Can the Patient Centered Medical Home Be Saved?

Posted by Michael Renzi, DO, FACP on Oct 10, 2017 9:01:00 AM

Yes – but only if insurers do their part.

Thousands of primary care providers transformed their practices to patient-centered medical homes in preparation for performance-based payment models. No doubt some groups submitted NCQA application for PCMH recognition status, but little changed in their day-to-day work flow. They just churned through as many patients as possible because their fee-for-service payments remained the key to their economic survival.

However, some of us actually made substantial investments in how we delivered patient care. We believed these new payment models promised to economically align payers, providers and, dare we even say it, patients. We examined and changed everything we did to prepare, with the full understanding that we were going to risk our payment if we missed the mark on quality and cost. We even considered alternative payment models (APMs), where we would pay money back to the payer if we missed the mark. Of course, these opportunities were touted to yield much bigger payments than the best of the fee-for-service contracts, but who would have ever “thunk it” -- doctors leaping head first into a risk-based payment model where they might have to refund payments to the payer for failure to meet cost benchmarks!

At first, it worked. High-performing practicesimprove patient outcomes and experience and lower the overall costs of care.[1] But in many markets, the APMs that would provide long-term economic sustainability to these high-performing groups never materialized.

Read More

Topics: Value-Based Healthcare, Patient-Centered Medical Home, APMs

Health Care's Future IT Value Proposition

Posted by Don McDaniel on Sep 7, 2017 11:00:00 AM

McKinsey & Company recently published the results and analysis of a global survey on IT’s future value proposition. While many expect IT, and CIOs for that matter, to play a growing role in improving business results, IT still suffers from performance issues and unfulfilled promise. The survey suggests that CIOs must raise their skills and influence within their respective organizations. Of the 709 respondents, many felt IT will contribute most through innovation and integration – that is, better integrating solutions that support business results. As I read this and applied it to the healthcare industry, I couldn’t help but think about how these issues related to the current malaise – an ambivalent sense that we’re not sure whether technology is advancing progress, or further complicating it. There are more than a couple of general conclusions from the survey that apply explicitly to healthcare.

First, integration seems to be even more important in industries with legacy technologies, and the healthcare business is full of proprietary, siloed, premise-based technologies. One explicit use case in today’s migration to value-based medicine is the challenge of providing relevant, timely information to caregivers operating in delivery environments with multiple electronic health records. There is no easy way to build sustainable integration today, but this must be solved in the future.

Read More

Topics: Value-Based Healthcare, Healthcare IT, IT and analytics, Role of CIO

What Could Medicare Do To Drive Change

Posted by Don McDaniel on Aug 29, 2017 11:00:00 AM

There’s been a lot of discussion about reforming our health care system over many generations and presidential administrations, and most recently in the run-up to and immediate period after the election of Donald Trump. Republicans promised for 7 years to repeal and replace Obamacare only to (so-far) fail miserably at walking-the-walk.  I believe the political milieu, is at best a red herring, innocuous and really noise.  The fact is the value movement that we’re talking about in health care is really a market movement.  The proverbial train has left the station and market principals are already starting to disrupt the industry.

I was participating in a recent panel about innovation in healthcare, and the moderator asked the panelists, “what one thing would you do to change the status quo, to drive innovation ?”. My colleagues, all experts, but all practioners in the “old health economy” shared all the conventional wisdom; all the responses were, at best, representative of incrementalism.  I had the luxury of answering last, and used the time to my benefit for once.  I suggested that completely privatizing Medicare would be my choice.  Privatizing or “Marketizing” Medicare would expose one of the world’s biggest monopolies (short of true single payer government plans) to market forces.  From a budgetary perspective, privatizing Medicare from its current defined-benefit approach to a defined budget, or defined-contribution model would allow CMS to more predictably budget for growth in the program, and leverage the market of many willing sellers of insurance and services. 
Read More

Topics: Value-Based Healthcare, medicare, Healthcare Innovation

Five Essential Population Health Management Tips

Posted by Continuum on Dec 6, 2016 10:30:00 AM

Success in VBC initiatives depends on smart pop health strategies

Population Health Management (PHM) is the buzzword of the moment when it comes to success in value-based care initiatives. There’s a good reason for that – done right, PHM has a strong chance of helping providers realize the goals of the triple aim and generate real revenue to reinvest in their organizations.

Don’t let all of the buzz distract you from reality. As we’ve learned from watching Big Data’s hype cycle, it’s important to focus on how you can make PHM work most effectively for you. It’s becoming clear that simply purchasing a PHM solution isn’t the silver bullet that’s going to deliver success.

Read More

Topics: Practice Transformation, Value-Based Healthcare, population health management, PHM

The medical home model: What physicians need to know

Posted by Continuum on Nov 1, 2016 1:08:19 PM

The concept of a “medical home” has evolved over the years, starting in the 1960s as the center of medical records for a child with special healthcare needs. Today, that definition is greatly expanded: A medical home is a partnership between the patient, family and primary care provider, in cooperation with specialists and community supports, according to the U.S. Department of Health and Human Services. It can encompass children and adults, regardless of their healthcare needs.

Read More

Topics: Value-Based Healthcare, MIPS, APMs

Effective financial incentives drive value-based care (VBC) adoption

Posted by Michael Renzi, DO, FACP on Oct 18, 2016 11:22:00 AM

For years, providers and payers have been at odds with each other. Arguments about reimbursement rates, network inclusion, and claims management created relationships that were, at best, adversarial. The move away from fee for service (FFS) to value-based care (VBC), however, is triggering a shift all its own—new lines of communication are opening between payers and providers. This change is helping control costs and improve how care is delivered.

No matter how you slice it, there’s one clear path to increasing payer satisfaction and provider satisfaction at the same time: increasing the percentage of physician revenue linked to value-based contracts. While there’s critical and wonderful benefits that come along with value based care, such as better quality and outcomes, lower costs, and higher patient satisfaction, the only thing that will make providers adopt new practices is if there’s a strong financial benefit to do so.

Payers should be providing every willing physician with per member per month (PMPM) payments and shared savings, and those PMPM dollars should fund positive innovation in people, technology, and operations. Yet, shared savings programs have two inherent flaws that limit their ability to keep providers focused on the goals of the program: uncertain revenue streams and limited financial potential in terms of FFS revenue. Even a highly successful shared savings program will only yield a few percentage points in top line revenue—meaning that more than 95 percent of revenue is still FFS.

Read More

Topics: Value-Based Healthcare, Alternative Payment Models, payer contracts

CINs: Providing Value Through Population Health Management

Posted by Continuum on Feb 27, 2015 11:25:00 AM



The U.S. Department of Health and Human Services (HHS) has set a goal of tying 30% of traditional, or fee-for-service, Medicare payments to quality or value through alternative payment models, such as Accountable Care Organizations (ACOs) or bundled payment arrangements by the end of 2016, and tying 50% of payments to these models by the end of 2018, proving that value-based reimbursement is swiftly becoming the norm in today’s healthcare environment.1

However, recent studies show that many of the institutions which were awarded value-based payments this year are now facing government-issued penalties. A recent article in Kaiser Health News reported that 55% of hospitals graded by Medicare on quality––some 1,700––earned higher payments this year for meeting quality metrics. However, fewer than 800 of the 1,700 hospitals that earned bonuses will actually receive extra money because they have been penalized for high hospital readmission rates and hospital acquired infections.2

Payment studies on hospitals, a microcosm of U.S. health care providers, provide useful insight into the pitfalls of value-based purchasing agreements. Moreover, they underscore the importance of understanding what happens to patients outside the hospital in an ambulatory setting. Improving the delivery and value of care requires more than just an electronic health record (EHR) – a robust, integrated healthcare technology infrastructure is critical for a Clinically Integrated Network (CIN) to achieve successful population health management.

Pursuing a population health strategy––the need for robust health technology capabilities

Quality and operational improvements are mandates for functioning CINs. Performance must be measured before it can be improved. The right technology platform is necessary not only to capture the complete picture of clinical and operational performance and form a basis for evaluating physician members, but also to identify patients in need of disease management and intense interventions.4, 5 Without the appropriate technology infrastructure, CINs will have difficulty providing clinical decision-support, reducing variability of care and coordinating care across the network. The right platform is also necessary for the administrative support, scheduling, and practice management needed to maintain a consistent revenue stream for continued network investment.5

Technology interoperability is the challenge

As a result of the recent HHS mandate, most physician groups, independent physician associations (IPA), and hospitals have already invested significant time and financial resources to replace paper-based records with an EHR. However, because not all EHR systems are the same, achieving interoperability across a network is often a challenge. HHS has recently proposed a draft Interoperability Road Map to address the secure exchange and use of electronic health information by both providers and consumers.6 It will, however, be a long time before standards are implemented.

For networks with differing EHR platforms, one solution to the interoperability challenge is to use an EHR-agnostic integrated platform that provides actionable data at the point-of-care. A simple performance dashboard that combines and organizes patient data can be developed to identify clinical gaps in care during a patient encounter and facilitate informed decision-making. Care coordinators are better positioned to intervene and manage a patient population with detailed care plans customized for individual patients and their healthcare needs.

Other dashboards can be developed for practice management reporting purposes. Allowing individual physicians, practice administrators and organizational leadership to track productivity, staffing efficiency, revenue and expenses by physician, site or in total, enables prompt identification of areas of underperformance and the development of concrete improvement strategies to attain performance targets. The ability to combine business intelligence and clinical intelligence is essential to establishing patient registries, improving the quality of care and lowering the overall cost of care.

Disease-based, patient registries are critical to population health management

One of the biggest success factors in transitioning from volume to value is the ability to identify clinically high-risk patients. According to the Medical Expenditure Panel Survey, only 1% of patients were responsible for 20% of health care costs in 2008, and the top 5% of the patient population accounted for nearly 50% of health care costs in 2008 and 2009.7

Proactively managing such clinically high-risk patients is necessary in order to reduce overall costs. A patient or disease registry for specific populations should be established and made accessible to providers across the network. In this way, proactive care and treatment can be delivered to individuals or groups of similar patients, enabling the network to reach quality goals. Patient or population cohort dashboards alert providers of gaps in care or quality measures at the point-of-care. Use of meaningfully-structured EHRs to help track and monitor clinical data across the continuum of services, and an effective ambulatory care strategy, such as the use of centralized care coordinators, can help to identify and engage clinically high-risk patients to keep hospital readmission rates low, for example.

The bottom line

With the appropriate decision-support technology and patient management strategies, a network can thrive in today’s value-based environment. Healthcare technology platforms must go beyond the EHR to improve point-of-care decision-making, improve coordination of patient care, enable implementation of clinical protocols, and track care costs. The ability to document the provision of high quality care at a lower overall cost is key to helping clinically integrated networks negotiate value-based opportunities with payors and employers.

To assist with your strategic planning, download Checklist #3: Does Your Organization Have the Right Tools for Population Health Management? 

New Call-to-action   

Read More

Topics: Value-Based Healthcare, population health management, clinical integration, clincially integrated network, performance metrics, gaps in care, population health tools

CINs: The Right Participants & Performance Metrics Drive Success

Posted by Continuum on Feb 20, 2015 1:00:00 PM



Clinical Integration: The Right Participants and Performance Metrics Drive Success

Clinical Integration (CI) represents a collaborative legal vehicle to allow physicians and healthcare systems to take advantage of value-based and risk arrangement-sharing payment models, while retaining the ability to continue to work in a fee-for-service (FFS) environment.1,2  The reward for establishing a CI network (CIN) is the ability to negotiate contract incentives directly with commercial payors in return for providing high-quality, cost-efficient healthcare to a specific population of patients. As an antitrust safe harbor, CI providers can jointly negotiate increased physician reimbursement rates and pay-for-performance bonuses to serve as recompense for provider costs and efforts incurred to establish a CIN. Because some payors are skeptical of CI’s financial value proposition, many CINs negotiate value-based payment models in which physicians benefit through shared savings agreements instead of higher physician base rates.2

To have the best chance of attracting value-based purchasers, CINs must build a program that can quickly address specific population needs––and because physicians are responsible for driving the clinical care of patients, the move to cost and quality accountability needs to start with them. That’s why recruiting and aligning physicians and determining the right value-based metrics and performance criteria are crucial first steps. 

Secure the right mix of providers both geographically and by specialty

Many CIN’s rely on primary care physicians to be the carehub for outpatient populations. However, some networks also seek to improve inpatient performance and care handoffs, leading them to attract proceduralists and other specialists.2 Determining the appropriate physician population for a CIN means assessing the patient population characteristics  and the needs of the service area, along with the competitive environment and local and national payors. That way the physician network can be appropriately sized and geographically distributed to meet market demands. If not, access limitations may lead to decreased patient satisfaction—one value-based metric of quality health care. Care coordination across a variety of ambulatory, acute and post-acute settings will be important as a CIN moves toward managing a population of patients. Organizations should focus human and financial  resources on obtaining the mix of providers that will support the quality targets, service lines, geographic area cost efficiencies and other goals in their communities, aligning with local service area drivers.

A CIN is no place for mavericks: physicians must support the quality vision

All physicians who participate in a CIN must work actively on care improvement initiatives relevant to their specialty. That’s why it’s necessary to make a selective choice of network physicians willing to adhere to standards and performance criteria, and cross-refer to participating providers. By prioritizing recruitment of physicians who are best prepared for performance improvement, or practices that expand coverage in critical market regions, CINs can avoid overtaxing their development capabilities. All members must sign a participation agreement outlining the expectations and requirements for participation. Physician participants must be comfortable with the idea of data monitoring, quality improvement and care standardization as a means to deliver more cost-effective care.

In addition, physician compensation must be tied to productivity, quality, service, cost-effectiveness, access and other strategic goals, and must provide physicians a fair and stable income. These arrangements must recognize the role the provider is playing and the differing variables that are within and beyond their control. However, finding the right balance of value-based metrics is key.3 

Establish baseline clinical performance and quality guidelines to help the move toward value

Start with the basics by leveraging existing technology and data to achieve attainable, measureable performance criteria and goals. For example, the Healthcare Effectiveness Data and Information Set (HEDIS), available from the National Committee for Quality Assurance (NCQA), is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. 

Benchmark performance across care episodes to identify strengths and weaknesses

Physician “report cards” address performance strengths and weaknesses. Physician participants must agree upon value-based metrics to track things like quality, outcomes, service, patient satisfaction, overall cost of care and other operational and financial benchmarks. Indicators must be specific, measurable, attainable, relevant and time bound. They also must be reviewed on a frequent and ongoing basis. Encouraging consensus-driven care protocols and engaging physicians in best practices will help give them the grounding to thrive in a population health management environment.

The bottom line

Depending on where your organization is on the development continuum, you could be looking at a ramp-up period of 2 to 3 years to develop baseline capabilities for managing population health.3-5 And the clock is ticking. According to a recent perspective article in the New England Journal of Medicine, the US Department of Health and Human Services (HHS) has announced a goal of requiring 85% of Medicare FFS payments tied to quality or value by 2016 and 90%  by 2018.6 During the same week, United Health Group also announced that they will increase value-based payments to doctors and hospitals by 20% in 2015.7 By recruiting the right providers and setting the right quality and value-based metrics, CINs can save time overall and avoid making decisions that, while appropriate for managing in a shrinking FFS environment, are less effective in a value-based setting. 

To assist with your strategic planning, download Checklist #2: Does Your Organization Have the Participants and Value-Based Metrics to Lead Care Transformation? 

New Call-to-action  

Read More

Topics: Value-Based Healthcare, clinical integration, clincially integrated network, performance metrics, physician mix

Clinically Integrated Networks: Physicians drive quality healthcare

Posted by Continuum on Feb 13, 2015 9:00:00 AM



Physicians the Driving Force behind CIN Success

With new pressures incurred by the Affordable Care Act and the increasing movement of the US population into Medicare and Medicaid, physicians and hospitals are aligning in different ways in order to take advantage of Shared Savings Programs and other value-based and clinical risk arrangement payment models. 

These associations, called Clinically Integrated Networks (CINs) are groupings of health care providers and facilities that (in theory) work together collaboratively to provide high-quality, cost-effective healthcare to a specific population of patients.1 However, not all CINs are aligned for success or truly clinically integrated. Because physicians are responsible for driving the clinical care of patients, the move to lower overall cost and improved quality accountability needs to start with them.

Quality Care and Clinical Value: Starts with physicians and ends with integration

Historically, physicians trained to work and make decisions autonomously are rewarded for individual achievement. Their value as physicians––as well as their sense of self––was built upon their ability to be the best in their area of specialty.2 This tradition, as well as the Fee-For-Service payment structure, resulted in competition rather than collaboration at its foundation. However, taking advantage of value-based payment opportunities cannot be accomplished working in isolation from integrated systems of care, and requires attention and resources to achieve positive outcomes for entire populations.

 In order to successfully deliver cost-effective quality care, physicians need to work together towards shared clinical goals, regardless of whether they are hospital employees (e.g. Physician Hospital Organization) or tightly managed independent practice associations (IPAs) or group practices. Physicians in an atmosphere of trust and transparency must agree to proven protocols and value-based metrics, and this is often best served by forming a physician-led clinically integrated entity that includes participation criteria. Creating an integration structure helps providers align to take on the higher levels of accountability needed to create a successful CIN. 

The advantage of legal integration

In 1996, the Department of Justice and the Federal Trade Commission set up a definition of clinical integration to allow physicians and health systems to collaborate without fear of antitrust violations.1 In return for setting up a physician-led professionally managed network, specifically defined as having “an active and ongoing program to evaluate and modify practice patterns” while creating a “high degree of interdependence and cooperation…to control costs and ensure quality”, legal entities are allowed to directly contract with large employers, private insurers and other payors for increased reimbursement rates and pay-for-performance rewards.1  However, to meet these requirements, network members, both physicians and hospitals, need to invest in processes and systems for enhanced communications, and services themselves must be coordinated toward a value-based result.1 That means physicians must be engaged and assume leadership roles in healthcare organizations.

Integrated governance and the need for physician leaders

Because many important decisions will require the “buy-in” of different stakeholders, it is important to foster the participation of a representative sample of network members in governance and leadership roles—including employed and independent physicians, primary care physicians, and specialty physicians, hospital executives, and other participating entities, if any. Physicians, used to making independent clinical decisions, may have the temptation to operate at “arm’s length” from the rest of the health system partners, but there is no room for siloed thinking in an integrated network --enter the need for physician leaders. 2

 Physicians who have been in private or group practices may be accustomed to running a small business and managing its resources. However, these skills are very different from those needed to lead delivery system change.  According to physician leaders from three major integrated healthcare delivery systems, the key factor that sets a leader apart from a manager is the ability to create a vision for the future.  Physician leaders must consider how to align all network providers to shape a healthcare delivery system that serves the physical, social, psychological, and financial needs of many patients, rather than individuals. The right leader can inspire physicians to change by helping them gain a clear understanding of why things must change.

Clinical risk arrangment payment models of many types allow IPAs and health systems to invest in leadership development as a strategic priority, and rewarding leadership and skill in group dynamics, as well as rewarding individual competence, may be key to successfully integrating for accountability.1

The bottom line

Medical groups, IPAs and health systems willing to pursue a CIN must empower physician leaders to have an influence on the future direction of the CIN. This will help to integrate the physician's clinical expertise into CIN operations and increase cooperation and credibility among the participants. Furthermore, dedicated physician and administrative leadership will be required to successfully implement a major change project of this magnitude.

Check back next week for Part Two in this series: CIN Participation Qualification and Quality Performance Criteria 




 To assist with your strategic planning, download our FREE Checklist: Is Your Enterprise or Group Ready for Clinical Integration? 

 New Call-to-action


Read More

Topics: Coordinated Care, Value-Based Healthcare, clinical integration, clincially integrated network

Next Generation RCM and Value-Based Reimbursement

Posted by Continuum on Dec 19, 2014 10:13:00 AM



Not your father's RCM anymore

In the days of strictly Fee-for-Service (FFS) reimbursement, the revenue cycle management process for physician groups was more straightforward. Deliver a service and receive a payment. Today's revenue cycle management (RCM) is changing to meet the challenges of today’s value-based healthcare environment, including new tools and practices that increase revenue collection performance. Providers have always regarded high quality care as imperative, but now must embrace additional competencies required to thrive in complex payor arrangements, especially those associated with accountable care programs.

Key factors affecting today's RCM process

Until the onset of healthcare insurance, payment for services was a matter simply between patient and provider. The entry of insurers meant the introduction of a third party and the use of claims with their even greater need to convey accuracy of patient data and coding. Managed care requirements introduced yet another level of complexity in the claims process. Databases that once featured a relatively simple set of data now include a vast amount of information, ranging from patient coverage and ICD-9 coding, to payor requirements and performance measurements.

Today at least four factors have made RCM a significant challenge:

  • The increasing complexity of medical care itself (witness the impending introduction of ICD-10 coding)

  • Each payor’s development of its own set of payment rules and standards, calling for each clinical practice to acquire large, multi-layered and highly complex data sets for any number of payors

  • Growing patient self-payment or high deductible obligations, a significant change in reimbursement patterns

  • Revenues based increasingly on performance measures, again varying by payor

As a result of all these factors, physician practices now face a highly complex revenue cycle. Consider the enormous variety of reimbursement models alone: fee-for-service, capitation, bundled payments, pay-for-performance and shared savings, and add to that the challenge of different rules and guidelines for each of a long list of payors, including many different payment models, reimbursement and incentive.

Where does billing begin?

Consequently, billing begins not at submission of the claim, but far earlier at the point of patient contact with the provider, sometimes even before patient registration. What is the patient’s insurer? What is the patient’s eligibility, correct billing address, previous denials? Once the patient has been seen, what is the correct coding? What treatment was actually delivered? Is this a patient with a chronic condition that qualifies the provider for non-face-to-face reimbursement associated with new CPT-9 code 99490 (effective Jan., 2015)? How much has the patient paid to date? What are the particular requirements and standards of the patient’s insurer?

A next generation RCM platform contains complete data about each payor’s requirements and also applies complex algorithms that access every piece of that data. Technology can perform many of the tasks, such as checking whether a claim has been paid, further freeing up staff from tedious manual work. 

Next generation RCM platforms must address:

  • Claims Accuracy

  • Tracking Claim Status

  • Improved Workflows

  • Tracking Patient Eligibility 

Two new challenges to futher complicate the process

Revenue cycle management is undergoing two additional changes that will continue into the foreseeable future: patients are responsible for a growing percentage of payment for services, and value-based reimbursement calls for a degree of reporting with its own complexities.

Read more about these areas, as well as challenges facing hospital-owned practices in our FREE whitepaper: Next Generation Revenue Cycle Management for Value-Based Healthcare.

 New Call-to-action


Read More

Topics: Value-Based Healthcare, value-based reimbursement, Insurance, Self-Pay, High-Deductibles, Next Generation RCM

Recent Posts

Posts by Topic

see all

Subscribe to Email Updates