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CMS Begins Implementation of Key Payment Legislation

Proposed Update to Physician Fee Schedule is First Since Repeal of SGR

Today, CMS released the first proposed update to the physician payment schedule since the repeal of the Sustainable Growth Rate through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).  The proposal includes a number of provisions focused on person-centered care, and continues the Administration’s commitment to transform the Medicare program to a system based on quality and healthy outcomes.

“CMS is building on the important work of Congress to shift the Medicare program toward a system that rewards physicians for providing high quality care,” said Andy Slavitt, Administrator of CMS.  “Thanks to the recent landmark Medicare and children’s health insurance program legislation, CMS and Congress are working together to achieve a better Medicare payment system for physicians and the American people.”

In the proposed CY 2016 Physician Fee Schedule rule, CMS is also seeking comment from the public on implementation of certain provisions of the MACRA, including  the new Merit-based Incentive payment system (MIPS). This is part of a broader effort at the Department to move the Medicare program to a health care system focused on the delivery of quality care and value.

The proposed rule includes updates to payment policies, proposals to implement statutory adjustments to physician payments based on misvalued codes, updates to the Physician Quality Reporting System, which measures the quality performance of physicians participating in Medicare, and updates to the Physician Value-Based Payment Modifier, which ties a portion of physician payments to performance on measures of quality and cost.  CMS is also seeking comment on the potential expansion of the Comprehensive Primary Care Initiative, a CMS Innovation Center initiative designed to improve the coordination of care for Medicare beneficiaries.

The proposed rule also seeks comment on a proposal that supports patient- and family-centered care for seniors and other Medicare beneficiaries by enabling them to discuss advance care planning with their providers. The proposal follows the American Medical Association’s recommendation to make advance care planning services a separately payable service under Medicare.

The release of the rule triggers a 60-day comment period, during which time CMS welcomes the input of stakeholders and the public.  A final rule will be published this fall. For a fact sheet on the proposed rule, please see here. For further information, please see the rule on display here.

July 8, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Overwhelming Majority of Payments to Doctors and Hospitals in New York State Are Still Made Using Fee-for-Service

New Scorecards Show One-Third of Payments in the Empire State Now Tied to Value

April 30, 2015 (New York) – An independent review of health care payments to doctors and hospitals reveals that the vast majority of payments in New York State continue to flow through a fee-for-service mechanism in both the commercial (94%) and Medicaid (73%) sectors. However, a significant proportion of payments are “value-oriented”—that is, designed to boost the quality of care patients receive. Approximately one-third of health care payments to doctors and hospitals in New York State are value-oriented.

Catalyst for Payment Reform (CPR) released the findings today in two Scorecards, commissioned by the New York State Health Foundation.

New York State is currently organizing an ambitious reform effort through its Delivery System Reform Incentive Payment (DSRIP) program and the State Health Innovation Plan (SHIP). DSRIP’s primary purpose is to restructure the health care delivery and payment systems through reinvesting in the Medicaid program. Similarly, a key goal of the SHIP is to ensure that, within five years, 80% of New Yorkers are cared for under value-based payment arrangements, rewarding providers who help patients stay healthy and achieve quality health care outcomes at an efficient cost.

“The shift toward value-oriented payments is critical for improving the quality and affordability of care in New York State,” said James R. Knickman, President and CEO of the New York State Health Foundation. “While we clearly have some work to do to move away from our antiquated fee-for-service system, it’s encouraging that a large proportion of payments are tied to quality and value. New York State is on the right path.”

The Scorecards, based on comprehensive surveys of commercial health plans and Medicaid health plans that collectively insure 16.3 million New Yorkers, found that:

  • Among commercial health plans, 34% of payments are tied to value; similarly, among Medicaid plans, 33% of payments are tied to value.
  • In the commercial sector, less than 15% of payments place health care providers at financial risk for their performance (that is, they stand to lose financially if they overspend or do not meet quality targets); in Medicaid this grows to 46%.
  • In the commercial sector, the most common form of value-oriented payment is pay-for–performance, which is typically traditional fee-for service payment with a bonus for meeting quality or efficiency goals (23%).
  • In Medicaid, the most common form of payment reform is a combination of some kind of non-fee-for-service base payment along with a shared savings agreement (13%). These arrangements are most often put into place to support patient-centered medical homes, or accountable care organizations (ACOs) for which providers may receive a care coordination fee or other per-member per-month payment and have an agreement with payers that they will share in any savings they produce.
  • In the commercial sector, less than 3% of payment arrangements contain “shared risk,” which means providers are financially responsible for any financial losses and have the opportunity to gain financially if there are any savings. In Medicaid this jumps to nearly 13%, likely because Medicaid health plans that are provider-owned are in a better position to hold providers financially responsible for exceeding cost targets.

In 2013 and 2014, Catalyst for Payment Reform produced National Scorecards on Payment Reform, measuring value-oriented payment in the commercial sector across the United States.

“These New York Scorecards released today are groundbreaking because it is the first time we have looked at payment reform by Medicaid in contrast to the commercial sector,” said CPR’s Executive Director Suzanne Delbanco. “We know health care providers need stronger and more consistent signals from payers. These Scorecards help public and private payers identify where there are opportunities for further alignment in their approach to payment.”

# # #

About the New York State Health Foundation

The New York State Health Foundation (NYSHealth) is a private, statewide foundation dedicated to improving the health of all New Yorkers, especially the most vulnerable. Today, NYSHealth concentrates its work in three strategic priority areas: expanding health care coverage, building healthy communities, and advancing primary care. The Foundation is committed to making grants, informing health care policy and practice, spreading effective programs to improve the health system, serving as a neutral convener of health leaders across the State, and providing technical assistance to its grantees and partners.

About Catalyst for Payment Reform

Catalyst for Payment Reform is an independent, non‐profit corporation working on behalf of large health care purchasers to catalyze improvements to how we pay for health services and to promote better and higher-value care in the U.S.

About the New York Scorecard on Commercial Payment Reform and the New York Scorecard on Medicaid Payment Reform

All data in the New York Scorecard on Commercial Payment Reform and the New York Scorecard on Medicaid Payment Reform come from commercial and Medicaid health plans, respectively. CPR collaborated with the New York State Department of Financial Services (DFS) to collect data from health plans. DFS issued a request for information pursuant to Section 308 of the New York Insurance Law to ensure participation by all health plans within the scope of the project. Ten commercial health plans and fifteen Medicaid plans completed a survey, from which CPR aggregated results. For additional information, please see the relatedMethodology documents.

April 30, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

WellHealth Quality Care Launches Innovative Healthcare Operating System from par8o

Nevada’s First and Only Accountable Care Network Implements par8o to Improve the Member Experience, Decrease Patient Costs and Enhance Quality of Care in Nevada

Boston, MA, February 26, 2015par8o, Healthcare’s Operating System, today announced that WellHealth Quality Care (WellHealth), Nevada’s first accountable care network, has launched the company’s EMR-agnostic platform to provide a seamless transition-in-care process for all WellHealth members. par8o’s platform enables clinical coordination across the network in order to enhance the member experience, manage costs and deliver high-quality care. WellHealth is the latest of a growing number of organizations in Nevada to adopt par8o, with others including the largest employer in the state, MGM Resorts.

“WellHealth is dedicated to providing our members access to a highly-qualified network of physicians,” said Dr. K Warren Volker, Chairman, and CEO of WellHealth Quality Care. “Physicians must be able to exchange health information easily in order to provide the best care possible, and par8o enables them to do so easily and effectively.”

WellHealth is partnering with payer groups such as the Nevada Health CO-OP to bring Nevada residents an efficient healthcare delivery system. WellHealth provides all medical specialties, from primary care and pediatrics, to neurosurgery and obstetrics. By utilizing the par8o platform, WellHealth’s network physicians will have a simplified workflow, ensuring that patients have access to the right physician at the right time.

“WellHealth is leading the way in quality based, efficient, and patient-centric health care initiatives,” said Nicole Flora, MD, Chief Medical Officer at the Nevada Health CO-OP. “The WellHealth provider network is composed of the area’s finest medical professionals, and by using par8o’s platform it is delivering high-quality, coordinated care to patients across the state.”

par8o’s Healthcare Operating System empowers healthcare organizations to optimize their networks of providers and other resources to deliver quality care by applying one of the most powerful and proven principles in economics: Pareto Optimization. This approach and the EMR-agnostic technologies par8o has developed to deploy it, are well-suited to the complex, multi-constituency nature of healthcare because they achieve continuous efficiency improvements while balancing the needs of all parties.

“Innovative new healthcare models, like WellHealth, are gaining a foothold in the industry, but there remains a significant need to bridge technology gaps to connect patients appropriately to the services they need, when they need them,” said Adam Sharp, MD, co-founder, President and CMO of par8o. “par8o provides a smarter application of technology that promotes easy communication between referring and receiving physicians. Together, par8o and WellHealth are moving toward a streamlined patient experience that is quality-driven and strategically focused.”

About WellHealth Quality Care

WellHealth Quality Care is Nevada’s first multi-specialty Accountable Care Network. Based on the principle of providing the very best in patient care, our network of hand-selected providers includes some of the area’s finest medical professionals dedicated to providing five-star, coordinated, and accountable care.  Our integrated and quality-based network of collaborative physicians provides both patients and providers with a sophisticated, efficient and cost effective healthcare delivery system. For more information, visit WellHealthQC.com or call (702) 545-6116.

About Nevada Health CO-OP

The Nevada Health CO-OP is a not-for-profit health insurance alternative created under the Affordable Care Act administered by Nevadans for Nevadans. “Health Insurance Simplified” is the mission of the CO-OP. The not-for-profit is focused on creating a simple member-owned and operated health plan that works easily for patients, doctors, employers and the community. Headquartered in the heart of Las Vegas, the CO-OP serves the Nevada community directly with great understanding of the needs of the people, particularly among diverse populations and small businesses trying to find access and provide healthcare coverage. To learn more, please visit the CO-OP at www.nevadahealthcoop.org or call 702-823-COOP (2667).

About par8o

par8o is a venture-backed, EMR-agnostic platform that creates a common point for coordinating care delivery and plan design, a technology that connects providers, payers, and patients. par8o is a cloud-based healthcare operating system enabling all parties to improve care and optimize towards several clinical and business goals in parallel rather than to the detriment of one another. par8o helps clients succeed by applying Pareto Optimization, a powerful economic principle that succeeds because it is well suited to the complex, multi-constituency nature of healthcare. Simply put, par8o helps organizations match the right patient to the right resource at the right time, ensuring that patients successfully transition to the next step in their care. To learn more about par8o, please visit www.par8o.com.

February 26, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Caradigm Enables Healthcare Providers to Participate in the Federal Government’s Delivery Reform Incentive Program

Medicaid Incentive Program Participants Can Help Improve Outcomes Required For Reimbursement With Caradigm’s Population Health Solutions

BELLEVUE, WA – Feb. 19, 2015Caradigm, the leader in enterprise population health, today announced a solution package designed to help Performing Provider Systems (PPSs) succeed under the federal government’s Delivery System Reform Incentive Payment (DSRIP) program.

The Center for Medicare and Medicaid Services (CMS) created DSRIP to improve both quality of care and healthcare access for underserved individuals. State governments use funding from CMS to encourage PPSs to participate in this program.

“U.S. healthcare is undergoing a transformation and DSRIP is one example of a program that is focused towards encouraging and incenting innovation in care delivery,” said Brian Drozdowicz, senior vice president, global population health, Caradigm. “Caradigm’s solutions are designed to support specific state-based initiatives such as DSRIP, which includes driving the system and clinical transformations needed to achieve population health.”

PPSs face the complexity of data consolidation and normalization; access to real-time data for performance management; and care intervention for patients. Caradigm’s DSRIP solutions, including healthcare analytics, care and risk management, enable PPSs to put functional population health management tools in place to identify, monitor and report on at-risk patient populations.

Further, Caradigm’s DSRIP solutions are unique as they not only report improvements, but deliver the means to achieve improvement goals, as PPSs are able to identify gaps in care quality improvement and find new ways to engage families and patients in their care. These benefits contribute to the overall DSRIP goals of reducing avoidable hospital use, improving health measures and transforming Medicaid into a more cost-efficient program with improved outcomes.

For more detailed information on Caradigm’s approach to DSRIP, interested parties can click here.

About Caradigm (www.caradigm.com)

Caradigm is a population health company dedicated to helping organizations improve care, reduce costs, and manage risk. Caradigm analytics solutions provide insight into patients, populations, and performance, enabling healthcare organizations to understand their clinical and financial risk and identify the actions needed to address it. Caradigm population health solutions enable teams to deliver the appropriate care to patients through effective coordination and patient engagement, helping to improve outcomes and financial results. The key to Caradigm analytics and population health solutions is a rich set of clinical, operational, and financial data delivered to healthcare professionals within their workflows in real time. Visit:www.caradigm.com.

February 19, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Modernizing Medicine’s Electronic Medical Records (EMR) System Supports Industry Movement toward Quality of Care Reporting and Outcome-Based Reimbursement

Boca Raton, FL – January 29, 2015 — Modernizing Medicine, Inc., the creator of the Electronic Medical Assistant® (EMA™), a cloud-based, specialty-specific electronic medical record (EMR) system, responded today to recent announcements from the Centers for Medicare & Medicaid Services (CMS), the U.S. Department of Health & Human Services (HHS) and leading health insurers, regarding the concerted push away from fee-for-service healthcare models in favor of outcome-based reimbursements.

CMS has announced that 85 percent of Medicare payments in 2016 could be based on quality of care, and that number could grow to 90 percent in 2018. Additionally, a UnitedHealth Group executive was reported to have said that the company plans to increase value-based payments to doctors and hospitals by 20 percent this year, forecasting over $40 billion in payments tied to value or quality of care.

“This major shift in payment models requires the right tools and reporting systems if physicians and provider organizations want to safeguard against penalties from volume-based medicine and benefit from related incentives,” said Modernizing Medicine’s CEO and Co-founder Dan Cane in a statement issued following the recent announcements from CMS and HHS. “Modernizing Medicine is deeply committed to the physicians and healthcare professionals we serve, and we believe that health information technology vendors share a large part of the responsibility to ease the impending transition toward quality reporting and outcomes-based reimbursements.”

Unlike EMRs using templates or macros, EMA was designed with unique structured data technology that handles the Value-based Payment Modifier and enables quality reporting including Physician Quality Reporting System (PQRS) program reporting. Cane believes Modernizing Medicine is in a market leading position in providing a system that addresses this burden for physicians, enabling them to focus on practicing medicine without fear of the upcoming changes.

Co-founder and Chief Medical Officer Michael Sherling, M.D., M.B.A., echoed Cane’s sentiment about the potentially huge implications of the impending move toward payment models that tie to quality of care.

“While the new mandates signify a big step toward providing improved quality of care, without tools to support and streamline quality reporting, these new payment models may constitute a substantial hurdle for private practice in this country,” said Sherling. “Since Modernizing Medicine’s inception we have focused heavily on accurately documenting patient encounters through structured data. This facilitates the ability to track patient outcomes and report quality of care in a way that doesn’t slow down physician productivity. We would urge providers to consider the implications of these new payment guidelines, and ensure that they are working with technologies that will support both their practice and the forthcoming revised payment structure.”

“With rich capabilities for PQRS reporting, Meaningful Use attestation and ICD-10 coding built in, EMA is ready for the changes in healthcare ahead,” said Cane. “The more than 30,000 physicians and health providers across the nation who use EMA are on solid ground.”

About Modernizing Medicine

Modernizing Medicine® is transforming how healthcare information is created, consumed and utilized in order to increase efficiency and improve outcomes. Our flagship product, Electronic Medical Assistant® (EMA™), is a cloud-based, specialty-specific electronic medical records (EMR) system built by practicing physicians. Available as a native iPad application and from almost any web-enabled Mac or PC, EMA adapts to each provider’s unique style of practice. This ICD-10 ready EMR system is available for the dermatology, ophthalmology, orthopedics, otolaryngology, gastroenterology, rheumatology, urology and plastic and cosmetic surgery markets and used by more than 4,800 physicians in the United States and its territories. The Modernizing Medicine family of companies also provides specialty-specific billing, inventory management and group purchasing services.

January 29, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value

In a meeting with nearly two dozen leaders representing consumers, insurers, providers, and business leaders, Health and Human Services Secretary Sylvia M. Burwell today announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.

HHS has set a goal of tying 30 percent of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50 percent of payments to these models by the end of 2018.  HHS also set a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as the Hospital Value Based Purchasing and the Hospital Readmissions Reduction Programs.  This is the first time in the history of the Medicare program that HHS has set explicit goals for alternative payment models and value-based payments.

To make these goals scalable beyond Medicare, Secretary Burwell also announced the creation of a Health Care Payment Learning and Action Network.  Through the Learning and Action Network, HHS will work with private payers, employers, consumers, providers, states and state Medicaid programs, and other partners to expand alternative payment models into their programs.  HHS will intensify its work with states and private payers to support adoption of alternative payments models through their own aligned work, sometimes even exceeding the goals set for Medicare.  The Network will hold its first meeting in March 2015, and more details will be announced in the near future.

“Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our common interest to build a health care system that delivers better care, spends health care dollars more wisely and results in healthier people.  Today’s announcement is about improving the quality of care we receive when we are sick, while at the same time spending our health care dollars more wisely,” Secretary Burwell said. “We believe these goals can drive transformative change, help us manage and track progress, and create accountability for measurable improvement.”

“We’re all partners in this effort focused on a shared goal. Ultimately, this is about improving the health of each person by making the best use of our resources for patient good. We’re on board, and we’re committed to changing how we pay for and deliver care to achieve better health,” Douglas E. Henley, M.D., executive vice president and chief executive officer of the American Academy of Family Physicians said.

“Advancing a patient-centered health system requires a fundamental transformation in how we pay for and deliver care. Today’s announcement by Secretary Burwell is a major step forward in achieving that goal,” AHIP President and CEO Karen Ignagni said. “Health plans have been on the forefront of implementing payment reforms in Medicare Advantage, Medicaid Managed Care, and in the commercial marketplace. We are excited to bring these experiences and innovations to this new collaboration.”

“Employers are increasingly taking steps to support the transition from payment based on volume to models of delivery and payment that promote value,” said Janet Marchibroda, Health Innovation Director and Executive Director of the CEO Council on Health and Innovation at the Bipartisan Policy Center. “There is considerable bipartisan support for moving away from fee for service toward alternative payment models that reward value, improve outcomes, and reduce costs. This transition requires action not only by the private sector, but also the public sector, which is why today’s announcement is significant.”

“Today’s announcement will be remembered as a pivotal and transformative moment in making our health care system more patient- and family-centered,” said Debra L. Ness, president of the National Partnership for Women & Families. “This kind of payment reform will drive fundamental changes in how care is delivered, making the health care system more responsive to those it serves and improving care coordination and communication among patients, families and providers. It will give patients and families the information, tools and supports they need to make better decisions, use their health care dollars wisely, and improve health outcomes.”

The Affordable Care Act created a number of new payment models that move the needle even further toward rewarding quality.  These models include ACOs, primary care medical homes, and new models of bundling payments for episodes of care.  In these alternative payment models, health care providers are accountable for the quality and cost of the care they deliver to patients. Providers have a financial incentive to coordinate care for their patients – who are therefore less likely to have duplicative or unnecessary x-rays, screenings and tests.  An ACO, for example, is a group of doctors, hospitals and health care providers that work together to provide higher-quality coordinated care to their patients, while helping to slow health care cost growth. In addition, through the widespread use of health information technology, the health care data needed to track these efforts is now available.

Many health care providers today receive a payment for each individual service, such as a physician visit, surgery, or blood test, and it does not matter whether these services help – or harm – the patient. In other words, providers are paid based on the volume of care, rather than the value of care provided to patients. Today’s announcement would continue the shift toward paying providers for what works – whether it is something as complex as preventing or treating disease, or something as straightforward as making sure a patient has time to ask questions.

In 2011, Medicare made almost no payments to providers through alternative payment models, but today such payments represent approximately 20 percent of Medicare payments. The goals announced today represent a 50 percent increase by 2016. To put this in perspective, in 2014, Medicare fee-for-service payments were $362 billion.

HHS has already seen promising results on cost savings with alternative payment models, with combined total program savings of $417 million to Medicare due to existing ACO programs – HHS expects these models to continue the unprecedented slowdown in health care spending.  Moreover, initiatives like the Partnership for Patients, ACOs, Quality Improvement Organizations, and others have helped reduce hospital readmissions in Medicare by nearly eight percent– translating into 150,000 fewer readmissions between January 2012 and December 2013 – and quality improvements have resulted in saving 50,000 lives and $12 billion in health spending from 2010 to 2013, according to preliminary estimates.

To read a new Perspectives piece in the New England Journal of Medicine from Secretary Burwell: http://www.nejm.org/doi/full/10.1056/NEJMp1500445

To read more about why this matters: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-2.html

To read a fact sheet about the goals and Learning and Action Network:http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

To learn more about Better Care, Smarter Spending, and Healthier People:http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26.html

A blog from Secretary Burwell is here: http://1.usa.gov/1CYFKAk

Participants in today’s meeting include:

  • Kevin Cammarata, Executive Director, Benefits, Verizon
  • Christine Cassel, President and Chief Executive Officer, National Quality Forum
  • Tony Clapsis, Vice President, Caesars Entertainment Corporation
  • Jack Cochran, Executive Director, The Permanente Federation
  • Justine Handelman, Vice President Legislative and Regulatory Policy, Blue Cross Blue Shield Association
  • Pamela French, Vice President, Compensation and Benefits, The Boeing Company
  • Richard J. Gilfillan, President and CEO, Trinity Health
  • Douglas E. Henley, Executive Vice President and Chief Executive Officer, American Academy of Family Physicians
  • Karen Ignagni, President and Chief Executive Officer, America’s Health Insurance Plans
  • Jo Ann Jenkins, Chief Executive Officer, AARP
  • Mary  Langowski, Executive Vice President for Strategy, Policy, & Market Development, CVS Health
  • Stephen J. LeBlanc, Executive Vice President, Strategy and Network Relations, Dartmouth-Hitchcock
  • Janet M. Marchibroda, Executive Director, CEO Council on Health and Innovation, Bipartisan Policy Center
  • Patricia A. Maryland, President, Healthcare Operations and Chief Operating Officer, Ascension Health
  • Richard Migliori, Executive Vice President, Medical Affairs and Chief Medical Officer, UnitedHealth Group
  • Elizabeth Mitchell, President and Chief Executive Officer, Network for Regional Healthcare Improvement
  • Debra L. Ness, President, National Partnership for Women & Families
  • Samuel R. Nussbaum, Executive Vice President, Clinical Health Policy and Chief Medical Officer, Anthem, Inc.
  • Stephen Ondra, Senior Vice President and Chief Medical Officer, Health Care Service Corporation
  • Andrew D. Racine, Senior Vice President and Chief Medical Officer, Montefiore Medical Center
  • Jaewon Ryu, Segment Vice President and President of Integrated Care Delivery, Humana Inc.
  • Fran S. Soistman, Executive Vice President, Government Services, Aetna Inc.
  • Maureen Swick, Representative, American Hospital Association
  • Robert M. Wah, President, American Medical Association
January 26, 2015 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

CMS releases new proposal to improve Accountable Care Organizations

Shared Savings Program Proposed Rule reflects focus on primary care and improved incentives for participation, quality, and efficiency

The Centers for Medicare & Medicaid Services (CMS) today released a proposal to strengthen the Shared Savings Program for Accountable Care Organizations (ACOs) through a greater emphasis on primary care services and promoting transitions to performance-based risk arrangements. The proposed rule reflects input from program participants, experts, consumer groups, and the stakeholder community at large. CMS is seeking to continue this important dialogue to ensure that the Medicare Shared Savings Program ACOs are successful in providing seniors and people with disabilities with better care at lower costs.

CMS Administrator Marilyn Tavenner said, “This proposed rule is part of our continued commitment to rewarding value and care coordination – rather than volume and care duplication.  We look forward to partnering with providers and stakeholders to continuously refine and improve the Medicare Shared Savings program.”

Through the Affordable Care Act, ACOs encourage doctors, hospitals and other health care providers to work together to better coordinate care when people are sick and keep people healthy, which helps to reduce growth in health care costs and improve outcomes.  ACOs become eligible to share savings with Medicare when they deliver that care more efficiently while meeting or exceeding performance benchmarks for quality of care.

The Shared Savings Program now includes more than 330 ACOs in 47 states, providing care to more than 4.9 million beneficiaries in Medicare fee for service. Recently, CMS announced first year Shared Savings Program (SSP) results:

  • 58 SSP ACOs held spending below their benchmarks by a total of $705 million and earned shared savings payments of more than $315 million.
  • Another 60 ACOs had expenditures below their benchmark, but not by a sufficient amount to earn shared savings.

Other Affordable Care Act initiatives to improve care and reduce costs have helped reduce hospital readmissions in Medicare by nearly 10 percent between 2007 and 2013 – translating into 150,000 fewer readmissions – and quality improvements have resulted in saving 15,000 lives and $4 billion in health spending during 2011 and 2012.

CMS is seeking comment on a number of adjustments to improve the Medicare Shared Savings Program, including:

  • Providing more flexibility for ACOs seeking to renew their participation in the Program. Many ACOs elect to enter the Program under a one-sided risk model, where the organization participates in shared savings with the Medicare program, but does not take on additional performance-based risk. More experienced ACOs that are ready to share in financial losses in return for the opportunity for a higher share of savings may elect to enter a two-sided model. CMS is proposing to give ACOs the option of a longer lead time to transition to a two-sided performance risk model after their first agreement period. ACOs would have the opportunity to renew under the one-sided model for one additional agreement period. ACOs that enter the Shared Savings Program under the two-sided performance risk model would see no change.
  • Encouraging ACOs to take on greater performance-based risk and reward. CMS is proposing to create a new two-sided risk model, called “track 3,” which integrates some elements from the Pioneer ACO model, such as higher rates of shared savings and prospective attribution of beneficiaries – a list of assigned beneficiaries provided at the start of the performance year, and no further beneficiaries will be added to the list during the performance year.
  • We are seeking comments on a number of care coordination tools that would make two-sided performance risk models more attractive to ACOs such as expanded use of telehealth, beneficiary attestation, and more flexibility around post-acute care referrals to help ACOs better coordinate care for beneficiaries using these services. These tools could all help encourage participating providers to improve quality and care coordination for Medicare beneficiaries, which in turn would result in better patient experiences and greater shared savings for both the ACO and the Medicare program.
  • Emphasis on primary care. CMS proposes to refine the way Medicare beneficiaries are assigned to an ACO to place greater emphasis on primary care services delivered by nurse practitioners, physician assistants and clinical nurse specialists and to allow certain specialists not associated with primary care to participate in multiple ACOs.
  • Alternative methodologies for benchmarks. CMS seeks comment on alternative methodologies that would make ACO benchmarks for determining shared savings and losses gradually more independent of the ACO’s past performance and more dependent on the ACO’s success in being more cost efficient relative to its local market. For example, we are considering whether shared savings received by an ACO should be added back to the benchmark in future performance periods.
  • Streamlining data sharing and reducing administrative burden. CMS proposes to streamline the process for ACOs to access beneficiary claims data necessary for health care operations such as quality improvement activities and care coordination while retaining the opportunity for beneficiaries to decline to have their claims data shared with the ACO.

A fact sheet with more information about the proposed rule is available at: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-12-01.html

The proposed rule will be open to a 60-day comment period.

The proposed rule is available for viewing at:  http://www.ofr.gov/(X(1)S(tofvuj12vvyo3oiwkp3jkln3))/inspection.aspx?AspxAutoDetectCookieSupport=1

Comments may be submitted at: http://www.regulations.gov/
This document is scheduled to be published in the Federal Register on 12/08/2014 and available online at http://federalregister.gov/a/2014-28388

December 1, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

New Affordable Care Act Initiative to Support Care Coordination Nationwide

The Centers for Medicare & Medicaid Services (CMS) today announced the availability of a new initiative for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. Made possible by the Affordable Care Act, ACOs encourage quality improvement and care coordination through the use of health information technology, helping to move our health care system to one that values quality over quantity and preventing illness over treating people after they get sick.

The new ACO Investment Model is designed to bring these efforts to better coordinate care to rural and underserved areas by providing up to $114 million in upfront investments to up to 75 ACOs across the country.

“The ACO Investment Model will give Medicare Accountable Care Organizations more flexibility in setting quality and financial goals, while giving them greater accountability for delivering quality care efficiently,” said CMS Administrator Marilyn Tavenner. “We are working with these organizations to make necessary investments that encourage doctors, hospitals and other health care providers to work together to better coordinate care and keep people healthy.”

Through the CMS Innovation Center, this initiative will provide up front investments in infrastructure and redesigned care process to help eligible ACOs continue to provide higher quality care. This will help increase the number of beneficiaries – regardless of geographic location – that can benefit from lower costs and improved health care through Medicare ACOs. CMS will recover these payments through an offset of an ACO’s earned shared savings.

Eligibility is targeted to ACOs who joined the Shared Savings Program in 2012, 2013, 2014, and to new ACOs joining the Shared Savings Program in 2016. The application deadline for organizations that started in the Shared Savings Program in 2012 or 2013 will be December 1, 2014.  Applications will be available in the Summer of 2015 for ACOs that started in the Shared Savings Program in 2014 or will start in 2016.

Recently, ACOs in the Pioneer ACO Model and the Medicare Shared Savings Program generated over $372 million in total program savings for Medicare ACOs while also improving the quality care delivered to Medicare beneficiaries.

ACOs are one part of the overall effort provided by the Affordable Care Act to help lower costs and improve care and quality. For example, the Affordable Care Act has helped reduce hospital readmissions in Medicare by nearly 10 percent between 2007 and 2013 – translating into 150,000 fewer readmissions – and quality improvements has resulted in saving 15,000 lives and $4 billion in health spending during 2011 and 2012.

For more information on the ACO Investment Model, please visit: http://innovation.cms.gov/initiatives/ACO-Investment-Model/

ACO Investment Model CMS Fact Sheet: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2014-Fact-sheets-items/2014-10-15.html

October 15, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Why Accountable Care Organizations Are Failing

By Richard Amerling, M.D.

Accountable Care Organizations (ACOs), a key piece of the Affordable Care Act (“ObamaCare”) “reform” plan, are failing because they must fail. ACOs are based on faulty assumptions, poor economics, and junk science. They would not exist in a truly free market, and are best viewed as a product of government central planners and crony capitalism.

I first characterized ACOs about a year ago as little more than HMOs with lipstick in response to a report on the poor performance of the 32 pioneer ACOs. Now comes news that three more of the original groups will jump ship, leaving only 19 of the original 32 still on board. A nearly 50 percent attrition rate should be seen as a death knell for the concept, as these were likely the best of the best, and the inducements most generous. Reasonable people would head back to the drawing board. But we are dealing with government bureaucrats, health policy wonks, and administrators. They will damn the torpedoes and push on at flank speed.

What is wrong with the ACO model? Pretty much everything. The idea that an organization with control over health care dollars will be able to improve actual hard outcomes (as opposed to secondary endpoint numbers) is a collective fantasy. Keeping patients healthy and out of hospitals is already the goal of all physicians I know. The only problems we encounter in collaborating are those imposed by federal regulations (HIPAA). The real problem is that outpatient primary care physicians are not paid enough to devote adequate time to patients with complex problems. The ACO does not solve this problem. Rather, it creates financial disincentives to hospitalize patients or to refer for advanced care (similar to HMOs). This will lead to poor outcomes for the sickest patients, and ultimately, higher costs.

Money saved by rationing care (or by improving care; let’s be optimists), will be consumed largely by the considerable administrative infrastructure required of the ACO. This includes hiring even more administrators to track outcomes and costs, installing and maintaining expense electronic health record systems, and training of staff. EHRs have many problems, do not improve productivity, and impinge on the patient-physician relationship, impairing quality of care.

“Quality” benchmarks are numerical targets for blood pressure, blood sugar, cholesterol, etc., determined by various guideline panels, most of which are dominated by industry-supported physicians. This will lead to inappropriate over-treatment in many individuals, with greater expense and worse outcomes over time. For example, aggressive targeting of low blood sugar has been shown to cause weight gain and higher mortality in patients with type 2 diabetes. It’s not a coincidence that Big Pharma heavily supported ObamaCare.

ACOs are based on the assumption that fee-for-service medical practice is responsible for the high cost of medical care. This is demonstrably false. Direct third party payment, spearheaded by Medicare, is the culprit.

And of course, when Uncle Sam is your partner, there is always risk that rules and payment will be changed, sometimes arbitrarily and without warning. As reported in Modern Healthcare, “as ACOs grow more efficient and Medicare adjusts savings targets accordingly, it may also grow increasingly difficult for ACOs everywhere to earn savings.” Furthermore, “Medicare’s ACO programs so far have produced inconsistent results, some of which policy experts and ACO executives have blamed on how Medicare calculates how much ACOs potentially saved the program. Last week, the CMS announced that the initiatives saved Medicare $817 million through 2013. Dozens of participants shared $445 million of that amount, but three-quarters of ACOs saw nothing after failing to do sufficiently well against the financial benchmarks” [emphasis mine]. So, only a handful saw any real profit, and you can be sure Medicare will alter their formula to not allow whatever they consider to be excessive profit.

It is clear that for ACOs to be profitable, they will need to engage in the old HMO practice of cherry-picking healthy patients. Last week I saw a 65-year-old woman with kidney disease on top of severe lung, liver and heart disease. It took more than an hour just to sort through her records and medications. ACOs will go out of their way to avoid recruiting patients such as this. The only hope for such patients is within the traditional fee-for-service system.

Our hope is that this system is allowed to survive.

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Richard Amerling, MD is an Associate Professor of Clinical Medicine and a renowned academic nephrologist at the Beth Israel Medical Center in New York City. Dr. Amerling studied medicine at the Catholic University of Louvain in Belgium, graduating cum laude in 1981. He completed a medical residency at the New York Hospital Queens and a nephrology fellowship at the Hospital of the University of Pennsylvania. He has written and lectured extensively on health care issues and is President of the Association of American Physicians and Surgeons. Dr. Amerling is the author of the Physicians’ Declaration of Independence and is a seasoned speaker and on-air contributor
October 6, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Boston Medical Center HealthNet Plan Chooses MedeAnalytics to Optimize Medicaid Performance Management

Medicaid health plan in Massachusetts adds robust analytics platform to improve financial, operational and clinical outcomes

Emeryville, Calif. – (March 11, 2014) – MedeAnalytics® today announced that Boston Medical Center HealthNet Plan (BMCHP), a non-profit managed care organization committed to providing the highest quality healthcare coverage to underserved populations, selected MedeAnalytics to implement its cloud-based technology platform to optimize care management activities for over 300,000 members, identifying gaps in care and tracking cost savings opportunities.

MedeAnalytics’ Medicaid Management solution enables payers like BMCHP to solve medical and provider network challenges they face in providing vulnerable populations access to care. By integrating the Medicaid Management solution into their care processes, BMCHP will be able to efficiently identify and stratify care for specific, at-risk patient groups. They will also leverage the solutions’ advanced analytics capabilities to monitor emerging trends, allowing them to proactively adapt and modify procedures to minimize costs.

“We are committed to providing the highest quality healthcare coverage to the traditionally underserved populations of Massachusetts and New Hampshire ” said Lisa Feingold, Vice President of Clinical Informatics at BMCHP. “In the wake of reform and the ever-evolving healthcare landscape, our care management team, as well as our provider partners, need a robust analytics solution that can be quickly implemented to support population health management. MedeAnalytics’ solution is a critical part of our efforts to improve the health of our members, improve the experience of care and reduce the cost of health care.”

Over the coming months, BMCHP will roll out the Medicaid Management solution for all its beneficiaries across Massachusetts and New Hampshire in order to provide a more centralized, robust view of care delivery, costs and quality. The go-live date is slated for May 2014.

“Given the complex healthcare needs of low-income and at-risk patients, Medicaid managed care plans need to run incredibly efficient operations,” said Andrew Hurd, MedeAnalytics Chairman and CEO. “BMCHP will leverage the MedeAnalytics platform to gain clear and actionable insights into cost, quality and risk, improving the way they care for the patients who need it most.”

BMCHP joins a long and prestigious group of Medicaid plans that are working with MedeAnalytics. MedeAnalytics’ robust solutions also empower hospitals and physician practices with the ability to ensure accountability and improve operational, clinical and financial outcomes. Due to its SaaS-based delivery model, time to value is under 90 days. For more details on health plan and provider success stories, please email MedeAnalytics@shiftcomm.com.

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About MedeAnalytics®

MedeAnalytics provides evidence-based insights to solve a real problem that plagues healthcare – how to use the immense amount of patient data collected along the care continuum to deliver cost-effective care and promote a healthier population. Its analytics platform delivers intelligence that helps healthcare organizations detect their greatest areas of risk and identify opportunities to improve their financial health. It empowers providers and payers to collaborate and use data to strengthen their operations and improve the quality of care. MedeAnalytics’ cloud-based tools have been used to analyze more than 21 billion patient encounters in the United States and United Kingdom, providing better care to more than 30 million patients and better business for 900 healthcare organizations. For more information, visit www.medeanalytics.com.

About Boston Medical Center HealthNet Plan

Boston Medical Center founded Boston Medical Center Health Plan, Inc. in 1997 as a non-profit managed care organization doing business in Massachusetts as BMC HealthNet Plan. Outside Massachusetts the business name is Well Sense Health Plan. BMC HealthNet Plan, the managed care organization with the largest number of MassHealth and Commonwealth Care members in Massachusetts, is ranked in the top 10 among Medicaid plans in the nation according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Rankings 2013-2014. BMC HealthNet Plan also continues to maintain Excellent Accreditation from NCQA as a Medicaid health maintenance organization. In addition, BMCHP’s Qualified Health Plan program has been awarded “Accredited” status from NCQA, the highest accreditation level available at this time.

March 11, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.