initiative. ONC’s proposed rule “promotes secure and more immediate access to health information for patients and their healthcare providers and new tools allowing for more choice in care and treatment.”

Several industry leaders have responded to the new proposed CMS and ONC rules in a positive manner. As reported by Health Data Management, “Matt Eyles, president and CEO of America’s Health Insurance Plans, said that healthcare payers are committed to establishing new, innovative ways to integrate and share data with patients and providers.” Eyles noted that “AHIP and our members support seamless access to health information by providers and patients to make better choices about care and treatment.”

Organizations such as the College of Healthcare Information Management Executives (CHIME) support interoperability of electronic health information and have asked members to provide input on the new proposed rules. Liz Johnson, chief innovation officer at Tenet Healthcare and vice chair of the CHIME Policy Steering Committee, stated that “Speeding interoperability and patient access to their records are priorities for our members.”

Don Crane, president and CEO of America’s Physician Groups, noted that the proposed rules “puts power back in the hands of patients by streamlining their ability to access health information literally from the palm of their hand.” Crane added that “Having this information readily accessible can help patients and providers make more informed choices about their care more quickly. And it can help preserve valuable healthcare resources by reducing waste, such as duplicate tests and unnecessary procedures.”

CMS is accepting 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.

Greg Miller
March 5, 2019


Report shows value-based care payments on the rise

In 2015, the U.S. Department of Health and Human Services (HHS) launched a public-private partnership known as the Health Care Payment Learning & Action Network (HCP LAN). That same year, HHS announced its goal of tying 30% of fee-for-service (FFS) Medicare payments to quality or value through Alternative Payment Models (APMs) by 2016 and 50% by 2018. An APM is a payment approach that gives added incentive payments for high-quality and cost-efficient healthcare services.

The HCP LAN has collected data among payers to track the progress of the value-based payment numbers. The report released in October 2018, “Measuring Progress: Adoption of Alternative Payment Models in Commercial, Medicaid, Medicare Advantage, and Fee-for-Service Medicare Programs,” found a steady increase in healthcare payments tied to APMs.

The results of the 2017 data collection “show progress, with 34% of total U.S. health care payments tied to alternative payment models (APMs) in 2017, a steady increase from 23% two years ago.” The report highlights include:

  • 41% of health care dollars in Category 1 (e.g., traditional fee-for-service (FFS) or other legacy payments not linked to quality)
  • 25% of health care dollars in Category 2 (e.g., pay-for-performance or care coordination fees)
  • 34% of health care dollars in a composite of Categories 3 and 4 (e.g., shared savings, shared risk, bundled payment, or population-based payments)

The collected data shows “a continued move away from a fee-for-service system that reimburses only on volume, and towards patient- and value-centered APMs.”

LAN’s data collection began on May 15, 2018, and ended on July 15, 2018, using “metrics to determine the extent of APM adoption, asking health plans and states to report dollars paid in either CY 2017 or in the most recent 12 months for which it had data.” Data collection participants included “61 health plans, 3 managed FFS Medicaid states, and Medicare FFS, representing approximately 226.3 million of the nation’s covered lives and 77% of the national market.”

Healthcare payers participating in the data collection were optimistic about the future of value-based care and payments tied to APMs. In fact, the researchers found that “90% of health plans believe that APM adoption will increase in the next 24 months.”

Greg Miller
February 19, 2019


CMS finalizes changes to Medicare Shared Savings Program (MSSP) and ACO overhaul

Pathways to Success has been billed as an “overhaul of Medicare’s ACO program” by the Centers for Medicare & Medicaid Services (CMS). Seema Verma, Administrator for CMS, announced the new program for Accountable Care Organizations (ACOs) as well as changes to the organization’s shared savings program in December 2018.

Seema noted that “the American healthcare system is on an unsustainable trajectory, with one in five dollars spent in our economy projected to be spent on healthcare by 2026,” so healthcare providers and CMS have a responsibility to “to ensure that patients are getting value for the care that is provided.” Pathways to Success introduces a new structure for the ACO Medicare Shared Savings Program (MSSP) that emphasizes value-based care.

The start date for Pathways to Success will be July 1, 2019. Replacing previous MSSP tracks, the new program offers participation in either the BASIC or the ENHANCED track:

(1) 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

(2) 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. Appendix A summarizes the characteristics of the participation options.

Seema notes that CMS is “setting the shared savings rate at 40 percent for ACOs not assuming risk for healthcare costs and 50 percent for ACOs at BASIC track levels of risk, to strengthen the on-ramp to the program while rewarding ACOs that take on greater risk with higher shared savings rates.”

ACOs will enter into 5-year agreements to participate in Pathways to Success, with 12-month performance years based on calendar years. Seema emphasized that part of the change is to reduce the amount of time an ACO can participate in the shared savings program “without taking accountability for healthcare spending.”

Greg Miller
February 6, 2019


ONC and HHS draft strategy to improve EHR user experience

A report required by the 21st Century Cures Act has been published by the Office of the National Coordinator (ONC) for Health Information Technology (IT). The report, Strategy on Reducing Regulatory and Administrative Burden Relating to the Use of Health IT and EHRs, is focused on improving the use of electronic health records (EHRs) and reducing the regulatory burdens placed on physicians.

ONC acknowledges that “clinicians and other health care providers point to the implementation, use, and regulation of health IT and the EHR as a key support tool for care delivery” but that there are also challenges involved. The organization indicates it has “heard from health care providers, practice managers, and hospitals that they experience challenges with EHR system design and the regulatory and administrative burdens associated with the use of EHRs during care delivery, required reporting activities, and documentation of claims for payment.”

The report lays out a series of strategies and recommendations that HHS is considering taking to mitigate EHR-related burden for health care providers, including strategies for EHR Reporting and Public Health Reporting. Strategies outlined for Clinical Documentation and Health IT Usability are also included in the report:

Clinical Documentation Strategies

Strategy 1: Reduce regulatory burden around documentation requirements for patient visits.

Strategy 2: Continue to partner with clinical stakeholders to encourage adoption of best practices related to documentation requirements.

Strategy 3: Leverage health IT to standardize data and processes around ordering services and related prior authorization processes

Health IT Usability Strategies

Strategy 1: Improve usability through better alignment of EHRs with clinical workflow; improve decision making and documentation tools.

Strategy 2: Promote user interface optimization in health IT that will improve the efficiency, experience, and end user satisfaction.

Strategy 3: Promote harmonization surrounding clinical content contained in health IT to reduce burden.

Strategy 4: Improve health IT usability by promoting the importance of implementation decisions for clinician efficiency, satisfaction, and lowered burden.

ONC Health IT is only accepting comments on the report electronically, at: https://www.healthit.gov/topic/usability-and-provider-burden/strategy-reducing-burden-relating-usehealth-it-and-ehrs.

Comment attachments should be in Microsoft Word, Excel, or Adobe PDF. The deadline for comment submission is 11:59 p.m. E.T. on January 28, 2019. ONC will review, analyze, and post on their website all public comments that are received by 11:59 p.m. E.T. on January 28, 2019.

Greg Miller
January 28, 2019


Medicare physician fee schedule updated to include virtual services

Recognizing that healthcare does not always happen in a provider’s office, the Centers for Medicare & Medicaid Services (CMS) has included payment for a number of virtual services in its Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019.

The revised fee schedule provides payment for certain types of telemedicine provided to Medicare patients. New codes enable independent physicians to be paid for “two newly defined physicians’ services … using communication technology:

  • Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012) and
  • Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)”

Previously, the physician was not able to bill Medicare for services provided outside the office visit. However, patients often call or communicate electronically to clarify instructions or to ask questions regarding a diagnosis or plan of care. Responding to the patients requires the physician’s time and attention, both to research and prepare the response as well as the actual response time. As of January 1, 2019, those physicians can be reimbursed for that time.

CMS has acknowledged that these virtual services have the potential to “increase efficiency for practitioners and convenience for beneficiaries.” Patients and providers can also take advantage of technology-based communication to determine whether an office visit is even necessary. Prior to calendar year (CY) 2019, the physician would not have been reimbursed for teleservices designed to help a Medicare patient avoid an unnecessary trip to the provider’s office.

In addition, in CY 2019, CMS “finalized payment for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) for communication technology-based services and remote evaluation services that are furnished by an RHC or FQHC practitioner when there is no associated billable visit.” RHCs and FQHCs can bill for teleservices using “a newly created RHC/FQHC Virtual Communication Service HCPCS code, G0071.”

Providers responding to a recent survey conducted by Reaction Data indicated that the new billing codes for virtual services would accelerate their plans to take advantage of technology such as telemedicine in providing quality, value-based care for their patients.

Greg Miller
January 22, 2019


CMS seeks contractor to ease MACRA compliance for physicians

Recognizing the concern that many physicians have regarding MACRA compliance, the Centers for Medicare & Medicaid Services (CMS) is searching for a contractor who can gather additional feedback and help clarify the requirements. The options under the Quality Payment Program (QPP), in particular, are confusing to independent physicians. The choice between the Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Models (APM) is challenging and especially crucial to provider payments.

CMS has issued a notice seeking a contractor to support all existing and future QPP system development and policy development with user research and human centered design. The task order “aims to solve current challenges faced by the Quality Payment Program (QPP), to identify and implement a consistent user experience for the clinician market, based on comprehensive user insights through market research with clinicians as well as to create a unified product strategy, visual identity, and smooth user experience across QPP products based on industry best practices.”

Cost performance will account for 30% of a provider’s MIPS score, as of 2021, and it is vitally important that the criteria for provider payments are clear. CMS recognizes that the “Cost performance category feedback presents the greatest challenge for providing feedback, since the measures are highly complex, the data is extracted from claim submissions and is not consciously submitted by clinicians. There is complex patient attribution rules, and cost normalization processes which are completely foreign to the average clinician.”

The transition of QPP to a Scaled Agile Framework (SAFe) has “created an opportunity to think holistically about the user experience for clinicians and ways in which our QPP teams can identify a product strategy, establish measurable objectives, and execute a plan aligned with the overall QPP vision through program increment planning.”

CMS has stated that the contractor will also work closely with the policy team to ensure Human-Centered Design (HCD), the process it uses to understand the people for whom it writes policies, and creates programs and services, is incorporated into policy writing.

Greg Miller
January 9, 2019


93% of MIPs-eligible providers will receive a positive payment adjustment

In a blog post published on November 8, 2018, Seema Verma, Administrator for the Centers for Medicare & Medicaid Services (CMS), shared data on the Quality Payment Program (QPP) Year 1 Performance. The results were overwhelming positive, with 93 percent of MIPS eligible clinicians receiving a positive payment adjustment for their performance in 2017 and 95 percent overall avoiding a negative payment adjustment.

CMS calculated that “1,057,824 MIPS eligible clinicians will receive a MIPS payment adjustment, either positive, neutral, or negative. Of that population, 1,006,319 MIPS eligible clinicians reported data as either an individual, as a part of a group, or through an Alternative Payment Model (APM) and received a neutral payment adjustment or better. Additionally, under the Advanced APM track, 99,076 eligible clinicians earned Qualifying APM Participant (QP) status.”

In her blog post, Verma provided a chart that illustrates the numbers for the various payment adjustments:

CMS recognizes that even though the majority of providers received a positive payment adjustment, those adjustments were “modest.” MIPS has a budget neutrality requirement, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). In addition, during the transition year of 2017, CMS offered providers a relatively low overall performance threshold for MIPS as well as a “pick your pace” option that provides three reporting options of test, partial year, or full year. These accommodations were offered to encourage flexibility and more robust provider participation.

Verma emphasized that, going forward, CMS is “committed to continue leveraging our Patients over Paperwork framework to review many of the MIPS requirements to reduce burden and add additional flexibilities so clinicians can successfully participate without sacrificing the time they spend with patients.” Providers are encouraged to send CMS feedback to “help identify areas of immediate need as well as shape the program for future performance years.”

Greg Miller
December 14, 2018


Exploring the CMS final rule for MACRA and 2019 Physician Fee Schedule

Adding payment options for virtual services and a subset of changes to the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) are two of the updates included in the final rule released by the Centers for Medicare & Medicaid Services (CMS) on November 1, 2018. The final rule includes updates to payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2019.

Many of the updates relate to communication technology, telemedicine, and virtual check-ins. One of the new payment provisions is listed under the category of “Modernizing Medicare Physician Payment by Recognizing Communication Technology-Based Services.” CMS is finalizing proposals to pay separately for two newly defined physicians’ services provided using communication technology:

  • Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012)
  • Remote evaluation of recorded video and/or images submitted by an established patient (HCPCS code G2010)

In a move toward making healthcare more efficient and more convenient, these payment provisions would mean that healthcare providers would be paid for “the brief communication technology-based service when the patient checks in with the practitioner via telephone or other telecommunications device to decide whether an office visit or other service is needed.”

Recognizing the value of telemedicine in the continuing efforts to reduce opioid addiction, CMS is also implementing a provision that removes the originating site geographic requirements from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, adding the home of the patient as a permissible originating site for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019.

In regard to ACOs, the CMS final rule addresses a number of changes, including:

  • A voluntary 6-month extension for existing ACOs whose participation agreements expire on December 31, 2018, and the methodology for determining financial and quality performance for this 6-month performance year from January 1, 2019, through June 30, 2019.
  • Allowing beneficiaries who voluntarily align to a Nurse Practitioner, Physician Assistant, Certified Nurse Specialist, or a physician with a specialty not used in assignment to be prospectively assigned to an ACO if the clinician they align with is participating in an ACO, as provided for in the Bipartisan Budget Act of 2018.
  • Revising the definition of primary care services used in beneficiary assignment.
  • Providing relief for ACOs and their clinicians impacted by extreme and uncontrollable circumstances in 2018 and subsequent years.
  • Reducing the Shared Savings Program core quality measure set by eight measures; and promoting interoperability among ACO providers and suppliers by adding a new CEHRT threshold criterion to determine ACOs’ eligibility for program participation and retiring the current Shared Savings Program quality measure on the percentage of eligible clinicians using CEHRT.

The final rule spans 2,378-pages; however, CMS has published a fact sheet on “Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019,” providing a list of the updates and changes to the PFS for calendar year (CY) 2019.

Greg Miller
December 10, 2018