Substance Use Crisis Challenge for Healthcare Champions

By | Annual Forum, Healthcare Policy, Health Literacy, Pharmacy | No Comments

We’re in the middle of a crisis, not only as healthcare leaders transforming our healthcare system but also as Americans. The opioid substance use crisis in America is real and if it’s not already there, it’s coming to your neighborhood – or immediate and extended family soon. How can you help? What small thing might you do?

The First Step to Help Solve Substance Use Crisis

The first step in helping to solve this crisis is acknowledging that it’s not an affliction of the seedy underbelly of our society. Rather it’s a demon that knows nor respects any boundaries. Being afflicted by substance use challenges is rarely, if ever, a choice. It happens to people just like you and me who may have been prescribed opioids after surgery, or to address chronic pain or other ailments.

Nobody grows up with aspirations of becoming addicted to opioids!

Bringing People Together to Address Substance Use Crisis

opioid Crisis. substance use disorder. HCEG. Healthcare Executive Group

Left: David Henderson (Kaden Health) and Gregory Marotta (CleanSlate Centers, Inc)

The second step is doing something more than just admitting the problem. At HCEG, we bring people together to talk about the issues facing healthcare organizations and professionals. But more than just talking about the problems, we discuss and debate solutions, encourage participants to take action and strive to support those actions.

At our recent 31st annual forum in Boston, we heard firsthand from two industry leaders who are doing much more than talking about our substance use crisis. David Henderson, CEO of Kaden Health (formerly Thrivee) and Gregory Marotta, President and CEO of CleanSlate Centers, Inc. shared the different but complementary approaches their companies are taking to help people with substance use problems. As the audience engaged in the conversation with our panel, we heard from real people about their personal experiences with substance use challenges and discussed how to breakdown the “not in my family or neighborhood” attitude.

Take a Small Step Today!

The panel was closed with a challenge to each forum participant to write down and share one action they personally or their organization could – and more importantly would – take to be part of the solution. The energy and conversation following our Substance Use panel were intense and the forum’s consensus was that it would be a crime for us to let it die.

Today, HCEG board members are challenging each and every person who reads this blog post to commit to one action to help address the substance use crisis in America and to share that commitment with us.  Please share your commitment to making a difference via any of the following public or private channels. We’ll respect everyone’s privacy and not publish any names or personal information unless informed otherwise.

  • Share on LinkedIn and/or Twitter – Use hashtag #opioidcrisis
  • E-Mail Us
  • Comment on this post below

Our goal is to collect all of your commitments and track the progress and the difference that we as individuals – many almost certainly directly or indirectly impacted by the opioid crisis – are making. We’ll assemble, acknowledge and share those ideas via our upcoming in-person events and virtual channels. Little things do add up to BIG THINGS!

Alone we can make a dent…Together we can make a difference!

Announcing the 2018 Industry Pulse Research Survey

By | Annual Forum, The Industry Pulse, HCEG Top 10, Healthcare Policy | No Comments

HealthCare Executive Group Announces 2018 Top 10 Industry Issues List Industry PulseMany people familiar with the HealthCare Executive Group (HCEG) know that the HCEG Top 10 list has been a keystone of the HealthCare Executive Group for over a decade – 13 years to be exact. The HCEG Top 10 identifies the current opportunities, challenges and issues that HCEG members and their healthcare organizations face during this era of healthcare reform and transformation. The items on the yearly HCEG Top 10 serve to encourage continuous and evolving dialog and drives HCEG’s programming, webinars, blogs, whitepapers, research and discussion throughout the coming year.

HCEG Top 10 as Basis for the Industry Pulse

The HCEG Top 10 also serves as the framework for the Industry Pulse – an annual research survey conducted jointly by HCEG and Change Healthcare. The Industry Pulse research survey collects additional insight, experiences and opinion on specific items of the HCEG Top 10 list. Healthcare executives, thought leaders and other industry participants serving all areas of healthcare may participate. The results of the Industry Pulse can provide valuable, relevant data-driven advice and end-to-end industry insights to help healthcare leaders navigate the complexities of our rapidly evolving healthcare system.

Share your Insight Today!

HCEG and Change Healthcare would like to invite healthcare leaders from across the nation to participate in the 2018 Industry Pulse research survey and to backdrop and contrast their own perspectives against the 2018 HCEG Top 10.Please consider sharing your insight, experiences and opinion as your perspective will help define the issues facing healthcare, and reveal how the industry is responding.

Everyone who completes the 8th Annual Industry Pulse Survey will be among the first to receive survey results as well as exclusive access to future webinars, content and events that will be delivered over the new year; expounding on survey results and providing additional insight and value to all healthcare constituents.

Part 2 of Health System & Health Plan Innovation, Change & Growth During Uncertain Times

By | AHIP, Payers, Waste & Abuse, Healthcare Policy, Health Literacy | No Comments

health systems health plans focus for 2017 health reform outcome literacy members consumers #HITsmIn Part 1 of this series of posts, we shared some insight, ideas and opinions on the first of six topics shared in last week’s Health Information Technology Social Media (#HITsm) tweetchat Health System & Health Plan Innovation, Change & Growth During Uncertain Times.” A total of 72 participants tweeted over 650 times in the chat co-hosted by the Healthcare Executive Group, @_GWConnect and @_GuideWell.

In this second post, select insight, ideas, comments and opinions on Topic #2: What must health systems & health plans focus on over next 8 to 18 months regardless of health reform outcome? are shared. The remaining topics will be addressed in future posts.

Insight, Ideas and Opinions on Topic #2

Connect with Members, Consumers & Patients

  1. Create a connection with the patient that goes beyond the office visit.
  2. Identify, understand & work with ‘impactable members’ to help them make good, cost-effective decisions about their healthcare.
  3. Health systems & plans need to engage w/ patients & members on a more meaningful & regular basis. Not just via EOB’s.
  4. Find out what’s going on in patients’ homes and determine the services they need to keep them healthy.
  5. Include the patient in everything – from the patient’s own care to the growth of the health plan/system. Act on what they hear.
  6. This’s the ‘Hatched, Matched & Dispatched’ cycle. Health plans only ‘engage’ at enrollment, w/ claim EOB’s & at termination.

Address Waste & Abuse

  1. At #AHIPInstitute, Eric Topol said ‘75% of top 10 high cost drugs are prescribed to non-responding patients.” STOP the waste!
  2. Waste and overtreatment, heard from @DocLazris #ErikRifkin are on a mission against it. Video here: https://t.co/OvfS9zjFAW
  3. IMHO it’s important to educate people about how to use their insurance effectively to control their costs. Price Transparency too

Help Consumers Become Better Patients

  1. Focus must be on enable patients to take control of their own care and to be more involved through easy integration of tech.
  2. Universal language – like, “Do you accept my health plan?” Simple question but so often answered wrong.
  3. When these languages are translated into HIT, all those stakeholders interpret associated rules & allowances differently
  4. If you adopt universal languages, IMHO, you will see some of these issues disappear or at least some clarity enter
  5. Smaller, more often, more meaningful. I have to write stuff that’s specific, timely, and actionable – why does H/C bury me in dross?
  6. Anthem has a monthly health plan summary to members that contains ‘personalized and actionable’ health & wellness insights.
  7. “Self-Care Shows Promise In Keeping Individuals w/ Behavioral Health Needs Out of the ER” – Video here: https://t.co/y4As4wkwkY

Don’t Ignore the Masses – Invest in Preventive Services

  1. Insurance! Invest now to save later is a motto that not many want to hear but need to have more faith in.
  2. Need to focus on treating the largely ignored ‘healthy people’ to prevent them from becoming the 5% of patients consuming 22%
  3. I am going 2 go there. Inclusion. No high risk pools. The One-Plan Plan. With a focus on prevention and wellness to mitigate risk
  4. We need to start providing preventive treatments to the masses vs. spending lion’s share of resources on the few sick.
  5. Such a good question. I think prevention costs are minimal compared to the other side of heart surgeries or chemo…
  6. I know a plan that’s feeding care gaps to physicians, so they can stay ahead of the gaps. Also helps scheduling.

Focus on Core Mission & Quality

  1. Shedding/outsourcing operations not core to their mission – like moving data centers to the cloud are long overdue.
  2. All #healthcare needs to focus on quality of care, especially since value-based care and payments look like they will stay

Smartphones – Everyone Has One – Leverage Them!

  1. IMO, health systems & plans must enable consumers and patients to use those things they’re always staring at: Smartphones.
  2. Our President Dr Rene Lerer suggests smartphones will be the “most important part of your body” for health

Interoperability

  1. No matter the #ACA result, plans and providers must get along, and have systems/infrastructure to enable real-time data exchange.
  2. Also interoperability among healthcare tech platforms to provide better utilization of collected patient data

More on the Remaining Four Topics Coming Soon

Check back later this coming week to learn what chat participants shared on the remaining four topics:
      T3: Who’s most likely to disrupt healthcare: insiders or outsiders? And what barriers do each face – right now or in near future?
      T4: What technologies will do the most to move healthcare supply-side toward improving outcomes, lowering costs & enhancing equity?
      T5: Incentives drive innovation. How can they be aligned to meaningfully support innovation that improves outcomes & lowers costs?
      Bonus: What are examples of innovative healthcare programs, processes, people and organizations – U.S.-based or elsewhere?

One More Time!

Thanks again to our co-hosts @_GWConnect and @_GuideWell, John Lynn (aka. @TechGuy) of Healthcare Scene and to all those who participated in the chat.  A complete transcript of the chat can be found here.

For more about opportunities, challenges, and issues impacting healthcare plans, health systems and payers, consider following @HCExecGroup on Twitter and join us on LinkedIn and Facebook too.

Health System & Health Plan Innovation, Change & Growth During Uncertain Times – Part 1

By | AHIP, Payers, Quality Measures, Healthcare Policy, Holistic Individual Health | No Comments

Healthcare-innovation-change-growth-executives-HCEG

Last week’s Health Information Technology Social Media (#HITsm) tweetchat was co-hosted by the Healthcare Executive Group, GuideWell and GuideWell Connect from the 2017 AHIP Institute & Exhibition in Austin, TX.

The theme of the chat was “Health System & Health Plan Innovation, Change & Growth During Uncertain Times” and following six topics were discussed:

T1: What specific ‘areas of opportunity’ must health plans/systems address to improve health outcomes, lower costs & improve equity?
T2: What must health systems & health plans focus on over next 8 to 18 months regardless of health reform outcome?
T3: Who’s most likely to disrupt healthcare: insiders or outsiders? And what barriers do each face – right now or in near future?
T4: What technologies will do the most to move healthcare supply-side toward improving outcomes, lowering costs & enhancing equity?
T5: Incentives drive innovation. How can they be aligned to meaningfully support innovation that improves outcomes & lowers costs?
Bonus: What are examples of innovative healthcare programs, processes, people and organizations – U.S.-based or elsewhere?

Thanks to Hosts & Participants!

Special thanks to John Lynn (@TechGuy) of Healthcare Scene, our co-hosts @_GWConnect and @_GuideWell and all the 70+ who participated in the chat.  A complete transcript of the chat can be found here.

Insight, Ideas and Opinions on Topic #1

This post shares insight, ideas and opinions shared by #HITsm chat participants on Topic #1. We’ll share more on the other topics in future blog posts.

Precision Medicine – aka. Personalized Medicine

  1. Precision medicine (aka ‘personalized medicine) was a hot topic at this week’s #AHIPInstitute in Austin.
  2. Patients with complex needs require a custom approach. Personalized medicine promises to improve outcomes at lower cost.
  3. Be excited when we get to the point where #AI effective for health plans. We’re still collectively digging for gold in claims data.
  4. Implementing positive changes in the healthcare industry that give clinicians the opportunity to view #PatientCare in a new light
  5. We definitely need this for #UX — the difference b/t changing your bank profile and your payer profile is enormous

Patients, Consumers & Health Plan Members

  1. It wasn’t that long ago that HC plan leaders were saying “HC plan members aren’t consumers,” LOL
  2. Addressing the healthcare needs of the #aging population of the country will need to take a seat in the front row
  3. Taking advantage of the data we are given to visualize the patient condition and identify at-risk patients earlier
  4. Getting members engaged and empowered in understanding, maintaining, and improving their own health journey
  5. Consumerism has been making inroads into healthcare, patients are acting like consumers about their healthcare options
  6. Until patients “get it” health outcomes can only improve so much

Importance of Basic Health Education, Literacy & Preventive Care

  1. Improving basic health education & literacy through active & coordinated outreach to members & patients is a big opportunity
  2. Improving education & literacy can be as simple as adopting universal languages so plan members aren’t constantly confused
  3. More focus to prevention & wellness. Reach patients before they get ill or have a major medical event.
  4. We need to focus more on prevention – spending too much on too few people – and often late in life.

Customer Relationship Management

  1. Customer service is an area of opportunity, healthcare needs to accept the change and adapt accordingly
  2. Before the healthcare industry dives into AI – they should incorporate basic CRM functions into #EHR systems. Huge communication disconnect!
  3. Addressing the need for clinical decision support and getting the right information available at the right time

Data is Critical to Healthcare

  1. Challenge w/ personalized medicine starts w/ lack of ability to accurately identify correct patient some crazy % of time…
  2. And, of course, standardizing data (#interoperability) to encourage cooperation between all #healthcare entities
  3. Systems that can use unstructured data to inform decisions. AI and machine learning?
  4. Real-time data sharing, especially clinical data, with providers and especially patients
  5. Absolutely! RTI approach needs to be incorporated from data driven perspective
  6. Systems need 2 embrace outcome-driven & SDOH/BDOH-driven ops to lower costs & affect outcomes. Walk the walk; we’ve heard the talk

The Importance of Home & Social Determinants of Health

  1. Health data taken from the home of the patient using this technology can be shown to doctors for perhaps better, tailored care
  2. Another area to take advantage of is using technology to bring healthcare to the home of patients.
  3. It is the space between heart beats where we live – IE not an “area” but care coordination between areas and with patients

Quality Measures & Measuring Outcomes

  1. How about better assessment & collection of what matters to members/patients? Instead of fancy analytics from quants?
  2. How do we measure feelings and happiness? Or are outcomes more quantifiable?
  3. System wide outcome driven treatment and outcome measures to tailor individual client centered care. Educate for prevention
  4. Analytics allows for effective clinical assessments by providing better patient outcomes
  5. We’re trying to do this now, in way, with HCAHPS/CAHPS, right? Don’t believe currently effective, but CAN be quantified.
  6. Do you see a worthwhile set of quality measures worth aligning to?
  7. Great idea: patient-centric measures. What outcomes do patients/members want to achieve, and what data do we need to drive them?
  8. We do this in OT for quality of life/ perceived ‘happiness’ with what is most valuable. All valid reliable and evidence based measure

Look for More on the Other Topics in Following Posts

Check back for more insight, ideas and opinions from the #HITsm chat. Thanks again to John Lynn and our co-hosts @_GWConnect and @_GuideWell and all those who participated in the chat.  A complete transcript of the chat can be found here. You can also follow @HCExecGroup to learn more about opportunities, challenges, and issues impacting healthcare plans, health systems and payers.

Advancing Together: Healthcare Innovation in Wine Country

By | The Industry Pulse, HCEG Top 10, Healthcare Policy, Value-Based Payment/Care | No Comments

Healthcare innovation forum unitedag hceg hcexecgroup napa ca topics value-based-care

Note: This post was first published by Ferris Taylor on LinkedIn

It could have been the combination of a beautiful day in California’s Wine Country or just the extraordinary and varied perspectives of healthcare executives representing a true cross-section of American healthcare – payers, providers, vendors, purchasers and UnitedAg partners – that elicited deep discussion about value-based relationships and made the jointly sponsored Healthcare Executive Group (HCEG)-UnitedAG Health Innovation Forum such a successful event.  But whatever it was, the forum’s theme – Advancing Together – was clearly a spot-on phrase used to describe an informative and inspiring event.

UnitedAG’s hospitality and the diverse cross-section of attendees at UnitedAg’s Annual Meeting and Conference could not have set a more congenial and thought-provoking setting. Led by Kirti Mutatkar, UnitedAg CEO, Mike DeMore, Superior TPA’s Managing Director and Christopher McDonald, UnitedAg’s Director of Underwriting, the Health Innovation Forum kicked off an open dialogue of the critical issues and opportunities facing healthcare in 2017 and beyond.

The Healthcare Industry Pulse

After 30+ participants introduced themselves to each other, Ferris Taylor, HCEG Office of the Chair and Change Healthcare consultants, Chris Link and David Gallegos, presented highlights from the 7th Annual Industry Pulse Research survey. As is commonly said, a picture is worth 1000 words and Eris Weaver, a graphic recorder meeting facilitator captured many key points throughout the fast moving discussions.

Key research insights among the participants were shared on the impacts that clinical and data analytics can have on stakeholder interactions, workflows and especially on population health.  The transitions from more traditional risk management (disease and care management) to more 21st century tools and technologies were explored. Measures of success for the transition to value-based relationships were considered, especially those that will best serve consumers, healthcare providers and payers.  The Industry Pulse research also highlighted the roles that both cost and quality transparency will play in the future of healthcare.

Alignment of Incentives is Key

As revealed in the excellent graphics created by Eris Weaver as the discussions unfolded, “trust” was a key word arising multiple times.  Dr.  David DiLoreto, SVP at GE Healthcare and HCEG member, facilitated dialogue on the importance of more detailed innovations that value-based relationships demand. Dr. DiLoreto shared some insight experienced in Scandinavia and Denmark versus here in the U.S.

Population Health & Value-based Care

Dr. Arjun Chanmugam, Vice Chair of Johns Hopkins’ Integration and Health Care Transformation, Dr. David Nace, Chief Medical Officer at HCEG sponsor partner MarkLogic and Dr. Craig Brandman, CEO of StepOne Health, contributed their unique insights about the challenges and secrets of value-based health care.

More on Wednesday, March 29th, 2017

The morning of discussion in Wine Country was just the start of innovative thinking around value-based relationships.  Those discussions and more details from the Industry Pulse Research Survey will be shared via a webinar presented by HCEG and Change Healthcare on Wednesday, March 29th at 2:00 PM Eastern.

Free registration is available here.

Highlights from Day 1 of 2017 AHIP National Health Policy Conference

By | AHIP, Payers, Next Generation Payment Models, Delivery System Transformation, Healthcare Policy, Value-Based Payment/Care | No Comments

The 2017 AHIP National Health Policy Conference kicked off today in Washington, DC.

Political, business, and health care leaders from across the nation gathered to dive deeply into our nation’s top policy priorities in an effort to move forward in today’s uncertain healthcare environment.

What a period for healthcare reform in the United States!

In addition to some general comments about healthcare policy and politics, today’s sessions addressed topics such as the following:

  • Risk-sharing and Cost Control
  • Value-based Care
  • Pharmacy Costs
  • Medicaid Exchanges
  • Importance of Social Determinants of Health

Social shares from conference attendees

As is happening more and more at many of today’s top healthcare conferences, conference proceedings, insights and other information were shared on Twitter – among other social channels. Here’s a sample of some interesting shares from Day 1 of the 2017 AHIP National Health Policy Conference.

Thanks to all those noted below who took the time to share with those who were unable to attend the conference.

General Stuff

HandleTweet
@ajmc_journalThere’s still a basic misunderstanding of how health insurance works, says @AHIPCoverage’s Tavenner
@rpalme01@MD_Insurance @al_redmer ACA “status quo is not an option, status quo is not a solution”  #ACA
@nancyrwiseNewt Gingrich sure that SOME bill will be passed this session…  but no direction on what it will include.  #AHCA
@nancyrwiseT. Nickel, thank you: “Association Health Plans are awesome… until they are not”  @NAIC_News

Cost of Healthcare & Risk-Sharing

HandleTweet
@ajmc_journalThe only cost containment strategy that works is cost sharing but it can be such a burden that it takes care away–@chipkahn
@avercloudHealthcare payers: Make the move from pilot to full-scale bundled payment adoption. Let’s discuss at #AHIPPolicy
@leah_a_brownThe discussion a few years ago was about coverage, now healthcare 2.0 is about cost.
@mahphealthGood point by MD Comm. Al Redmer Jr on NAIC panel Can’t do anything on premiums unless moderate cost of delivering #healthcare
@nancyrwiseGreat quote: “Pay for value = transferring risk to providers.” M. Chernew
@nancyrwiseIf health orgs are bigger & more integrated, they are better positioned to own market power: unlikely to lower costs. M. Chernew
@suemontgomery2Cost of premiums is all about the cost of delivering care. – Ted Nickel at #AHIPPolicy

Value-based Care & Reimbursement

HandleTweet
@ahipcoverageConsumers want affordable coverage & high-quality care – that’s what value-based care delivers.
@avercloudDebate the policy, but value-based healthcare is here to stay. Let’s discuss bundled payment success at upcoming #AHIPPolicy

Pharmacy

HandleTweet
@springstexPrescription drug costs pass physician services as biggest slice of health insurance premium
@rpalme01Keep talking to your local pharmacist and sharing what he tells you.

Medicaid Exchanges, Access & Importance of Social Determinants of Health

HandleTweet
@ajmc_journalHealthcare reform is a question of access vs true availability. The devil is truly in the details, said @AndyGurmanMD
@nancyrwiseInterested in continuing conversations about potential intersection of #Medicaid and Exchange markets in #healthcare #simplicity
@ahipcoverageFrom transportation, housing & environmental health, plans are addressing social determinants of health

Keep on Top of More Insight on Healthcare Reform

Be sure to follow the Healthcare Executive Group on Twitter, Facebook and LinkedIn where we share insight into the challenges, opportunities and issues facing healthcare executives and others in today’s fast-changing healthcare environment.

“ACA: The Road Ahead in Transitioning from “Accessible” Care Act to the true “Affordable Care Act”

By | Healthcare Policy

Last week one of HCEG’s sponsor partners, HealthEdge, co-hosted a webinar “Payment Reform: Exploring Technology Implications for Health Insurers” with Medica. The hour long webinar, available here on YouTube, was presented by Andrew Davis – VP & GM of Medica’s Medicare segment  and Harry Merkin, VP of Product Marketing at HealthEdge.  The webinar addressed the move from fee-for-service to value-based reimbursement models; specifically the underlying technology systems health insurers are using or will soon need to use to avoid left behind. The impact of new MACRA legislation was another topic discussed throughout the webinar and during the Q & A period at the end of the webinar.

Value-Based Reimbursement is Big – And Getting Bigger

The move to value-based reimbursement (VBR) and other business models based on quality and value is dramatically reshaping the U.S. healthcare system and is happening faster than anyone could have anticipated even just a couple years ago. Currently, CMS is on track to have 30% of its reimbursements under value-based arrangements this year in 2016. And CMS is targeting 50% of all its reimbursements to be value-based by 2018 and 75% by 2023.

Agility – Efficiency – Transparency

A survey by McKesson – Journey to Value: The State of Value-Based Reimbursement in 2016 – reveals that 61% of payers and 41% of hospitals expect VBR reimbursement to positively impact their organizations.  In order for payers and hospitals to realize positive benefits from VBR, or at least avoid being unduly impacted by new value-based systems in a negative way, these healthcare organizations need to focus on three technology imperatives

Agility – health plans must be able to adapt to new payment models and rollout new benefit designs and lines of business quickly. And they must be willing and able to rapidly share relevant, actionable information with their provider networks.

Efficiency – the increase in administrative and reporting processes demanded by value-based reimbursement dictate that health plans automate key processes to enhance their competitive position.

Transparency health plans must be able to provide a patient-centered, 360 degree view of their members to the entire care team. Member experience and engagement should no longer be nice to haves.

Additional Insight from the Webinar

 The webinar provided a lot of statistics, information and actionable ideas for webinar attendees. The reader is urged to watch the webinar on YouTube where they will be presented with information and ideas like the following:

“MACRA raises a concern about ensuring adoption across all provider types. MACRA is ‘Meaningful Use on steroids’”

“There is widespread concern about conflict and misalignment between quality measures under Medicare FFS and the quality measures proposed MACRA”

“There will be a significant administrative burden managing multiple measure sets needed to comply with existing quality measure reporting programs and MACRA’s new Merit-Based Incentive Payment System (MIPS)  – at least as far as these programs are defined today.”

“Larger provider organizations working w/ ACO’s have a significant advantage under MACRA”

“Medicare Advantage is gold standard for effective risk-based contracting in today’s healthcare marketplace”

healthcare“Providers must treat all Medicare beneficiaries the same regardless as to whether they’re reimbursed via FFS, Medicare Advantage risk or new MACRA reimbursement”

“MACRA brings a bigger set of carrots and sticks that payers can with providers.”

“MACRA will enable Medicare and Medicaid programs to keep providing healthcare for generations to come”

Other Webinars by the HealthCare Executive Group

The HealthCare Executive Group (HCEG) is a national network of select executives from across the entire healthcare spectrum; coming together to continually learn, grow, share and reshape the healthcare industry. HCEG periodically sponsors webinars such as the one described in this post. For more information on becoming a HCEG member, see Why Join HCEG? on the HCEG website.

Payment Reform and MACRA: The World is Speeding Up

By | Healthcare Policy

Payment reform is much talked about, often written about and now becoming real in today’s world. The move to value-based reimbursements and other new business models is an inevitable reality that is dramatically reshaping the US healthcare system. In the Fee for Service model, providers were typically compensated for the volume: the number of patients seen and tests conducted; in the new world of value-based reimbursements they will increasingly be paid for successful outcomes, promoting healthy behaviors and the prevention of expensive episodes of care. As Richard Migliori, MD, Chief Medical Officer of United HealthGroup recently stated at an industry conference, In a Fee for Service world, the typical physician used to worry about who was in the waiting room. Now in the value-based world they have to worry about who is NOT in the waiting room. He went on to share that of United’s $100 billion in reimbursements, 43% have some tie to value today.

Now CMS is taking a leading role in the transformation, with the recently released MACRA (Medicare Access and CHIP Reauthorization Act of 2015) rule, designed to push quality measures tied to reimbursement incentives for Medicare providers. With the fastest growing segment of health insurance members belonging to government sponsored programs, including Medicare, Medicaid and Duals, CMS has publicly stated it is targeting 30% of all of its reimbursements to be value-based by 2019, with 50% by 2021 and 75% by 2023. The initial MACRA quality measures will start on January 1, 2017, with payments beginning in 2019. And the MACRA rule is written with specific intent of moving the model beyond Medicare into Medicaid, and ultimately into the commercial market over time.

Health plans are compelled to prepare for the change to value-based contracting and quality-based outcomes that MACRA will bring with it. Payors, particularly those with Medicare Lines of Business, must be ready to capture data related to the new quality and performance measures, beginning on January 1, 2017. Payors must have the ability to adjust the way services delivered are reimbursed under Medicare, and embrace the value-based models that MACRA is introducing and reinforcing. And to do so, payors need to leverage a technology infrastructure with the agility to move quickly in order to adjust their benefit and payment models.

Industry experts have been weighing in on MACRA through the recent comments period and in other public forums. A few examples are:

Deloitte: MACRA is poised to drive payment and delivery reform across the payer mix for the foreseeable future.

American Medical Association President Steven Stack: “Our initial review suggests that CMS has been listening to physicians’ concerns,” adding, “In particular, it appears that CMS has made significant improvements by recasting the EHR Meaningful Use program and by reducing quality reporting burdens.”

PwC: In many ways, MACRA genuinely reflects Medicare and Medicaid’s drive towards payments that are based on the quality of care physicians deliver rather than the quantity of procedures they perform.

Senator Debbie Stabenow, Democrat from Michigan: MACRA is a truly historic piece of legislation.

 

In June, a select group of health plan executives and other healthcare leaders gathered for an industry roundtable, sponsored by HealthEdge and Deloitte, for a discussion and to share their perspectives on MACRA.

Executives attending the roundtable considered many aspects of the anticipated changes, including:

  • How quickly the government’s push for pay for performance could truly extend beyond Medicare, into Medicaid and commercial plans and the resulting changes to payer-provider networks and contracts
  • The need for process changes and improved efficiency in how a population is identified and treated, particularly those in at-risk categories.
  • The urgency for health plan IT organizations to have a detailed understanding of the agility and flexibility required to handle changes to provider payments based on performance. Participants stressed that this is a key ingredient for system success that will translate to the financial health of the plan.
  • The ability for a health plan to consider members strategically and with a long-term view, particularly by establishing quality results for younger members and those with lower risk, to create a membership base with high loyalty for the future.
  • The potential impact the law will have on smaller and rural practices. Virtual groups of providers will be facilitated by CMS, along with $20 million of funding, all designed to aid providers of all sizes to participate in the Advanced Payment Model program
  • How the inclination for health plans to narrow provider networks to work with highly rated physicians must be balanced with proper access to healthcare services.
  • The consensus that much of healthcare is local and community based, and MACRA could encourage opportunities to strengthen those relationships in places where the linkage is already strong.
  • The realization that those providers and provider entities that are in denial (I.e. some IDNs) are in for a shock.

With the January 1, 2017 start of the first quality measurement period fast approaching, MACRA promises to be a significant force in how payment reform is accelerated, beginning with Medicare and expanding to all forms of health insurance in the future.

 

About the Author

3bf5dd8Harry Merkin, Vice President, Product Marketing, HealthEdge

Harry Merkin has worked with both payers and providers through many dynamic changes in healthcare for a number of years. He is currently responsible for Product Marketing at HealthEdge and previously had similar responsibilities at Evariant and NaviNet. Merkin has collaborated with many transformative entities across the healthcare landscape. He has helped introduce and promote enterprise software solutions that enable payers to improve their competitive effectiveness, as well as perform valuable communications between payers and providers, and allow providers to effectively collaborate with patients and consumers as well as with each other. Merkin is the parent of two Millennials and is a long-time New England Patriots season ticket holder.

Meaningful Use is far from Done

By | HCEG Top 10, Healthcare Policy

2015.09.21 - ReimbursementyIn the Stage 1 Federal Register, CMS mentions that incentive payments may be received until 2021. The Stage 2 Federal Register identifies increasing levels of Meaningful Use Compliance stages through 2021. Also, the Secretary of CMS has the authority to increase annual penalty percentages for each year. So there is statutory evidence to believe providers will be held accountable to Meaningful Use at least through that date.

We also know that auditors will be involved. MU creates a structure within which CMS can reduce Medicare costs by forcing penalties that will be paid out at least through 2023 (two years after the last year of Meaningful Use). Under current legislation, the Secretary of CMS is obligated to charge penalties of up to 3% of Medicare Reimbursement, and is permitted to increase those penalties to 5%, depending on market conditions.

Here’s a credible two-part speculation. Congress has stated that Meaningful Use of EHR is an important part of the Federal goals of Health Care effectiveness, cost reduction and access to information. The legislation charged CMS with continuously increasing the sophistication by which providers use their EHR technology, through the end of the current program.

  1. Speculation part #1 is that Congress could extend the Meaningful Use program to extend on through increasingly more sophisticated and rigorous usage as technology and internet infrastructures improve.
  2. Speculation part #2 is that CMS, in seeing the ability to assess penalties for non-compliance, could use Meaningful Use to reduce Medicare payments at least for some providers. Further, it is hard to imagine either Congress or CMS to rescind legislation that has the effect of reducing Medicare payments.

Even if Meaningful Use sunsets in its current legislative and regulatory authority, providers need to retain well-organized Meaningful Use data for six years (the audit period) after the last Meaningful Use Attestation has been filed, in 2021. However, we believe it is likely that once Meaningful Use has become institutionalized within CMS, and within the provider community, the program will be difficult to halt.

Every provider, regardless of whether they have “chosen” Medicare or Medicaid programs, will be subject to sustaining increasingly rigorous Meaningful Use status, or be subject to penalties; and are subject to audit over that period as well.

The Ticking Time Bomb of Meaningful Use

What’s the Ticking Time Bomb? The Bomb is Recoupment. It is delivered by CMS Auditors, and has a fuse that is up to six years long (although we will see a little later on that the length of the fuse could be changed at any time). What it means is that any money the government gave you could be taken away, at any time up to six years after you have spent it.

Although the Auditors deliver the bomb, the boom is really out of their hands. Any single trigger event, no matter how small, causes a full recoupment of any Stimulus paid in a year being audited. The Auditors simply look for triggers.

The triggers they look for are not necessarily whether a hospital or physician was compliant in a given year, but simply evidence showing proof of compliance. And therein lies the real issue. The Government (CMS) has never really defined what it takes to fully prove compliance, and in fact has actually issued a statement that they really can’t predict all the documentation that a provider should have.

What this means, is that Auditors are put in the position of making some impactful judgment calls. An auditor, in reviewing a Provider’s attestation of Meaningful Use from some time in the past, must decide whether the Provider can prove they were truly in compliance with each of 24 or 25 complex rules. Providers, although generally quite diligent in becoming compliant, have often been far less worried about the paperwork.

Here’s a good example. Let’s consider CPOE (Computerized Provider Order Entry). CPOE is neither more complex, nor less complex than most of the other rules, so it forms a good example. To fully understand CPOE, a diligent professional needs to read at least five separate documents. This simple four letter acronym is supported by 21 columns of fine print in the Stage 1 Federal Register, and another six columns of the Stage 2 Federal Register, eight FAQ’s (buried in a list of 300 on a CMS Website), and several pages of technology specifications in each of two separate issues of the Federal Register dedicated to what functionality a Certified EHR must have. Sound complicated yet? And yet it is quite common for a provider to rely on a single line item on a summary report from their EHR system that shows a single summary percentage.

Now, put yourself in an Auditor’s shoes for a moment. CMS has contracted with Auditors, under Congressional direction to be the steward for Program Integrity over Meaningful Use. After all, Congress authorized gross expenditures of over $30 Billion and they expect a couple things. First of all, they expect a return on that investment. That ROI should primarily consist of increased efficiencies in healthcare delivery (remember that on average, Congress pays for about 40% of healthcare in the form of Medicare and Medicaid claims). Since those efficiencies are, at best somewhere in the future, it will be impractical to try to measure ROI directly.

What this means is the Congress? stewards (the Auditors) have only one yardstick to use in measuring Program Integrity, and that yardstick is the body of regulation supporting Meaningful Use. Using CPOE as an example, an Auditor should be familiar with the entire body of regulations and use that familiarity to judge whether each provider was compliant with all of it. Auditors, being skeptical by nature (in fact, professional skepticism is actually a formal requirement of being a CPA), are unlikely in their Stewardship role, to accept a single line item on a summary report as evidence of compliance with any single rule so complex as CPOE.

What this means, is that when an audit happens, providers will be asked to produce documentation proving compliance with complex regulations, some of which have changed, using EHR Technology which almost certainly has changed, against patient data that is also time-sensitive. Further, some of what it means to be compliant with a rule will be quite hard to prove with a report. For CPOE, providers may be asked to prove that each entry was made by a licensed healthcare professional, and that it was input to the EHR in a sufficiently timely fashion that a physician could react to any alerts generated by the entry before the associated medications are administered.

Remember, the auditor has the right to expect this kind of proof.

Of course, the Auditor has some latitude. Some of their latitude is based on the normal judgment implicit in the job. Every day, Auditors have to decide how likely it is that their current target is to be non-compliant. Based on that judgment, each individual Auditor makes a choice to dig either deeply or shallowly. But even beyond that judgment call audit practices will be shaped by the policies and politics of their current client.

The Auditor’s client of course is the Federal Government, but the practicalities are a bit more complicated. CMS is part of the Executive Branch. But Meaningful Use is a recent invention of the Legislative branch, which continues to deploy their oversight agencies (GAO and OIG for starters), to make sure the Executives are administering the Congressional Mandate consistently with Congressional Intent. Does all this sound as if there could possibly be some conflicting agendas.

In 2013, the Executive Branch is eager to be part of Stimulating the Economy. Relative to Meaningful Use that translates into making sure as many providers as possible receive as much Stimulus Payment as possible. Congress, of course passed the law and is (largely) of the same mind. At the moment, anyway. But even so, Congress has already initiated multiple reviews of CMS’s administration of the Meaningful Use Program, and has at times been critical of some aspects.

All this plays into the Auditor’s latitude when reviewing proof of compliance. If Congress and/or the Executive Branch wanted to be sticklers on making sure every attestation was squeaky clean, the complexity of the regulations opens a lot of doors for denial of compliance, based on whether or not a provider, up to six years in the past, developed, organized and deployed adequate documentation to support attestation to a complex set of regulations, in a complex organization.

So far, Auditors seem to be taking the position of only looking for egregious or intentional non-compliance. Still, when faced with a lack of documentation, they have little latitude other than to judge a provider as non-compliant. In a case of non-compliance, CMS has little latitude other than to demand recoupment, based on the law passed by Congress.

The Ambiguity of Documentation Requirements

CMS has published over 1,600 pages defining and describing Meaningful Use. In none of those pages is there a definition of what documentation a provider is required to produce in the event of an audit. In spring of 2013, almost three years after passage of the Meaningful Use law, CMS finally published a five page briefing on how providers should document their compliance. While this booklet gives some direction, one single sentence puts providers on notice that they should expect no definitive structure, and that significant individual judgment is the only standard:

An audit may include a review of any of the documentation needed to support the information that was entered in the attestation. The level of the audit review may depend on a number of factors, and it is not possible to detail all supporting documents that may be requested as part of the audit.

As time passes, providers will share their experiences with audits. We will all learn more about what documentation techniques and strategies best mitigate audit risk, and what cost is reasonable to incur in developing defensive documentation. The problem will always be that today’s audit program is not necessarily tomorrow’s audit program. CMS’s policy is to review their audit program each calendar quarter and make adjustments, based on their success in defending program integrity.

It could be simple, in an environment of easy audits to assume that all future years will be equally as easy. The danger in this perspective is that CMS could decide, at any point, to reach back to the initial years of the Meaningful Use program and audit aggressively.

The Difficulty of Documenting Compliance

EHR’s are certified to be able to support Meaningful Use. Supporting Meaningful Use is quite a different story than proving it, though. Remember back to CPOE. In order to become Certified, an EHR is required to correctly calculate a percentage from a numerator and denominator. Certification testing does not extend to exhaustively proving that the population in either the numerator or the denominator is correct. In cases where hospitals (or even physician staff) use multiple EHR technologies during a reporting period, it is often necessary to combine data from multiple systems. We refer to this numerator / denominator calculation as the Certified EHR Report.

The Certified EHR Report is not in itself acceptable proof to an auditor that a provider is compliant for multiple reasons. First, it only shows summary statistics for each measure, and auditors are notorious for wanting to see the details making up those summaries. It is important to understand that there is no assumption that simply because software is certified, that its reported Meaningful Use percentages are accurate. The certification process is not required to exhaustively test for completeness or accuracy, but simply to verify that the EHR will create percentages.Second, the existence of a measure, even if accurate, does not in itself assure that the underlying processes were compliant. In one well-known case, a hospital officer was prosecuted for fraud when he loaded his Meaningful Use content into the EHR after patients were discharged from the hospital.

How Meaningful Use Audits differ from other compliance audits

Consider the example of Joint Commission Audits in hospitals. The auditor conducts a review, issues a report, and provides the opportunity for any procedural shortfalls to be remediated. The hospital corrects its documentation, and the actual non-compliant processes, then invites the auditor to return and verify. In the case of Meaningful Use, though, audits are always ?fter-the-fact, and it is not possible to correct a process that was flawed in a prior year. And if you can’t prove what your process was in a prior year, you may have difficulty refuting an auditor’s assertion of non-compliance.

What’s the bottom line? Even after all your providers have achieved compliance with all the Meaningful Use measures and requirements you will need to sustain a Meaningful Use compliance process, individual and database to support ongoing scrutiny from CMS or bear penalties based on reductions of your Medicare fee schedules from now on.