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Healthcare Leaders React to CMS’ 2019 QPP Proposed Rule and E&M Coding Changes

July 18, 2018
by Heather Landi
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Many health IT industry groups, policy experts and other industry stakeholders continue to delve into the 1,473-page proposed rule released by the Centers for Medicare and Medicaid Services (CMS) on July 12 that provides updates to the Physician Fee Schedule and Quality Payment Program (QPP), which encapsulates the Medicare Incentive-based Payment Program (MIPS) and Advanced Payment Models.

When CMS announced the proposed rule last week for CY 2019, the agency said the changes will “fundamentally improve the nation’s healthcare system and help restore the doctor-patient relationship by empowering clinicians to use their electronic health records (EHRs) to document clinically meaningful information.”

These changes, according to CMS, would increase the amount of time that doctors and other clinicians can spend with their patients by reducing the burden of paperwork that clinicians face when billing Medicare. The proposals would also modernize Medicare payment policies to promote access to virtual care, CMS said in a July 12 announcement.  

Some key changes in the proposed rule include:

  • Adjustments to the MIPS program such as the removal of 34 low-value measures, a proposal to add 10 new measures, an increase of the cost component calculation weight from 10 to 15 percent, and the doubling of the performance threshold to 30 points;
  • Major reforms to Evaluation and Management (E/M) payments including single blended payment rates for both new and established patients for office/outpatient E/M level 2 through 5 visits and a series of add-on codes to reflect resources involved in providing complex primary care and non-procedural services;
  • Streamlining documentation requirements including eliminating the requirement to justify the medical necessity of a home visit in lieu of an office visit;
  • Reduction of quality measures from 31 to 24 in the Medicare Shared Savings Program (MSSP) and additional focus on the measure set on more outcome-based measures, including patient experience of care; and
  • Expansions to telehealth and virtual care reimbursement, including payment for virtual check-ins and evaluation of patient-submitted photos or recorded video and Medicare-covered telehealth services for prolonged preventative care

Healthcare Informatics Contributing Editor David Raths interviewed telehealth advocates about expansions to telehealth and virtual care reimbursement, and his article on the telehealth provisions of the rule can be read here.

In a podcast interview with Healthcare Informatics Managing Editor Rajiv Leventhal, Jeff Smith, vice president of public policy at AMIA (the Bethesda, Md.-based American Medical Informatics Association), shared his high-level takeaways and noted that the proposed rule signals CMS’s efforts to align the MIPS Promoting Interoperability (formerly called Advancing Care Information) performance category for clinicians with the proposed new Promoting Interoperability program for hospitals, which he anticipated would be welcome news to the physician community.

According to Administration officials, the proposed changes in the PFS and QPP will streamline documentation requirements to focus on patient care and modernize payment policies, and, overall, these changes seem to be welcome news to health IT and healthcare stakeholders.

The Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME) expressed support for CMS’s proposed rule. In a statement, Liz Johnson, R.N., CIO, acute hospitals and applied clinical informatics at Tenet Healthcare, who serves as the CHIME Public Policy Steering Committee Chair, said, “CMS is certainly heeding calls from the provider community to reduce administrative burdens. We support efforts to reduce these burdens on clinicians, whether they were created by paper or electronic processes, and to give physicians more time to care for patients. We also applaud the discussion of expanded telehealth reimbursement, something that has been a priority for CIOs, and we commend efforts to incent use of PDMPs (prescription drug monitoring programs) as we seek ways to leverage technology in our ongoing efforts to combat the nation’s opioid crisis.”

Gerald Maccioli, M.D., chief quality officer at Envision Healthcare, a Nashville-based physician staffing company, said in a statement that CMS is moving in the right direction by focusing on measures that will enhance the delivery of patient-centered care.The streamlined measures signify that CMS is listening to clinicians and acknowledging the need to lessen their administrative burden by focusing on the measures that will make the most tangible impact on care delivery and patient outcomes. Clinicians are the voice from the front lines of patient care so it’s imperative that we involve them in quality improvement initiatives,” he said.

Don Crane, president of America’s Physician Groups (APG), said APG staff are still reviewing the proposed rules but are “cautiously optimistic that CMS has taken real action here to advance the value movement.” “Importantly, these rules include a re-affirmation of the recently announced Medicare Advantage Qualifying Payment Arrangement Incentive (MAQI) Demonstration,” he stated.

However, some industry groups voiced concerns that the CMS proposals, specifically in its proposed rule for the third year of the QPP, will undermine efforts to move Medicare provider payment to value.

The Alexandra, Va.-based trade group AMGA (formerly the American Medical Group Association) said in a statement, “In its proposed rule for the third year of the Quality Payment Program, CMS again is proposing policies that do not further the program’s intent and potential. Based on initial review of the proposal, AMGA is particularly disappointed that CMS kept a high low-volume threshold that will continue to reduce the payment adjustments for providers that are invested in value-based care.”

The proposed rule maintains the low-volume threshold at $90,000 in Part B allowed charges or less than 200 Medicare patients. In year 1 of the QPP, CMS set clinicians’ low-volume threshold at $30,000 or less in Medicare Part B allowed charges or less than 100 Medicare patients and the agency increased the threshold in year 2. For the 2018 performance year, CMS estimated that about 60 percent of otherwise eligible clinicians were excluded from MIPS, although some clinicians are not subject to MIPS requirements due to participation in advanced APMs.

“When we think about MACRA (the Medicare Access and CHIP Reauthorization Act), when it was first passed, as a statute, it essentially represented Congress’ view about moving Medicare to value, and they essentially did that by putting payments at risk. If you look at the statute in 2017, your reimbursements were at risk plus-or-minus 4 percent, depending on how you did, and it goes all the way up to plus-or-minus 9 percent by 2023,” Chet Speed, vice president of public policy, AMGA, says.

“CMS has excluded so many providers from MIPS that there are now a couple of effects: one is, the promised rewards for those who did well under MACRA are no longer occurring, and even CMS acknowledges that,” Speed says.

As authorized by MACRA, providers have the opportunity to earn an adjustment of up to 7 percent on their Medicare Part B payments in 2021 based on their 2019 performance. However, as indicated in this latest proposed rule, CMS estimates the overall payment adjustment will be 2 percent, according to AMGA.

“When you think about incentives, generally, you need both a carrot and a stick to make change. With Medicare moving to a value-based system, you need a carrot, in the form of higher payments for doing well, and you need a stick, if you don’t do well, you have less reimbursements. These exclusions get away from that. So, in essence, MIPS has gone from a significant value-based transition tool to a regulatory compliance exercise with little impact on cost or quality,” Speed says.

In fact, the House GOP Doctors Caucus, a group of 16 Republican members of Congress who are also medical providers, sent a letter to Administrator Verma on July 3 urging CMS to lower MIPS’s exclusion thresholds, so more clinicians can participate in the program. In 2020, CMS is projecting a 1.5 percent payment adjustment for high-performers, compared to a potential 5 percent adjustment level authorized under the law, the lawmakers wrote in the letter.

“This trend of continued actual adjustments that are significantly less than authorized fails to incentivize meaningful participation in MIPS,” the lawmakers wrote. “If MIPS does not provide meaningful incentive and opportunity for providers to be rewarded for the quality and cost of care provided, we are concerned MIPS will not fulfill its potential to improve quality and control cost.”

MIPS Changes and Continued Pain Points for Providers

Regarding year three of MIPS, CMS is proposing to:

  • Remove MIPS process-based quality measures that clinicians have said are low-value or low-priority, in order to focus on meaningful measures that have a greater impact on health outcomes; and
  • Overhaul the MIPS “Promoting Interoperability” (formerly called Advancing Care Information) performance category to support greater EHR interoperability and patient access to their health information, as well as to align this performance category for clinicians with the proposed new Promoting Interoperability Program for hospitals.
  • For the Promoting Interoperability performance category, CMS is requiring that MIPS-eligible clinicians to use 2015 Edition certified EHR technology beginning with the 2019 MIPS performance period.

AMIA’s Smith says he anticipates stakeholder pushback on the requirement to use 2015 CEHRT technology and the 365-day quality reporting period.

And, in fact, the Colorado-based Medical Group Management Association (MGMA), which also has offices in Washington, D.C., issued a statement voicing disappointment that CMS plans to continue its “burdensome” 365-day MIPS quality reporting policy rather than 90 consecutive days. Rather than continue with a high, low-volume threshold that exempts tens of thousands of physicians, CMS should focus on reducing the reporting burden in the MIPS program, and, therefore, “make it more accessible and less burdensome to report,” Anders Gilberg, senior vice president, government affairs, MGMA, says.

In a MGMA statement issued last week, Gilberg said, “Reducing the reporting burden would allow more physicians to participate in MIPS and focus the program on rewarding quality care rather than quality reporting. Requiring medical groups to submit excessive amounts of data to the government has little impact on the quality of care delivered to Medicare beneficiaries.”

In a letter to CMS Administrator Seema Verma back in April, MGMA, along with the American Medical Association (AMA) and the American Academy of Family Physicians (AAFP), urged CMS to shorten the data reporting period for the “Quality” component of MIPS from 365 to 90 days, saying the reduction was necessary “due to the lack of timely and direct notification by CMS on whether a physician is considered MIPS eligible, as well as a severe delay by CMS in updating the Quality Payment Program interactive website with 2018 information.”

“The final rule for these programs is often not out until early November, so there’s very little turnaround time,” Gilberg says. “You need to decide things like, what kind of quality measures report are we going to report and are we going to report through a registry or some another means to report? We think it would be more administratively simple to have the quality reporting period be at 90 days and that would allow the government to get the data they need on quality, but it reduces the burden for physician practices and gives them some flexibility throughout the year to submit the data that they need to.”

Gilberg said in the MGMA statement that the CMS rule proposes requiring physicians to deploy “costly EHR upgrades for 2019 and takes further steps toward implementing burdensome appropriate use criteria.”

“At first glance, the rule doesn’t meet MGMA’s definition of administrative simplification,” Gilberg said in the statement.

E&M Documentation Reforms

In the announcement about the proposed rule, officials from CMS and the Office of the National Coordinator for Health Information Technology (ONC) said they have heard from stakeholders that CMS’ extensive documentation requirements for Evaluation and Management (E&M) codes have resulted in unintended consequences.

To meet these documentation requirements, providers have to create medical records that are a collection of predefined templates and boilerplate text for billing purposes, in many cases reflecting very little about the patients’ actual medical care or story, according to federal officials.

Christopher Longhurst, M.D., CIO at UC San Diego Health, says, “The evidence is clear that extensive billing requirements contributes substantially to physician frustration with the EHR. I applaud administrator Seema Verma and the CMS proposal to ‘put patients ahead of paperwork’ and both patients and providers will benefit if these E&M changes come to pass.”

Gilberg notes that the proposed E&M documentation changes, specifically the proposal of a single blended payment rates for both new and established patients for office/outpatient E/M level 2 through 5 visits, was a “bombshell.” “We expected CMS to address E&M documentation guidelines, but we didn’t think they would eliminate four levels of billing,” he says. He also notes that whether these documentation changes are beneficial to physicians will be largely dependent on medical specialty.

AMGA’s Speed says, “At first blush, I can only assume that most physicians will welcome eliminating these documentation guidelines. It’s not clear what the blended rate would mean to our members. Some of our groups are taking care of very sick, chronically ill patients, so how does the blended rate work for them? We’re still reviewing that.”

Gilberg agrees that a single blended payment rate raises issues with regards to physicians who treat complex patients. “Medicare patients seeing certain types of specialists often have multiple chronic conditions. So, you have a specialist who is billing a lot of level 5 or level 4 visits, who sees patients with three or four chronic conditions and has to spend a lot of time with that patient, and now you’re reducing the payment to the same payment a physician who did a very brief level 2 visit would receive; I think there is going to be some concern expressed about that. There are some issues that are going to have to be addressed, such as whether that creates a disincentive for physicians to see these highly complex patients,” he says.

He adds, “It remains to be seen whether it’s received by the physician community in the same way that it’s being conveyed by the Administration. The Administration says they are simplifying the coding requirements and therefore, the payment will pay for itself, because it’ll be so much easier, but we’re not sure yet.”

These concerns about potential lower reimbursement were addressed during a CMS media call with reporters July 18, featuring a panel discussion with Verma and other CMS and ONC leaders. During that call, Anand Shah, M.D., CMMI Chief Medical Officer, said, “This [the lowered reimbursement] is a question we are exquisitely mindful of. In cardiology and oncology, for instance, providers spend a lot of time billing for level 4 and 5 visits. But we estimate that the decrease in reimbursement will only be in the 1-2 percent range.”

National Coordinator for Health IT Don Rucker, M.D., also said, “And that will be offset because we think the gains in time [saved] by documenting less will be very large. You will save time in almost every single note.”

AMIA’s Smith also notes that time will tell if changes to E&M coding and billing and documentation requirements will improve the usability of EHRs, as many contend. “It will take some time for the policies to matriculate into the technology and then for the technology to be in a state where you can say definitively that fixing E&M coding definitely helped EHRs be more usable and effective,” he says.

 


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When It Comes to The Big Debate on ACOs, What Is “Big Enough” Savings?

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The back-and-forth interaction between CMS Administrator Seema Verma and the ACO community is unfolding at a key inflection point in the evolution of the MSSP program

Intense debates on every subject are constantly swirling in the healthcare policy sphere; that has always been the case. But one debate that is both impactful and being closely watched is the intensifying argument between the Centers for Medicare and Medicaid Services, particularly CMS Administrator Seema Verma, and some leader organizations in the accountable care organization (ACO) area.

At its base, the proposal on the part of CMS, as outlined in a proposed rule published in August, to push more ACOs into two-sided risk, is being pushed back against by many ACO leaders, particularly by their nationwide association, NAACOS (the Washington, D.C.-based National Association of ACOs). As Managing Editor Rajiv Leventhal noted in his report Dec. 5, CMS’s “core aim” is “to push these organizations into two-sided risk models—so that Medicare isn’t on the hook when ACOs overspend past their financial benchmarks—suggested to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years.”

As Leventhal noted, “One option, per CMS’ proposal, would be the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk. The second option would be the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program. But where CMS, in its proposals, truly clamped down was through two core recommendations that stakeholders took issue with: shortening the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years; and cutting potential shared savings in half, from 50 percent to 25 percent for one-sided risk ACOs. These proposals, if finalized, will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny.”

Clifton Gaus, Sc.D., NAACOS’s president and CEO, recently gave Leventhal an interview, and in that interview, he confirmed his association’s stance that the reduction of shared savings and the shortened time allowed in one-sided models are two of the biggest problems the group has with the proposal. Indeed, Gaus said in that interview that the reduction in potential shared savings “would be very devastating to the growth of new ACOs.”

In fact, Gaus said, in polling their members, NAACOS’s leaders asked them whether they would in theory join a federal ACO program knowing that, at least at first, they would be limited to 25 percent of shared savings at most; and, in fact, “the near universal response was no, they wouldn’t have joined the program,” Gaus said, adding that “The potential of 25 percent savings just isn’t enough to offset our investment costs of starting and operating the ACOs,” noting that ACOs have to obviously put up money to get going, and sometimes it’s very hard for medical group practice-dominant ACOs to buy IT systems, not to mention the whole clinical transformational aspect of ACOs where they are typically hiring nurse coordinators, and in some cases opening 24/7 call centers. “There is a real start-up and operational cost that’s involved, and [getting] 25 percent of the shared savings doesn’t return enough income to offset those,” he said.

Meanwhile, this morning, NAACOS issued a new press release focused on the value that the MSSP program has created for CMS. “In the latest data proving the financial benefits of accountable care organizations (ACOs), Medicare’s largest value-based care initiative – the Medicare Shared Savings Program – saved $859 million in 2016, an independent analysis published today shows,” the press release began. “Since 2013, the first full year of the program, ACOs have saved Medicare $2.66 billion, well above the $1.6 billion calculated by the Centers for Medicare and Medicaid Services (CMS).” What’s more, the press release reported, “After accounting for bonuses paid to ACOs for hitting spending and quality targets, the program, which accounts for 561 ACOs and 10.5 million patients nationwide, netted more than $660 million to the Medicare Trust Fund between 2013 and 2016, contrasting the net loss of $384 million CMS estimates.”

And the press release quoted NAACOS’s Gaus as stating that “These results are the latest data point in a growing body of evidence unequivocally proving ACOs’ value. ACOs are saving American taxpayers hundreds of millions of dollars at a time when it’s most needed.” Indeed,  he added, “Given the natural lag time in collecting and analyzing data and the well-established trend that ACOs need a few years to start demonstrating results, we are only seeing the beginning of the nation’s return on investment in accountable care. This data doesn’t even mention the quality benefits ACOs have generated, which have also been substantial.”

Further, the press release noted, “A sizable amount of recent data show ACOs are saving money: 472 Shared Savings ACOs generated gross savings of $1.1 billion and netted $314 million in savings to the Medicare Trust Fund last year; CMS’s August 17 proposed rule estimates the overall impact of ACOs, including ‘spillover effects’ on Medicare spending outside of the ACO program, lowered spending by $1.8–$4.2 billion in 2016 alone.”

So now we reach the rubber-meets-the-road place. Here’s the fundamental question: Do Seema Verma and her fellow CMS and HHS (Health and Human Services) senior officials truly understand the complexities involved in what they’re asking of provider leaders? Verma and her fellow federal healthcare officials are facing a kind of Scylla and Charybdis situation right now. On the one hand, as everyone knows, the Medicare actuaries have predicted that total U.S. healthcare spending will explode from $3.1 trillion annually (in 2014) to $5.4 trillion annually (by 2024), in the next several years, amounting to a 70-percent increase in less than a decade, and bringing the percentage of GDP spent on healthcare in this country from 17.4 percent in 2013 to 19.6 percent in 2024.

On the other hand, as Clifton Gaus and the NAACOS folks have pointed out, based on surveying their membership, patient care leaders are going to recoil at the over-intensification of change mandates coming out of CMS. That feeling is quite widespread. As one ACO CEO told me just two weeks ago, Seema Verma is deluded if she thinks that ramping up the downside-risk requirements in the Medicare Shared Savings Program is going to inspire more patient care leaders to join the MSSP program or renew their participation in it. And, as this morning’s press release notes, ACO community leaders are documenting real progress in capturing savings.

The million-dollar (or maybe, $1.1 trillion-dollar?) question is, is the broad level of savings that ACOs are netting for CMS, progress enough? Indeed, what is “enough”? And what is “fast enough”? Because Administrator Verma and her fellow senior federal healthcare officials seriously risk cratering the MSSP program, the core federal ACO program, if they push too hard on the downside-risk issue. On the other hand, if they don’t push hard enough, the progress made so far could simply be dwarfed, in the broader scheme of things, by the current acceleration of overall U.S. healthcare spending inflation.

So right now really does feel like an inflection point—but one without an obvious resolution. Only time—and the interactions of federal healthcare officials and providers—will tell.

 

 

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At UPMC, Turbo-Charging Quality Improvement Efforts through Data Analytics

December 11, 2018
by Mark Hagland, Editor-in-Chief
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At UPMC, Dr. Oscar Marroquin is leading a team of data analysts whose work is facilitating intensive efforts around readmissions

At a time when the leaders of patient care organizations are facing intensifying pressure to shift away from a dependence on volume-based payment and to plunge into value-based care delivery, some U.S. hospitals, medical groups, and health systems are helping to lead the way into a future of continuous clinical improvement and of clinical transformation. That topic—of organized continuous quality improvement—was the subject of the fourth-quarter 2018 Healthcare Informatics cover story. Numerous leaders of pioneering organizations were interviewed for their insights into the health system change focused-quality improvement movement that has been emerging across the U.S. healthcare system.

Among the leaders interviewed for that cover story was Oscar Marroquin, M.D., a practicing cardiologist and epidemiologist, who is helping to lead a team of clinical data experts at the vast, 40-hospital UPMC health system in Pittsburgh. Dr. Marroquin and his colleagues have been busy harnessing the power of creating and nurturing purpose-specific teams focused intensively on the management of data to power performance improvement, particularly in the clinical area. Marroquin’s team, of about 25 data specialists, was first created five years ago. Of those, half are IT- and infrastructure-focused, and, says Dr. Marroquin, “The rest are a team of folks dedicated to data consumption issues. So we have clinical analysts, data visualization specialists, and a team of data scientists who are applying the right tools and methods, spanning from traditional analytical techniques to advanced computational deep learning and everything in between. Our task is to use the clinical data, and derive insights”—and all 12 clinically focused data specialists report to him.

And that work—“allowing people to ask questions to generate opportunities”—has paid off handsomely. Among the advances has been the creation of a data model that predicts the chances of patients who are being discharged, being readmitted. The model, based on the retrospective analysis of one million discharges, is also helping case managers to more effectively prepare patients for discharge, specifically by ensuring that patients being discharged are promptly scheduled for follow-up visits with their primary care physicians. “If those patients are seen within 30 days of discharge,” he notes, “there’s a 50-percent reduction in their 30-day rate of readmission.” The program is now active in six UPMC hospitals.


Oscar Marroquin, M.D.

Below are excerpts from the interview for that cover story that Healthcare Informatics Editor-in-Chief Mark Hagland conducted with Dr. Marroquin this summer.

From your perspective, what does it really mean to be data-driven, in the pursuit of continuous quality improvement and clinical transformation?

From my perspective, I’m very passionate in that I feel that you really can’t do any of the things that doing in terms of moving towards value, without having a robust data infrastructure, a robust strategy on how to use data and analyze it, and without then deriving evidence for how you’re going to transform your organization. There are a lot of buzzwords involved in all of this, but the only way to get from a buzzword to a true action of transformation, is if it’s data-driven.

I’m a cardiologist by training and an epidemiologist; I still practice. Over the past five or so years, I’ve been asked to oversee how we’ll derive insights from clinical data in our system; in other words, this work is around anything related to big-data analytics, with those analytics being used to help our clinicians. In order to do that, we’ve had to do many different things, including more intelligently aggregating our data, and focusing on specific analytical purposes. They’ve been structured as databases for transactional systems, but not with the intent of improvement.

So we’ve spent a lot of time creating a purpose-built environment for analytics. That’s involved a lot of technical work, to create tables, what we call our consumable layers, for analytical purposes. And we’ve created a team whose only job is to do analytics. We’ve had folks in the past managing back-end databases, who have generated reports, but that doesn’t lead to a sustainable way of using data. And so we have a team that is dedicated to maintaining the warehouse and consuming the data.

With regard to the team of 25 data analysts, do all of them report to you?

The 12 who do data consumption report directly to me; the others have a dotted-line report to me. They sit on our infrastructure team within our IT Information Services Division. Both teams are part of the Clinical Analytics Team. Data analytics—Health Services Division. Integrated team. Two sides of the same coin.

When did these teams come together?

There have been different phases. The analytics program development started in 2012, and we learned a lot of lessons. A lot of the work early on had to be dedicated to technical issues—identifying data sources, etc. That was a pretty labor-intensive process. We really got enough aggregated data to use it consistently in 2015, so from 2015 on, we’ve had this structure of teams dedicated to doing this as I’ve described.

Can you share a few examples of key advances that your team has made so far?

When asked what our team does, I tell folks we do work at the higher level in three different buckets. The first bucket is the entry point for the majority of projects. Not everybody in the system necessarily knows which questions to ask.

We allow people to ask questions to generate opportunities. Off of that, two things will happen. One, hypotheses can be generated, and so we can do hypothesis testing, we can do comparative effectiveness studies, we can formal testing of hypotheses. Also, when insights get generated, one can say, oh boy, there’s a lot of heterogeneity in this population, why is one group more at risk? So we can identify who is at high risk of a condition, and who within the high-risk category is at high risk of developing specific conditions? And the third level or bucket, we apply machine learning and AI tools to develop models that allow us to do a variety of things, from more precise phenotyping of our populations; we can build predictive models to identify patients at various levels of risk. And we also use these models to do unsupervised learning, where we can start to generate hypotheses. So most people in this space love to talk about the latter part, the predictive modeling, and we have done a fair amount of work there, with things like identifying patients at highest risk of rehospitalization after 7 or 30 days of discharge, and we’re using that in our hospitals to guide clinicians. There are resources everywhere.

So we developed a model derived out of retrospective analysis of one million discharges, and we’ve prospectively verified that the model allows us to identify patients at the highest risk of readmission, so our case managers can help us identify plans to help those patients transition from hospitalization to post-acute care in a more effective way. And we see that if they’re seen within 30 days of discharge, there’s a 50-percent reduction in their 30-day hospitalization if they get in to see a clinician. So we make sure that the patient has an appointment made and is ready to see their doctor once they’re discharged, to address any issues.

When was that program put into place?

We spent a lot of last year validating the data. And then this year, we started rolling this out to our hospitals in a phased approach, so throughout 2018, we’ve been deploying this to our hospitals, and we’ve trained and educated different hospitals to use the model, and we’re actively following patients to measure the impact of the tool. And as an epidemiologist, I’m always cautious about declaring victory too soon. We’re seeing good trends, our smaller hospitals are seeing decreases in patients coming back early.

So you don’t have any metrics to share yet?

We have three hospitals, smaller ones we started the program with first, that different units, have shown that this program has had an impact. The numbers are still small enough that I have reservations about absolute certainty. But already, we’re using the program in 20 of our hospitals.

What would your advice be for CIOs, CMIOs, and other healthcare IT leaders, as they consider these kinds of initiatives?

If we all are serious about transforming the way we care for patients, we need to do it in a data-driven way. There has to be a philosophical belief and commitment to do that. Number two, as a result of the institutional commitment and philosophy, then there has to be a team that’s dedicated to this work. I don’t think this is achievable in an ad hoc way, when people just have time. And three, it’s not for the faint of heart; it takes time and effort, but if you have the philosophical belief and institutional commitment, it’s doable. If I say to myself, I don’t ever want to leave my house and get drenched because I wasn’t prepared for a storm, then I need to check the weather app before I leave my house. In medicine, we haven’t yet taken that approach, but the data and analytics are there to guide us in helping us to make decisions, and making it a part of the everyday decision-making process. And in the same way I use examples of rehospitalization prediction, we also do condition-specific predictive analytics, around patients with asthma, kidney disease, etc., so there’s a lot of work going on there. And the message I give clinicians is, there will be companies that say they don’t’ sell you the predictive models they’ve developed; but in our experience, the models have to be a part of an organic process that leads to the building of the models. Clinicians won’t feel alienated, disenfranchised, or threatened, if you bring them in and engage them from the beginning.

 


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EXCLUSIVE: NAACOS President Foresees “Shrinkage in Accountable Care Movement” Pending MSSP Final Rule

December 5, 2018
by Rajiv Leventhal, Managing Editor
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If CMS doesn’t scale back some of its proposed changes to the MSSP, the government’s largest value-based payment program will be significantly affected, says one ACO leader

When the Centers for Medicare & Medicaid Services (CMS) released its proposals to overhaul the federal Medicare Shared Savings Program (MSSP), it was expected that industry associations, along with the ACOs (accountable care organizations) themselves, would push back strongly.

After all, in the August proposed rule, CMS, which has the core aim to push these organizations into two-sided risk models—so that Medicare isn’t on the hook when ACOs overspend past their financial benchmarks—suggested to redesign the program’s participation options by removing the traditional three tracks in the MSSP model and replacing them with two tracks that eligible ACOs would enter into for an agreement period of no less than five years.

One option, per CMS’ proposal, would be the BASIC track, which would allow eligible ACOs to begin under a one-sided model and incrementally phase-in higher levels of risk. The second option would be the ENHANCED track, which is based on the program’s existing Track 3, providing additional tools and flexibility for ACOs that take on the highest level of risk and potential rewards. At the highest level, BASIC ACOs would qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.

But where CMS, in its proposals, truly clamped down was through two core recommendations that stakeholders took issue with: shortening the glide path for new ACOs to assume financial risk, reducing time in a one-sided risk model from the current six years to two years; and cutting potential shared savings in half, from 50 percent to 25 percent for one-sided risk ACOs. These proposals, if finalized, will certainly deter new entrants to the MSSP ACO program. So far, the proposed rule has been met with varying degrees of scrutiny.

One of the trade groups that has done much of the heavy lifting when it comes to pushing back on the government’s proposals, and offering evidence as to why ACOs need more time in one-sided risk models while being able to reap more of the shared savings, is NAACOS (the National Association of ACOs,) an association comprised of more than 360 ACOs across the U.S.

In a recent interview with Healthcare Informatics, Clif Gaus, president and CEO of NAACOS, confirmed that the reduction of shared savings and the shortened time allowed in one-sided models are two of the biggest problems the group has with the proposal. Specifically, Gaus says that the reduction in potential shared savings “would be very devastating to the growth of new ACOs.”

He explains that after polling NAACOS’ members, asking them if they would hypothetically apply to be an ACO knowing that at first, they would be limited to 25 percent of shared savings at most, “the near universal response was no, they wouldn’t have joined the program.” Gaus adds, “The potential of 25 percent savings just isn’t enough to offset our investment costs of starting and operating the ACOs,” noting that ACOs have to obviously put up money to get going, and sometimes it’s very hard for medical group practice-dominant ACOs to buy IT systems, not to mention the whole clinical transformational aspect of ACOs where they are typically hiring nurse coordinators, and in some cases opening 24/7 call centers.

“There is a real start-up and operational cost that’s involved, and [getting] 25 percent of the shared savings doesn’t return enough income to offset those,” he says.

Regarding the proposal to shorten the time in a one-sided risk model from the current six years to two years, Gaus points to CMS’ own data which shows that more experience in a federal ACO model drives more savings, but typically the first few years are not profitable for the ACO.

“We have many examples where an ACO has been in the program and was able to turn the corner by the fifth or sixth year,” he says. “Medicare has to have a long-term view of this. We are investing in a totally new redesign of the healthcare system, so give us time to learn how to transform that care into more efficient and higher-quality care. We are troubled by two years,” Gaus frankly admits. He believes that capping the time in a one-sided risk model at three to four years “is reasonable,” and is what many other associations have proposed.

Indeed, while NAACOS and other industry groups have made their arguments to CMS clear, the federal agency has so far taken a firm stance that upside risk-only ACOs have not been effective. A such, CMS seems to be fine with these ACOs leaving the MSSP— by far the largest federal ACO model, with 561 participants—if they are unwilling to take on more risk.

But Gaus believes that even though CMS did come out of the box with an “aggressive negative message” about one-sided ACOs, the agency has now moderated its views. To this end, a recent study from NAACOS and Dobson Davanzo & Associates, based on a different way of measuring financial success—by comparing actual costs over time in the ACO’s market as opposed to CMS’ method of calculating an initial risk-adjusted spending benchmark for each ACO based on its historical spending, without considering underlying market factors—revealed that MSSP ACOs generated gross savings of $1.84 billion for Medicare from 2013 to 2015, nearly double the $954 million estimated by CMS.

“The whole dialogue has changed,” says Gaus. “We have met with Seema and a number of her staff over the last two months, and the driving factor to this change in dialogue is that the 2017 data, from CMS’ benchmarks, turned the corner and showed that net-net the ACO program was saving Medicare money. You don’t see CMS coming out anymore arguing that the program is losing money,” he says.

What a Final Rule Might Look Like

Gaus acknowledges that a core challenge for CMS is being in the precarious position of pushing down too lightly in its regulations, which could result in the pace of change being too slow, or pushing down too hard, which could result in provider organizations fleeing value-based care initiatives.

“We know the government is wrestling with this issue, and so are we,” Gaus says. “In the crafting of our comments to CMS, as well as the comments from the AHA [American Hospital Association], AMA [American Medical Association], and others, we felt that the balance is the issue here, and there needs to be some movement toward the direction that CMS is pushing. We do respect their concerns, to a degree, but we just thought they were too aggressive in their speed to risk, or speed to remove an ACO from the program,” he says.

Gaus is hopeful that the final rule on the future of the MSSP—which he believes could come by the end of the year, but no later than the end of January—will reflect the industry’s concerns. “History says that this administration, like many others, does listen to input from stakeholders that the rule affects. I believe that they really do understand our positions,” he adds.

At the same time, NAACOS’ position is that the reduction in potential shared savings, as currently proposed, is a “total deal breaker,” and that there is no wiggle room for a number between 25 and 50 percent, Gaus asserts. He adds, “If they don’t go back to 50 percent, we will see a long-term significant shrinkage in the ACO movement and a significant emanation of accountable care.”

Importantly, Gaus also notes that ACO programs are voluntary in nature, a key consideration that he believes CMS often forgets. “Nobody has to be an ACO. [Providers] are making a bet of their capital, that they can invest that capital in cost containment, in care transformation, and [in return], they will get back in the shared savings more than they invested. It’s almost like buying stock—you made the investment and you hope the return is worth it,” he says.

Gaus says that he has told Verma in their many conversations that in many ways “we are at a crossroads, and we have to get the balance right, or we are going to see a denigration of what still remains the largest government value-based payment program.”


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