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Doing the Right Thing in the Era of MACRA: The Role of Care Coordination

August 15, 2017
by Thomas James, III, M.D.
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Concerns over the cost of health care and apparent lower health outcomes in the United States compared to other developed countries have significantly influenced program development by the Centers for Medicare and Medicaid Services (CMS). New reimbursement strategies intended to address cost and drive quality—specifically the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)—are placing new clinical and operational demands on the health care industry.

So in the era of MACRA, providers need to balance reporting requirements (which can be time-consuming) while continuing to put patients first. One of the best ways to do this is to ensure patient care is well coordinated.

Moving Forward with MACRA

MACRA made fundamental changes in the way health care providers are paid for Medicare patients. MACRA included the repeal of the Sustainable Growth Rate (SGR) and moved toward rewarding providers for performance through the Merit-based Incentive Payments System (MIPS) and, ultimately, the Advanced Alternative Payment Model (AAPM).

Thomas James, III, M.D.

Under these rules, providers have to take on more financial risk, including bundled payments in a system reminiscent of capitated payments from the 1990s. The capitated model from the 1990s resulted in a system negatively perceived in part for its “gatekeepers” and resulting decreased access to services.

Providers have an opportunity with this new system to do the right thing by coordinating care so that patients get the services they need and don’t fall through the cracks—to avoid repeating history from decades ago.

Care Coordination Goals

Delivering “coordinated care” involves having mechanisms in place to ensure that information about the patient diagnosis and treatment is shared with the patient and all participants concerned with the patient’s care. This enables the patient to receive necessary health care in a timely manner. The primary goals of care coordination are clear:

  • Patient Centeredness: Improve health outcomes by empowering patient participation in determining case priorities to achieve greater engagement in diagnosis and treatment.
  • Health System Focus:  Enhance sharing of clinically actionable information among all care providers engaged in the care of an individual patient.
     

Patient preferences should be part of the decision-making process and “participants” include patient caregivers and the full range of providers across relevant health care settings (e.g., referring physicians, specialists, diagnostic centers, pharmacies, home care agencies, acute care hospitals, skilled nursing facilities and emergency departments).

Coordination of care is especially important as patient health issues increase in complexity and include multiple providers. Centers for Disease Control and Prevention (CDC) data indicate that there are 297 office visits per 100 patients and slightly more than half (53 percent) are primary care provider visits. This information indicates it is likely that a significant number of patients are seeing both primary care and specialty providers, highlighting the importance of coordinated patient care.

Care Coordination Management

Care coordination can be managed by a single person, usually a nurse or medical social worker. A care coordinator may be the employee of a physician group, a hospital or health care facility, a payer, or social service agency. Virtual care coordination, whereby physicians participating in the care of the individual patient use a common electronic medical record (EMR) to share information on diagnosis and treatment with other participating providers, is another option.

Studies indicate there is room for improvement in the coordination of care among multiple providers, and there are many tools to help providers accomplish this, such as:

  • Tracking systems for patient tests
  • Referrals and follow-up appointments
  • Automated reminders regarding scheduled care

Tracking systems can be a key component in care coordination as they reduce the chances of patient care falling through the cracks while also increasing patient satisfaction, according to study in the Joint Commission Journal on Quality and Patient Safety. Simply offering tools such as online tracking systems as part of electronic health records (EHRs) without guidance through an implementation process is often insufficient. Providing guidance tools and assessing the success of implementation using a rapid-cycle quality improvement activity may be effective in improving laboratory test preparation, tracking of laboratory tests and patient notification, according to a study published in the journal of the American Board of Family Medicine.

Another asset for care coordination management is performance benchmarking and standards that guide quality improvement. The National Quality Strategy identifies “promoting effective communication and coordination of care” as one of six priorities to target the triple aim. Accrediting organizations—such as AAAHC (Accreditation Association for Ambulatory Health Care)—have care coordination standards requiring documentation in the clinical record of consultations and referrals, as well as missed, after-hours and follow-up appointments. AAAHC Standards also require that transitions of care are proactively planned, coordinated and documented in the clinical record.

In the surgical/procedural setting, AAAHC Standards require organizations to have written guidelines for the transfer of care from one provider to another that includes information about the patient’s care, current condition, and any recent or anticipated changes. These Standards are comparable to those required by other accreditors/regulators.

To assist care coordination managers in developing processes, measuring performance and implementing quality improvement strategies to meet requirements, there also are several toolkits available including:

  • An upcoming AAAHC patient safety toolkit, Tracking Patient Tests and Referrals, summarizes the evidenced-based research on the topic and includes resources for providers in both the primary care and ambulatory surgical/procedural care settings. 
  • The Agency for Healthcare Research and Quality (AHRQ) PCMH Resource Center offers online resources to help clinicians, clinical teams and health care administrators measure care coordination and learn more about how to incorporate care coordination into routine primary care practice.
  • An American College of Physician (ACP) High Value Care Coordination (HVCC) Toolkit contains out-patient referral request templates and response checklists. ACP also has developed two care coordination agreements templates. One template is an agreement between the primary care practice and the hospital and the other is an agreement between the primary care physician and the specialist. These templates define the expectations and responsibilities for the providers involved in a referral relationship.

New regulation doesn’t mean having to repeat past problems; instead, this is a continued opportunity to put patients first, hear their input and help them navigate the different components of their care to ensure there are no gaps. Providers have a growing number of resources available to assist them in all aspects of care coordination and if they haven’t already, this is the time to use these resources to their fullest.

 

Thomas James, III, M.D. is corporate medical director for Medical Management and Quality for Highmark, Inc. In this role, Dr. James provides clinical oversight to Highmark’s quality and wellness departments. He is actively involved with organizations working to improve the quality of health care including the National Quality Forum and AAAH. Prior to joining Highmark, Inc., Dr. James served as senior medical director for such organizations as Baptist Health in Kentucky, AmeriHealth Caritas, Humana, Anthem, Traveler’s Health Network, Sentara and HealthAmerica. He has experience with commercial, Medicare and Medicaid health plans. Dr. James is board certified in internal medicine and pediatrics. He received his medical degree from the University of Kentucky and served his residencies at Temple University Hospital, Pennsylvania Hospital, and Children’s Hospital of Philadelphia.

 


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Should Physicians and HIT Leaders Worry about the Implications of the Walgreens/Microsoft Deal?

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As architect Daniel Burnham once said, “Make no little plans”; the leaders of the Walgreens/Microsoft alliance, like so many others, certainly are thinking big these days
architect Daniel Burnham

Nearly every day, it seems, new business combinations are announced that are threatening to alter the landscape of U.S. healthcare forever. CVS’s acquisition of Aetna, completed last November; the announcement a year ago now that the executives of Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. were launching a broad (if not well defined) initiative to improve consumer satisfaction and reduce costs for their employees; Cigna’s acquisition just last month of pharmacy benefit management (PBM) company Express Scripts; and Amazon’s acquisition last summer of online pharmacy company PillPack.

Every one of those business deals represents a disruptive move in U.S. healthcare, with unalike “species” of organizations combining with one another. And now, the retail drugstore giant  Walgreens Boots Alliance Inc. and Microsoft Corp. are coming together in yet another disruptive venture. As Managing Editor Rajiv Leventhal wrote in an article on Tuesday, the corporations “are joining forces on a major seven-year healthcare partnership that will aim to ‘deliver innovative platforms that enable next-generation health networks, integrated digital-physical experiences and care management solutions.’” As he wrote, “The companies announced today that they will combine the power of Microsoft Azure, Microsoft’s cloud and AI (artificial intelligence) platform, healthcare investments, and new retail solutions with WBA’s customer reach, volume of locations, and outpatient healthcare services to accomplish their goals: to make healthcare delivery more personal, affordable and accessible.”

As Leventhal noted in his report, “While innovation in healthcare has occurred in pockets, officials of the two companies believe that ‘there is both a need and an opportunity to fully integrate the system, ultimately making healthcare more convenient to people through data-driven insights.’” Further, he noted, “As part of the strategic partnership, the companies have committed to a multiyear research and development (R&D) investment to build healthcare solutions, improve health outcomes and lower the cost of care. This investment will include funding, subject-matter experts, technology and tools, officials noted in the announcement. The companies will also explore the potential to establish joint innovation centers in key markets. Additionally, this year, WBA will pilot up to 12 store-in-store ‘digital health corners” aimed at the merchandising and sale of select healthcare-related hardware and devices.

“This gap creates an opportunity for the pharmacist to help monitor the patients’ health and prompt the patient to receive preventative care in the retail clinic or through a virtual care visit. Using an enterprise health cloud, like Azure, you create a more connected ecosystem so that we can share that data with the patient’s additional providers, track outcomes, and intervene earlier when an issue arises,” Microsoft CEO Satya Nadella said in a statement Tuesday.

And, Leventhal wrote, “Notably, the companies will also work on building an ecosystem of participating organizations to better connect consumers, providers—including Walgreens and Boots pharmacists—so that major healthcare delivery network participation will provide the opportunity for people to seamlessly engage in WBA healthcare solutions and acute care providers all within a single platform.”

Speaking to the difference between retail pharmacies and traditional care providers, Forrester analyst Arielle Trzcinski said in a statement emailed to the press that “[R]etail pharmacies offer an opportunity to engage with the patient much more frequently than at an office visit, giving an example of how chronic care patients see their pharmacist frequently, while some figures indicate that the average diabetic patient sees his or her provider once every six months.”

The implications of all of this are, of course, huge. For one thing, if one were to ask the average patient/healthcare consumer with whom they interacted more, doubtless, the vast majority would cite their retail pharmacists, rather than their primary care physicians. What’s more, what happens if Walgreens is able to follow through, as CVS also intends to do, in creating minute clinics in retail pharmacy locations? The impact could be revolutionary.

Indeed, it’s no secret that many patients are dissatisfied with the cumbersome, challenging processes around accessing primary and specialty care in the U.S. healthcare system. Simply accessing a timely appointment often proves to be a major hassle; and encounters around needed follow-ups and around questions to doctors and nurses often turn out to be such a hassle that many patients simply give up, with the result of medication non-compliance and other issues.

So what will happen if Walgreens, like CVS, manages to achieve success with one or more elements of this initiative? Those could include enhanced continuum of care for patients, especially those with chronic diseases; improved communication among all care delivery stakeholders; and enhanced patient/consumer satisfaction.

A few stakeholder groups should be paying particular attention here, including practicing physicians and healthcare IT leaders. For practicing physicians, could anyone deny that this business initiative, along with the others mentioned above, should be disconcerting at the very least? Already, patients needing relatively immediate medical attention, are turning en masse to urgent care centers, as both health systems and health insurers are working to cut down on the volume of emergency department visits, which are tremendously expensive, and which burden the healthcare delivery system in ways that are not sustainable. But now, with both Walgreens/Microsoft and CVS/Aetna, is anyone denying that the era of pretty-close-to-immediate medical attention is on the horizon?

The reality is that, while most patients like their primary care physicians and are satisfied with their care overall, strong majorities, in polls, continue to complain about poor service, bad communication, and delays accessing care and accessing follow-up support. What happens when most decent-sized Walgreens and CVS drugstores are staffed up with PCPs or advanced practice nurses, to handle the colds, coughs, flus, strep throats, and minor skin and digestive issues that could easily be handled by such service offerings?

One of the core policy issues here is that the U.S. healthcare payment system remains largely predicated on primary care physicians physically touching patients in order to get paid. Yes, telehealth services are expanding daily; but in most situations, patients still need to go through the awkward, inconvenient, sometimes even-arduous process of scheduling an appointment, using some form of transportation to get to that appointment, and waiting in a crowded physician office, in order to access primary care.  But in 2019, when GrubHub can deliver one’s banh mi Vietnamese sandwich to one’s home, and Amazon is sending everything from books to clothing to furniture to God-knows what, directly to people’s doors, how much longer will healthcare consumers continue to be patient with the glacial pace of care delivery change in U.S. healthcare?

Meanwhile, healthcare IT leaders will inevitably find themselves somewhat behind a proverbial eight-ball on all this, caught between the intensifying demands on the part of practicing physicians, especially primary care physicians, for full clinical IT support for their practices, and constant business changes, including merger-and-acquisition activity in their own organizations that is continuously scrambling their long-term planning.

So we’re seeing both business and technology changing, and changing quickly, with numerous examples already of industry-disruptive business combinations, and technology advancing to the point where previously unimagined breakthroughs are now imaginable. For example, Walgreens and Microsoft noted that, “Through this agreement, Microsoft becomes WBA’s strategic cloud provider, and WBA plans to migrate the majority of the company’s IT infrastructure onto Microsoft Azure,” as corporate officials put it. And “Microsoft also plans to roll out Microsoft 365 to more than 380,000 Walgreens employees and stores globally.” And, to make things just that more intriguing, the announcement quoted Stefano Pessina, executive vice chairman and CEO of the Walgreens corporation, as stating that “WBA will work with Microsoft to harness the information that exists between payors and healthcare providers to leverage, in the interest of patients and with their consent, our extraordinary network of accessible and convenient locations to deliver new innovations, greater value and better health outcomes in health care systems across the world.”

As renowned Chicago architect Daniel Burnham so famously said, “Make no little plans; they have no magic to stir men's blood and probably themselves will not be realized.” There’s no question that the senior leaders of all of these business alliances, combinations, and initiatives are going to be “no little plans.” It would behoove clinicians, clinician leaders, healthcare IT leaders, and all c-suite leaders in provider organizations to think Burnham-sized thoughts; these businesspeople from outside traditional healthcare delivery are certainly doing so.

 

 

 

 

 

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Blue Cross NC, Five Health Systems Announce Major Shift to Value-Based Care

January 16, 2019
by Heather Landi, Associate Editor
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The insurer aims to have half of its 3.89M customers covered by VBC contracts by next year; all customers in VBC arrangements in five years
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Blue Cross and Blue Shield of North Carolina (Blue Cross NC), one of the state’s largest insurers, and five of the state’s major health systems in North Carolina have announced a new value-based care program that encompasses hundreds of thousands of healthcare customers throughout the state.

The five health systems—Cone Health, Duke University Health System, UNC Health Care, Wake Forest Baptist Health and WakeMed Health & Hospitals—and their accountable care organizations (ACOs) have committed to participating in Blue Premier, a new value-based model of care in which Blue Cross NC and the health systems will be jointly responsible for better health outcomes, exceptional patient experience and lower costs, according to a Blue Cross NC press release.

“With agreements from five of the state’s major health systems and their ACOs, Blue Premier is one of the most rapid and comprehensive shifts to value-based payments in the nation,” Blue Cross NC officials stated. Patrick Conway, M.D., serves as president and CEO of the Durham-based health insurer and previously served as the Chief Medical Officer, Deputy Administrator, and Director of the Center for Medicare and Medicaid Innovation (CMMI), a division of the Centers for Medicare and Medicaid Services (CMS).

Within five years, Blue Cross NC has committed to having all 3.89 million customers covered under Blue Premier’s value-based care contracts. By early 2020, fifty percent or more of all Blue Cross NC members will have a provider who is jointly responsible for the quality and total cost of their care, the health insurer stated.

“As a practicing physician, I have experienced first-hand the challenges plaguing our health care system,” Conway said in a statement. “Historically, our health care system pays for services that may or may not improve a patient’s health, and our customers simply cannot afford this approach. Moving forward, insurers, doctors and hospitals must work together, and hold each other accountable for improving care and reducing costs. We applaud the leadership and commitment of these five leaders in health care to help transform health care delivery in North Carolina.”

During the HLTH Conference, held at the Aria Resort in Las Vegas last May, Conway discussed the payer-provided landscape in North Carolina and alluded to opportunities accelerate the move to value-based care and payment models, according to reporting from Editor-in-Chief Mark Hagland. “We’re looking at a new model, where patient care organizations can partner more fully with Blue Cross North Carolina,” Conway said, per Hagland’s report. And Conway continued, “We’re saying, you can take this alternative pathway with us. And we’ll jointly be accountable for the total quality and cost of care. And we want you to go into two-sided risk. And we’re wondering, should we turn off all prior authorization? And documentation other than for risk coding and STARS measures, we won’t worry about how you document. And for people in the audience, those kinds of partnerships are very exciting, because you’ve now got a provider and payer that are no longer locked into rigid rules, but where you can innovate on quality and customer experience.”

According to the insurer, Blue Premier ties payments to doctors and hospitals over time to the value of services that improve patient health. This means that total payments to the health systems under Blue Premier will be based on the health systems’ ability to manage the total cost of care and their overall performance, measured by industry quality standards. Through a “shared risk” financial model, the health systems will share in cost savings if they meet industry-standard goals to improve the health of patients – and share in the losses if they fall short. “The unprecedented commitment from these five large health systems makes Blue Premier one of the most advanced and comprehensive value-based care programs in North Carolina and the nation,” Blue Cross NC officials stated.

“This unprecedented step by Blue Cross NC and many of the state’s leading health care organizations will make a big difference in advancing high-quality, innovative care in North Carolina,” Mark McClellan, M.D., Ph.D., director of the Duke-Margolis Center for Health Policy said in a statement in the press release. “At Duke-Margolis, we remain committed to supporting state government and private-sector initiatives to reform payment and improve care – providing needed examples for the nation.” 

In a statement, Donald Gintzig, president and CEO, WakeMed Health & Hospitals, said, “This collaboration represents an important step forward in our efforts to provide patients in our area and across the state with high quality, coordinated services for the best value. Our health systems are bringing together valuable resources in a more integrated way that will ultimately lead to better health and more affordable health care.”

The news of the value-based care collaboration comes a month after the health insurer announced a partnership with Aledade, a Bethesda, Md.-based company focused on physician-led ACO development, to launch a value-based care initiative to support primary care physicians across the state. Through the initiative, the two companies will support physician-led ACOs tailored specifically for primary care physicians and the communities they serve. Through these ACO arrangements, Blue Cross NC will collaborate with Aledade to provide physicians with technology and data analytics tools to better manage patient care and costs. After joining these ACOs, practices gain a more comprehensive view of their patients’ total cost of care, gaps in quality of care, and experiences throughout the entire health care system, the companies said.

 

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Kaiser Health News Report: Clinics Treating Immigrants Find Themselves in Limbo Around Notification

January 15, 2019
by Mark Hagland, Editor-in-Chief
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The clinicians and leaders of U.S. patient care organizations continue to find themselves in a policy limbo around the information they share with federal and state authorities around their care for undocumented immigrants

The clinicians and leaders of U.S. patient care organizations continue to find themselves in a kind of policy limbo around the data and information they share with federal and state authorities around their medical care for undocumented immigrants, a new report in Kaiser Health News finds.

As Ana B. Ibarra wrote in a new report in Tuesday’s Kaiser Health News, “While the Trump administration decides whether to adopt a controversial policy that could jeopardize the legal status of immigrants who use public programs such as Medicaid, doctors and clinics are torn between informing patients about the potential risks and unnecessarily scaring them into dropping their coverage or avoiding care.” In her story, Ibarra quoted Tara McCollum Plese, chief external affairs officer at the Arizona Alliance for Community Health Centers, which represents 176 clinics, as saying, “We are walking a fine line. Until there is confirmation this indeed is going to be the policy, we don’t want to add to the angst and the concern.” However, if immigrants do come to a clinic wondering whether using Medicaid can affect their legal status, trained staff members will answer their questions, Plese told Ibarra.

Patient care organization leaders are working to figure out how to handle the situation, with some providers deciding to prepare their patients for the potential enactment of the proposal. At Asian Health Services, a clinic group that serves Alameda County, Calif., staff members pass out fact sheets about the proposed changes, provide updates via their patient newsletter and host workshops where patients can speak to legal experts in several Asian languages. “We can’t just sit back and watch,” CEO Sherry Hirota told Ibarra. “We allocate resources to this because that’s part of our job as a community health center — to be there not only when they’re covered, but to be there always,” even when that coverage is in jeopardy, she said.

The proposed “public charge” rule, which is awaiting final action by the U.S. Department of Homeland Security, would allow the federal government to consider immigrants’ use of an expanded list of public benefit programs including Medicaid, CalFresh and Section 8 housing as a reason to deny lawful permanent residency — also known as green card status. Medicaid is the state-federal health insurance program for low-income people. Currently, people are considered public charges if they rely on cash assistance (Temporary Assistance for Needy Families or Supplemental Security Income) or need federal help paying for long-term care.

 

 

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