Empirical Risk Management
Empirical Risk Management

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Empirical Risk Management

Phone: 772-210-2823

Fax: 772-210-2824

 

Kameron Gifford, CPC

772-267-9453

 

Todd Gifford, MBA

772-267-8156

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15.04.2018
Empirical Risk
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You will love these 5x7 HCC Coding Cards! This 6 pack includes all the basics to jump start you risk adjustment project. 1.Diabetes: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 2.COPD: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 3.Heart Failure •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 4.Major Depressive Disorder: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 5.Malnutrition and Morbid Obesity: •ICD-10 Coding Tips (side 1) includes RAF •Clinical Documentation Tips (side 2) includes RAF 6.Complications with Internal Devices and Dependence •ICD-10 Coding Tips for Complications (side 1) includes RAF •ICD-10 Coding Tips for Dependency(side 2) includes RAF Post one to your bulletin board, stick one near the EHR or tape it to your workstation! HCC CodingCards are made to last all year on thick 16 pt cardstock with a gloss finish.  Order yours today!
03.04.2018
Empirical Risk
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Announcement of Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter    April 2, 2018 For payment year 2019, CMS will implement the updated CMS-HCC model without count variables that was provided in Part I of the Advance Notice for comparison. "This model incorporates the proposed additional Chronic Kidney Disease, mental health, and substance use disorder conditions, updates the data years used to calibrate the model from 2013 diagnoses predicting 2014 cost to 2014 diagnoses predicting 2015 cost, and selects 2014 diagnoses for calibration with the CPT/HCPCS-based methodology that is used to select risk adjustment eligible diagnoses submitted to the encounter data system. " See New Coefficients Below: Encounter Data CMS is also finalizing the proposal to calculate 2019 risk scores by adding 25% of the risk score calculated using encounter data and FFS diagnoses (with inpatient RAPS data to supplement encounter data) and 75% of the risk score calculated using RAPS and FFS diagnoses.  Download the entire Call Letter here
30.03.2018
Empirical Risk
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What will define those who claim victory and those who are defeated in the battle towards value based care? Will it be those organizations with the most money, power and seats at the table? Or will it be those who are nimble, flexible and open to change?  I believe it will be both. As victory will not be defined by the owners and head coaches but instead by how the players execute on the field. It will be the game time decisions that matter most. A quarterback who can read the defense and adjust accordingly will provide far greater value to the offense than the most athletic quarterback who misses the blitz every time. Perhaps Napoleon said it best, “Battles are won by the power of the mind.” For in a game of inches, the winners and losers will be defined by those who can execute in the moments that matter most. Prepare your team for victory with information at the point of care! ERM Consulting has developed the industries best tools for players on the frontline. Order yours today! Clinical Documentation Guide for Providers and Coders This 42 page guide includes proper ICD-10 coding and clinical documentation for the most common diagnoses included in the risk models. A complete list of CMS-HCCs with RAF and demographics included. Order 1 for your entire team! Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to kgifford@ermconsultinginc.com after purchase. CMS-HCC Quick Coder This 36 page guide contains a list of the most common HCC codes in the Medicare (CMS-HCC) model. Includes both medical (HCC) and pharmacy (RxHCC) codes. Orders of 100 or more can be white labeled with your logo at no charge. Please email logo to kgifford@ermconsultinginc.com after purchase.  Visit our online store for a full list of available tools. https://erm.ecwid.com/
By Shannon DeConda   CPC, CPC-I, CEMC, CMSCS, CPMA® Three key takeaways from this effort by healthcare giant UnitedHealthcare UnitedHealthcare (UHC) is continuing its quest to revamp many facets of our healthcare industry. Last year, they adapted mandatory policies for the use of the SA modifier to indicate that a professional service was performed as incident-to, and now the company is introducing a mandatory review of high-level ED facility-based service codes. The newest UHC policy took effect March 1 and applies to both UHC’s commercial plans and its Medicare Advantage plans, as well as claims submitted to UHC from non-participating facilities. Organizations that submit claims to UHC have begun to see a dramatic change in coding policy, with emergency department (ED) service codes of Level 4 and 5 now undergoing review for adjustment or outright denial. Let’s review the policy change and the explanation posted by UHC, and then we will walk through concerns providers have including the following: Simply selecting ED codes 99284 and 99285, which represent moderate-complexity and high-complexity cases, will result in the claim being reviewed by UHC using its Optum Emergency Department Claim (EDC) Analyzer tool, which is a software module that supposedly “systematically evaluates each ED visit level code in the context of other claim data (i.e., diagnosis codes, procedure codes, patient age, and patient gender) to ensure that it reasonably relates to the intensity of hospital resource utilization as required per CMS (Centers for Medicare & Medicaid Services) guidelines.” UHC stated in its December 2017 bulletin, that the other ED codes, 99281-99283 (in the same family of codes) will not be subject to this automatic review by the EDC tool. UHC further stated that those facilities submitting claims with 99284 or 99285 will have those claims “adjusted” in level, which is to say downcoded, or completely denied, based on “the reimbursement structure within their agreements with UnitedHealthcare,”. There are some exceptions to the automatic EDC review, which include: Admissions from the ED; Critical care patients; Patients younger than 2 years of age; Certain diagnoses requiring greater-than-average resource use when performed in the ED; Patients who die in the ED; and Facilities whose billing of Level 4 and 5 evaluation and management (E&M) codes does not abnormally deviate from Optum's EDC Analyzer tool determination. Facilities that see either a reduction in their ED code levels or denials will be able to submit reconsideration or appeal requests if they disagree with the EDC analyzer’s findings and the subsequent “adjustments,” according to the UHC bulletin. The massive increase in scrutiny created by this new policy is needed, UHC said, to “support UnitedHealthcare’s commitment to the triple aim of improving healthcare services, health outcomes, and overall cost of care.”  Now, let’s break it all down:  Facility coding guidelines are different from professional coding guidelines. Therefore, although the codes used to bill and support the facility-based services are the same, the utilization of these codes are quite different. When reported for Facility services codes are chosen based on the volume and intensity of resources utilized by the facility to provide patient care. In fact, while physicians pay homage to documentation guidelines with every single service they provide, CMS has yet to create a standard by which facility ED codes are applied to an encounter. ACEP has created a set of standards than many ED’s across the country have adopted, and therefore has become somewhat of an industry standard, but again- previously no formal process has been adapted. Therefore, many would stay that there is no definitive correlation between facility and professional coding and therefore no rational basis for the application of one set of codes for the determination of the other on a case-by-case basis.  However, when we begin to review the steps the EDC analyzer will evaluate the line between facility services, and the professional use of the code set begins to get lost in the sand. According to the EDC analyzer (https://edcanalyzer.com/EDCAnalyzerGuide/Overview), Step one is a consideration of the level of risk of the patient’s presenting problem to drive the standard resource valuation for the presenting problems in that ED visit level and include the costs associated with the following: Nursing and ancillary staff time (for a routine arrival, triage, registration, basic patient/family communications, and a routine discharge) The room Creation of a medical record Coding and billing These four resource valuations are driven by the risk associated with the patient’s presenting problem as referenced within the MDM scoring process for professional based services. So, while these coding systems are supposed to be different, we begin to see how the facility service is also driven by the complexity of care of the patient identifying their stated medical necessity. While medical necessity should be the determination of what is billed and why it should be reimbursed, the problem in UHC’s step one determination is the initial weighted costs related to the presenting problem. For clarity, this methodology is better explained with an example. The weight of a patient presenting for a blood pressure check may seem anteriorly low, but if their blood pressure is severely high, then our presenting problem just increased 1-2 levels to a higher level of severity, which depending on the severity may pose imminent threat to support the highest cost weight category. Step two within the EDC provides for a review of all line-level services on the claim to identify diagnostic tests as follows:  Laboratory tests X-ray tests (film) EKG/RT/other diagnostic tests CT/MRI/ultrasound tests Consideration was allowed to provide for costs of creating orders, time and staffing to provide the testing, and communication with the patient. These cost weights are then added together per each category to find the total weighted consideration. WOW, this sounds much like the data and complexity section of MDM scoring of professional services but extending them beyond the scope of the physician service and realizing the facility burden associated with each category of service. Step 3 will then take into all diagnoses assigned to the patient that may impact utilization of resources based on complicating factors, i.e., the risk imposed by the patients care level needed. UHC has indicated that they have Patient complexity cost weights that were developed for each complicating condition by analyzing the additional services typically provided to patients with that complicating condition. UHC provides examples of diagnoses and conditions that they have weighted. However, they do not provide the weighted costs associated with each. UHC’s final step, once again, sounds suspiciously comparative to professional services as we will use the 3 categories to assess our service collectively. The formula they have published is the following: Total Weight = Standard Cost Weight (Step 1) + Extended Cost Weight (Step 2) + Patient Complexity Cost Weight (Step 3) Translation: Pricing = resources required based on presenting problem + resources expended based on Categories of service used + the potential resources consumed based on the diagnoses of the encounter There is one curiosity that the EDC by UHC does not indicate and that is the weighted cost of each step. This information has been redacted from their website and not published, and therefore we do not know exactly the scoring process that has been implemented. At least on the professional services side, the scoring process of the medical decision making (MDM) —again comparative in nature— does provide us with the guidance of the weight of each element to support the overall service. However, UHC has chosen to keep this information confidential. So let’s apply this to a condition. There are two words that when put together, escalate care in the ED: chest pain. I do realize that facilities have protocol requirements for this type of scenario, but before we engage in a debate, please be reminded that is a facility’s protocol and not the carrier’s. Unless the medical necessity can support the appropriateness of the services rendered, the carrier may decline reimbursements. However, let’s proceed. Patient reports to the ED for chest pain and of course lab, radiology, and diagnostic testing is performed, but ultimately it is determined that the patient’s problem is merely heartburn and they are discharged to home. The UHC EDC would consider our formula as follows: Remember your algebra rules for this one: Total Weight = Chest pain + (lab + Radiology + EKG) + GERD Translation: Pricing = Extensive resources needed for chest pain presenting problem + 3 categories of service line resources + a lower resource consuming formal diagnosis of the encounter In conclusion, three final points: Industry Modeling: UHC has created a “scoring methodology” through what they consider an analytics program, but what it really seems like is they have tried to use E&M Documentation Guidelines for Professional Services to create an industry modeling scoring of these facility-based services. Now come on, everyone knows how gray and ambiguous E&M Guidelines are, and let’s get serious… the MDM is one of the MOST troublesome parts! Therefore, it seems this may end up causing more confusion as opposed to providing valued guidance. UHC Mandatory Automatic Reviews: This policy has provided some basis for facilities to better apply the proper ED service code, but it will likely raise overhead expenses on both sides. As we pointed out through this article, much of this scoring process is based on MDM related scoring principals which are gray and ambiguous at best and part of Marshfield Guidelines, which “technically” have never been formally adopted as part of the official guidelines. Now facilities will be required to produce proof to substantiate every single level 4 and 5 encounter through an appeal process. Additionally, UHC is now going to have to review every single appealed encounter. Who loses? Patients! This increased overhead will affect them on both sides: as a consumer and an insured. Data Analytics Reviews: It’s the new buzz-phrase in healthcare. Not only has data analytics created new avenues in which carriers can track all services by facilities and providers, but more importanty, facilities and providers can now analyze their own risk and focus on their compliance dollars. However, analytics cannot assess medical necessity regardless of the type of service- be it facility or professional. Keep in mind that UHC essentially has an algorithm that raises red flags of alert, but that should only be a flag, as it truly takes a reviewer to analyze services for medical necessity. Is the point of this policy to encourage undercoding? Maybe, but rather than point fingers in this way, let’s ponder for just a moment what this policy still does not do. It does not provide an avenue to educate the masses on the proper use of these codes. Instead, this policy will increase labor by driving unnecessary medical reviews. We need the carriers to back educational efforts to help improve code usage, rather than introducing burdensome policies that increase healthcare costs to all involved. READ MORE
07.03.2018
Empirical Risk
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The American Journal of Accountable Care. 2018;6(1):29-32 Much has been written about the crippling effect of America’s overreliance on opioids and the country’s ongoing chronic pain crisis.1 Major news outlets have chronicled the tragic individual circumstances, often focusing on rural communities and overwhelmed primary care providers (PCPs). Simultaneous to this pain and opioid crisis, there has been an expansion in alternative payment models, such as accountable care organizations (ACOs), in which providers take on some degree of financial risk for the total cost of care for a population based on outcomes and quality metrics. As a result of taking on financial risk, the hope is that providers will care for patients using a more holistic approach and may be increasingly involved in treating conditions that pay poorly in a fee-for-service (FFS) environment but have a significant impact on the total cost of care (eg, behavioral health conditions). At University of California, San Francisco (UCSF) Health, we currently participate in a number of commercial ACOs. This arrangement motivated us to understand what conditions drive the total cost of care. Chronic pain has been a hot topic, but this is the first exploration of chronic pain in the ACO context at a major academic medical center. As a result of clinical expertise on our ACO team, we asked the question: Do our patients with chronic pain have greater-than-​expected healthcare utilization? If so, can we design interventions that improve the quality of care while simultaneously decreasing costs? Anecdotally, providers felt that patients with uncontrolled pain often sought care in the emergency department (ED) and perhaps had longer lengths of stay when they were admitted to the hospital.  To answer these questions, we analyzed both the prevalence of chronic pain in the UCSF Health ACO population and its link to utilization. Using the Tian et al algorithm,2 we identified that nearly 20% of the UCSF Health commercial ACO populations had chronic pain. The rate of chronic pain at UCSF Health was nearly identical to the rate of hypertension and 3 times the rate of diabetes there. This algorithm was based on billing coding, pain scores, and prescription medications and was validated with reported sensitivity and specificity of 84.8% and 97.7%, respectively. Tian et al reported more accurate identification of patients with chronic pain using their algorithm than estimates based on pain scores or International Classification of Diseases, Ninth Revision codes alone. Given the high specificity of the Tian algorithm, the 20% chronic pain prevalence may be conservative. Epidemiologic estimates of the prevalence of chronic pain have historically varied, ranging from 2% to 45% of primary care populations.3 Most recently, an analysis of the 2012 National Health Interview Survey estimated 126.1 million American adults as reporting pain in the previous 3 months and 25.3 million adults suffering daily pain.4 Substantiating clinicians’ instincts, subsequent analysis of utilization patterns among UCSF Health ACO patients indicated that patients with chronic pain had 2 to 3 times the rates of ED, inpatient, urgent care, and primary care visits compared with patients without chronic pain (Table 1). Utilization was used as a proxy for cost.5  Given the finding that chronic pain was highly prevalent in our ACOs and was associated with increased overall utilization of healthcare services, we considered the current state of pain management and possibilities for improvement. We interviewed over 30 internal stakeholders and external experts, including PCPs, pain management specialists, alternative medicine providers, general and pain-specific psychiatrists, physical therapists, opioid specialists, inpatient pain nurses, and representatives from a local integrated pain treatment center. We found that pain management was divided into silos of excellence within UCSF, with limited communication or coordination of services between providers. Providers described limited integration and misaligned expectations between PCPs and specialists. Guided by these interviews with clinicians at the front lines and based on evidence in the literature and proposals suggested by the individuals we interviewed, we identified the following opportunities for redesigning chronic pain management (specific solutions are outlined in Table 2): Education Physicians and other healthcare providers need education and training in pain management. Less than half of US medical schools dedicate more than 10 teaching hours to pain management, resulting in underprepared physicians.6 Similarly, the goals of pain education could be reframed to focus on patient communication and multimodal treatment while approaching medications as just one part of a broader plan. In addition to provider education, patients must understand the risks of pain management and be informed so they can set realistic expectations and be active participants in shared decision making. As chronic pain has not been a point of emphasis in the past, changing medical education would require both individual institution- and national-level changes in curriculum development.  Communication and Coordination of Care Improvement in clinical chronic pain management could involve change at 2 levels: primary care and specialty centers. Integrating pain management into primary care could take the form of embedded psychiatric and physical therapy services within primary care centers.7 The specialty pain center could also be integrated by offering patients with complex pain management needs joint evaluations by a pain specialist, psychiatrist, and physical therapist during longer visits.8 Integrating chronic pain management into primary care, following the model of behavioral health integration efforts by UCSF Health and other health systems, could yield substantial benefits, but it requires significant investments of money and time, as well as culture shifts, in order to alter provider approaches to chronic pain.  Opioid Utilization Opioid prescribing patterns are being increasingly scrutinized in the setting of the US opioid epidemic, and specialized pain centers have an opportunity to shape application of the newly released CDC opioid guidelines.9  Pain centers can lead their institutions toward adopting responsible forward-thinking opioid prescribing policies and press other departments to think critically about chronic pain management. More broadly, pain centers can serve as advocates for individuals struggling with opioid addiction and explore novel strategies to decrease opioid usage.  Research More research into alternative approaches to manage and treat chronic pain and the impact of treatment on healthcare utilization is needed to guide future interventions. During the transition from FFS to ACO models, there will likely be the need to develop improved short-term FFS payment models for comprehensive pain management. No single strategy has been shown to effectively and reproducibly treat chronic pain, making ongoing research of paramount importance. It is important to acknowledge the obstacles preventing change in chronic pain management. The proposed changes are focused at the system level, requiring changes in culture, infrastructure, and care patterns.  As many health systems across the country take on financial risk for the total cost of care for specific populations, it may be time to take a closer look at chronic pain. With chronic pain increasingly recognized as a disease, we hope that it will be addressed with preventive measures that focus on nonmedication and noninterventional approaches to pain management, including rehabilitation, pain psychology, and several modalities of complementary and integrative medicine. It may be the perfect time to make systematic changes to how we deliver care to patients with chronic pain. Systems that take the lead in such changes will improve care for people with chronic pain, help better control the opioid crisis, and control costs in the setting of alternative payment mechanisms. Well-designed interventions to help provide coordinated effective care for patients with chronic pain could truly improve the value of care delivered at the population level. Read more and download the PDF here
29.01.2018
Empirical Risk
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Join Us for a Day of Risk Adjustment!  Review the different risk adjustment models and their impact on medical practice management.  Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims? Take a deep dive into HCC Coding and clinical documentation. Review real examples to see what validates, what doesn’t, and why. Tips for engaging physicians. Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments.   Each Attendee Will Receive:     ($130+ value) Color Presentation Clinical Documentation and Coding Guide HCC Quick Coder Laminated Coding and Documentation Tools Who Should Attend:  Medical Coders and Billers Providers, Managers and Frontline Staff CDI Specialists Executive Leaders ACO, MSO and IPA Teams Rural Health Centers Health Alliance Members Medicare, Medicaid and Commercial Plans   Upcoming Dates and Locations:       Wed May 9th, 2018        9:30 AM – 3:30 PM        Cypress Creek Executive Center        1451 W. Cypress Creek Road, Fort Lauderdale, FL, 33309            Register Now - Very Limited Seating Available              Wed October 24th , 2018         10:00 AM – 4:00 PM         Hilton Garden Inn Tampa / Riverview         4328 Garden Vista Dr., Riverview, FL 33578             Register Now - Early Bird Pricing $199               Thursday, November 8th 2018         9:30 AM – 3:30 PM        Cypress Creek Executive Center        1451 W. Cypress Creek Road, Fort Lauderdale, FL, 33309                    Register Now - Early Bird Pricing $199                        View additional details and download the complete agenda here                         
The Centers for Medicare & Medicaid Services (CMS) released Part I of the 2019 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part D Payment Policies (the Advance Notice), on December 27, 2017, which contains key information about proposed updates to the Part C Risk Adjustment Model and the use of encounter data. The following HCC Categories were proposed: Drug Abuse, Uncomplicated, Except Cannabis (HCC 56) Reactive and Unspecified Psychosis (HCC 58 - the current HCC 58 will be renumbered as HCC 59) Personality Disorders (HCC 60) CKD Moderate, Stage 3 (HCC 138) CMS also proposed the following changes to the CMS-HCC Risk Adjustment model Add selected drug and alcohol “poisoning” (overdose) codes to existing “Drug/Alcohol Dependence,” to create “Drug/Alcohol Dependence, or Abuse/Use with Complications” (HCC 55).  Add new factors to the six community and single long term institutional (LTI) segments that take into account a beneficiary’s number of conditions that are in the payment model. You can view the entire notice here: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2019Part1.pdf Part II was released on February 1, 2018 View Part II of this notice here: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSpecRateStats/Downloads/Advance2019Part2.pdf
21.12.2017
Empirical Risk
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    Register your team today - Orlando is SOLD OUT!    Join Us for a Day of Risk Adjustment!  Review the different risk adjustment models and their impact on medical practice management.  Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims? Take a deep dive into HCC Coding and clinical documentation. Review real examples to see what validates, what doesn’t, and why. Tips for engaging physicians. Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments.        Each Attendee Will Receive:     ($130+ value) Color Presentation Clinical Documentation and Coding Guide HCC Quick Coder Laminated Coding and Documentation Tools      Who Should Attend:  Medical Coders and Billers Providers, Managers and Frontline Staff CDI Specialists Executive Leaders ACO, MSO and IPA Teams Rural Health Centers Health Alliance Members Medicare, Medicaid and Commercial Plans       Thursday January 25th 2018       10:00 AM - 4:00 PM         Symphony Presentation Center          2875 S Ocean Blvd, Suite 200, Palm Beach, FL 33480            Register Now - Very Limited Seating Available               Thursday, April 5th, 2018       10:00 AM - 4:00 PM                   Hilton Garden Inn Tampa / Riverview         4328 Garden Vista Dr., Riverview, FL 33578           Register Your Team Today - Save 10% on 3 or More             View additional details and download the complete agenda here             https://www.ermconsultinginc.com/upcoming-events/
The American College of Physicians (ACP), expressed support for some of the provisions included in the final rules for the Medicare Physician Fee Schedule and the Quality Payment Program (QPP) for 2018, and noted some areas of concern in the rules that were released by the Centers for Medicare and Medicaid Services (CMS) on Nov. 2.  “As a practicing primary care internist, I am greatly encouraged that CMS is proposing improvements in the physician fee schedule to help me and my colleagues provide coordinated, patient-centered, high value and team-based care to our patients” said Susan Thompson Hingle, MD, MACP, chair, Board of Regents, ACP. “We look forward to providing CMS with detailed comments to support these improvements while recommending other changes to strengthen primary care.” In the 2018 fee schedule, ACP called particular attention to improvements made in three areas: Evaluation and Management (E/M) Documentation Guidelines Comment Solicitation: ACP appreciates that CMS is immediately focused on revision of the current E/M documentation guidelines in order to reduce unnecessary administrative burden. As the Agency moves forward with this process ACP will continue to provide input to CMS officials.  Further Refinement of Care Management Services Codes: ACP applauds CMS for continuing to reduce the burdens associated with the care management services code set. The clarification of the CCM planning code (G0506), will allow for some or all of the care planning to be performed by the billing clinician on a subsequent day. Appropriate Use Criteria for Advanced Diagnostic Imaging Services: ACP supports the additional 1-year delay in implementation of the Appropriate Use Criteria for advanced diagnostic imaging services until 2020 while physicians are still learning the evolving policies of the QPP and gaining increasing experience reporting for the program. CMS also released the final rule for Year 2 of the Quality Payment Program, with an opportunity to provide comments on the rule to CMS by Jan. 1. Year 2 maintains many of the flexibilities from the first year of the QPP, to help physicians with the continued process of transitioning to the new payment incentive program established by the Medicare Access and CHIP Reauthorization Act of 2015. “We will be looking at the QPP rule closely to identify positive improvements that CMS has already made and to make more detailed suggestions about changes that CMS can make to ease some of the regulatory burdens on physicians,” continued Dr. Hingle. Specifically, ACP is pleased that CMS made some positive improvements to the Quality Payment Program (QPP). Extreme and Uncontrollable Circumstances: ACP strongly supports CMS’ new policy to allow clinicians who are impacted by extreme and uncontrollable circumstances to be provided relief from reporting requirements associated with QPP in 2017 and 2018. Physicians treating patients in areas impacted by the hurricanes this year will be able to focus their efforts on much needed patient care without worrying about complying with new reporting requirements under QPP. MIPS Bonus for Complex Patients: ACP appreciates that CMS accepted our recommendation to increase the amount of bonus points available for treating medically complex patients. This increase will better adjust for the risk for those physicians treating more complex patients. Small Practice Options: ACP thanks CMS for finalizing new policies to provide flexibilities for small practices in 2018 including the virtual groups option, small practice bonus, Advancing Care Information hardship exception, and increased low-volume threshold. However, ACP has concerns about several of the provisions of the rule; in particular some of the provisions are inconsistent with recently announced CMS initiatives on “Patients Over Paperwork” and “Meaningful Measures.” Complex Scoring: We are disappointed that Merit-Based Incentive Payment System (MIPS) scoring remains overly complex and lacks standardization across performance categories. The measures and activities should more directly align with the weight they have in the overall score. This should follow with the efforts of CMS’ new initiatives. Cost Performance Category: CMS increased the weight of the Cost Performance Category for 2018 from zero percent, as proposed, to 10 percent in the final rule. Given that there are not yet adequate cost measures that have been developed, ACP opposes this increase and encourages CMS to reverse this decision. Quality Data Threshold: ACP is discouraged that CMS chose to increase the data completeness threshold for quality reporting data from the proposed 50 percent of patients to 60 percent in the final rule. This adds unnecessary burden to practices at a time when CMS has acknowledged that measures need improvement and excessive burdens should be reduced. Low-volume Threshold Opt-in: While we appreciate that CMS finalized an increase in the low-volume threshold to exclude those with less than or equal to $90,000 in Part B charges or 200 or fewer Part B patients from MIPS, ACP strongly encourages CMS to allow clinicians below the threshold to have the opportunity to opt-in to participate. If a practice believes that they will be able to participate successfully, they should have that option. “We were heartened to see the announcement from CMS this week of their new initiatives designed to ease unnecessary administrative burdens on physicians; Patients Over Paperwork and Meaningful Measures,” concluded Dr. Hingle. “In light of the recent announcement we are encouraged that CMS will follow through and address our concerns.” Read more from the ACP: American College of Physicians Additional Links from CMS The Physician Fee Schedule final rule (CMS-1676-F) can be downloaded from the Federal Register at:https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-23953.pdf For a fact sheet on the Physician Fee Schedule final rule, please visit:https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-11-02.html The Quality Payment Program final rule with comment period (CMS-5522-FC and CMS-5522-IFC) can be downloaded from the Federal Register at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2017-24067.pdf For a fact sheet on the Quality Payment Program final rule with comment period, please visit: https://www.cms.gov/Medicare/Quality-Payment-Program/resource-library/QPP-Year-2-Final-Rule-Fact-Sheet.pdf
  CMS Results Demonstrate Promise of Alternative Delivery and Payment Methods for Improving Care and Reducing Costs Accountable Care Organizations (ACOs) reduced gross Medicare spending by $836 million in 2016, returning $70.6 million in net savings to the Medicare Trust Fund according to data on four federal ACO programs quietly released this month by the Centers for Medicare & Medicaid Services “These results demonstrate the promise of new models of care delivery and financing for improving patient outcomes and reducing spending,” said David Lansky, chair of the Health Care Transformation Task Force, an industry consortium that brings together patients, payers, providers and purchasers who share a commitment to accelerate the pace of delivery system transformation. “This provides further evidence that we need more, not less, public and private sector investigation of alternatives to traditional fee-for-service medicine.” The four programs and their reported results were: The Medicare Shared Savings Program (MSSP). Participants in Medicare’s largest ACO program saved a total of $652 million. While CMS paid more in shared savings than it saw in net returns, 56 percent of MSSP participants reduced their expenditures, and 31 percent reduced expenditures enough to earn shared savings. MSSP has three different tracks that allow ACOs to select an arrangement that makes the most sense for their organization. Track 1, which offers upside-only financial risk, and Track 2 and 3, which both incorporate upside/downside risk and count as Advanced APMs under the Quality Payment Program (authorized by MACRA). The Next Generation ACO Model (Next Gen). In the first year of the program, Next Generation ACOs saved $48M overall, with a net savings to Medicare of $63M. Eleven of 18 ACOs saved enough to earn a shared savings payment. The Next Gen model offers providers greater opportunities for shared savings in exchange for taking on greater risk. The model sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care. The Pioneer Accountable Care Organization (ACO) Model. In the fifth and final year of the program, all 8 Pioneer ACOs produced gross savings of $61M, with 6 of 8 ACOs reducing spending enough to earn a shared saving payment. The net savings to CMS was $23M. One of the earliest Medicare ACO models, the Pioneer program was designed for health care organizations and providers that were already experienced in coordinating care for patients across care settings. The Comprehensive ESRD Care (CEC) Model. The CEC model is designed to evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD), which showed promising results for future specialty ACOs with all 13 participants producing a total of $75M in savings. The net savings to CMS was $23.9M, as all but one of the 13 CEC participants earned shared savings. Total savings are calculated by CMS based on what Medicare would have expected to spend on the beneficiaries covered by the ACO in traditional fee-for-service Medicare.  Net savings reflect the total minus shared savings payments to the ACOs for meeting spending targets, and accounting for repayments from ACOs for shared losses. Barbara Walters, DO, Executive Vice President and Chief Population Health Officer of Task Force member Trinity Health, said, “It is important to note the performance results demonstrate that – on average – both savings and quality are improved the longer an ACO participates in the program. As organizations move down the learning curve and benefit from the substantial investments in delivery transformation, we see our performance continue to improve.” In a recent report, the HHS Office of the Inspector General found that ACOs participating in the program longer were more likely to reduce spending, and by greater amounts. This is to be expected, as population health management is a long-term strategy. An analysis of CMS’s PY 2016 Quality and Finance Results shows that MSSP ACOs reporting in 2015 and 2016 improved average performance by over 10 percent on five key performance measures. Task Force member organization Atrius Health, selected as one of 32 original Pioneer ACOs, showed steady improvement in savings to Medicare in each of its five years participating in the Pioneer ACO Model. For the over 25,000 Medicare beneficiaries served by Atrius Health clinicians participating in the Pioneer ACO Model in 2016, Atrius Health saved Medicare $10.4 million compared to its target, returning $6.8 million in savings to the organization. It also achieved more than a 95 percent quality score from CMS.  “By knowing our patients well, we are able to provide the right coordinated care that keeps them healthy in the comfort of their homes,” said Richard Lopez, MD, Senior Vice President of Population Health at Atrius Health. “As we continuously strive to innovate care delivery to improve quality, access and convenience, we are delighted to see these efforts reflected in a quality score of over 95 percent. We are proud to help our patients lead happier, healthier lives and look forward to continuing this work.” Atrius Health showed steady improvement in savings to Medicare in each of its five years participating in the Pioneer ACO Model. Offering evidence that ACOs also are reinvesting their savings to produce continuous improvement, Atrius has applied its savings to investments in care coordination, training, data analytics, information technology, and other resources serving its Medicare beneficiaries and other patients. Cleveland Clinic ACO’s $42.2 million savings in 2016 represents a 24.5 percent increase from 2015. The ACO will receive $19.9 million back in shared savings, a 19.8 percent increase over 2015. The number of shared beneficiaries increased by more than 6,500 and the health system’s quality score was 96.3 percent.  “The ACO helps to unify our enterprise by bringing together primary care, specialty care and independent participating physicians,” said James Gutierrez, M.D., president and medical director of Cleveland Clinic ACO. “The care model is further enabled to manage our patient populations across the whole continuum of care. This validates the work we have done in recent years to provide outstanding quality of care while being better stewards of healthcare resources.” Task Force member Aledade, Inc. partners with primary care physicians to operate ACOs across 15 states and in partnership with more than 240,000 patients in more than 200 practices. During the 2016 performance period, Aledade’s ACOs – comprising 142 practices with over 80,000 patients in 11 states – saved Medicare more than $9.3 million. “In every Aledade ACO – not just those that earned shared savings—avoidable emergency room visits dropped, readmissions plummeted, preventable hospitalizations from congestive heart failure, pneumonia, and pulmonary disease fell,” said Farzad Mostashari, MD, Founder & CEO at Aledade, Inc. “Collectively, our ACOs prevented more than 1,500 hospitalizations. Aledade ACO practices are giving their patients better care – and we hear it in their stories, and we see it in the data.” Arizona Care Network, a physician-led Track 1 ACO co-administered by Task Force member Dignity Health, received an 89.9 percent score for quality of patient care and reduced the cost of Medicare spending by more than $5.78 million.  “Our care coordination helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services. This level of coordination is highly effective and reduces costs,” noted David Hanekom, MD, ACN’s chief executive officer. In addition to those mentioned above, the following Task Force member organizations successfully lowered Medicare expenditures through the Medicare Shared Savings Program: Ascension MissionPoint Health Partners: $1.64M MissionPoint Evansville, LLC: $3.26M Dignity Health Arizona Care Network: $5.78M Greenville Health System MyHealth First Network, LLC: $21.7M Trinity Health Trinity Health Michigan d/b/a St. Mary Mercy Hospital: $11.4M Task Force member Fresenius Medical Care successfully lowered Medicare expenditures by $43.3M and earned $29.7M in shared savings across six ACOs participating in the Comprehensive ESRD program: ·         Fresenius Seamless Care of Philadelphia: $6.9M  ·         Fresenius Seamless Care of San Diego: $10.3M ·         Fresenius Seamless Care of Chicago: $11.2M ·         Fresenius Seamless Care of Columbia: $4.4M ·         Fresenius Seamless Care of Dallas: $8.2M ·         Fresenius Seamless Care of Charlotte: $2.4M About the Health Care Transformation Task Force The Health Care Transformation Task Force is an industry consortium that brings together patients, payers, providers and purchasers to align private and public sector efforts to clear the way for a sweeping transformation of the U.S. health care system. Our members are committed to rapid, measurable change, both for ourselves and our country. Our members aspire to having 75 percent of our respective businesses operating under value-based payment arrangements by 2020. To learn more, visit www.hcttf.org. https://data.cms.gov/Special-Programs-Initiatives-Medicare-Shared-Savin/2016-Shared-Savings-Program-SSP-Accountable-Care-O/3jk5-q6dr http://hcttf.org/releases/2017/10/30/acos-reduced-direct-medicare-spending-by-836-million-in-2016#_ftn1 Read the full release here.
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