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The Centers for Medicare and Medicaid Services (CMS) recently launched an Innovation Center that “supports the development and testing of innovative health care payment and service delivery models.” One of those innovations is Comprehensive Primary Care Plus (CPC+), a national advanced primary care medical home model. The CMS Innovation Center has published a number of updates and changes to the 2019 CPC+ program in its report, “CPC+ Payment and Attribution Methodologies for Program Year 2019.”
According to the Innovation Center, 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. CPC+ is a five-year model that began in January 2017 for 2017 Starters and will begin in January 2018 for 2018 Starters.
In addition to the information provided in the Innovation Center’s publication, a new track initiative that will reduce the reporting requirements for quality care is expected in 2019 as well. The new initiative should relieve independent physicians of many of the current reporting burdens they face in delivering value-based healthcare.
In 2019, CMS is providing the Care Management Fee (CMF) to CPC+ practices to support them in the expectation that CPC+ practices provide “wrap-around” primary care services. CMF is a non-visit-based fee that will be paid to practices in both tracks quarterly. The amount of the CMF is determined by (1) the number of beneficiaries attributed to a given practice per month, (2) the case mix of the attributed beneficiary population, and (3) the CPC+ track to which the practice belongs.
In its report on 2019 payment and attribution methodologies, the Innovation Center specifies that practice performance is measured against absolute performance thresholds. The minimum and maximum thresholds are determined from a reference population external to CPC+ participation. In turn, a practice’s own performance relative to these thresholds determines the incentive amount the practice retains. In addition, minimum and maximum performance goals are established using absolute thresholds that are the same for all practices. The performance goals are the same for both tracks and for all Starters.
CMS states that “In Program Year 2019, the minimum threshold is set to the 30th percentile of performance in the reference population for clinical quality and patient experience of care, and to the 50th percentile of performance in the reference population for utilization. Practices are not eligible to retain any of the PBIP (Performance-Based Incentive Payment) for the relevant measure if their performance score on an individual measure falls below this minimum threshold. This requirement ensures that practices are not rewarded for poor performance and encourages practices to place the highest priority on measures with very low scores to bring them above the minimum threshold.”
Damien Neuman July 8, 2019Read
On June 3rd, Elation Health joined 33 other organizations to submit a letter in support of a CMS proposal which would require hospitals participating in Medicare or Medicaid to send event notifications – also known as admission/discharge/transfer or ADT feeds – to other health care facilities or community providers.
Why is this important? If adopted, hospitals would be required to tell independent practices when a patient is admitted. This allows primary care physicians to know that their patients have been admitted to the hospital, which can drive critical follow-up and longer-term preventative activities to reduce readmissions.
Currently, many hospitals choose not to share ADT feed alerts for competitive reasons, even though they have the ability to share this information. As the organizations in the letter stress, “these notifications are critical to improving patient safety through better care transitions and are key to enabling value-based care at scale.” By having access to ADT feeds, independent physicians can spend less time trying to understand pertinent details around admissions, discharges, transfers, and encounters for their patients to ensure optimal follow-up care.
Elation Health strongly supports any initiative that attempts to streamline data sharing, especially when it is in the interest of patient care. A number of studies have demonstrated how valuable this kind of data exchange could be for readmission rates and other areas of patient care.
As the only EHR platform that signed onto this letter, we are eager to continue advocating for improved interoperability standards. At the same time, we’ve invested in features like our Collaborative Health Record to put the patient’s story in the center of their care experiences, whether that includes visits to physicians in-network or out of network.
Tyler Comstock June 21, 2019Read
The Centers for Medicare & Medicaid Services (CMS) published its Quality Payment Program Year 3 Final Rule in November 2018. The document details a number of changes for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) for independent physicians in 2019. In its fact sheet, CMS highlights the following changes:
Damien Neuman May 30, 2019Read
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, 2019Read
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:
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, 2019Read
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, 2019Read
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:
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, 2019Read
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.
(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, 2019Read
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, 2019Read
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:
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, 2019Read