This document discusses principles for achieving an optimal future state of quality measurement to support performance-based clinician payment under MACRA. It outlines five principles: 1) Every Medicare enrollee needs a dedicated and well-organized primary care team; 2) Measurement must be specified appropriately for each different unit of accountability; 3) Measurement should support rapid improvement and clinical decision making; 4) A core set of measures will let all stakeholders make comparisons across programs; 5) Quality measure results should be easy for consumers and payers to get and use. The document emphasizes the importance of coordinated, team-based primary care and having measures tailored to different payment and delivery models.
The document discusses challenges that health systems face in managing costs under new bundled payment programs and global budgets. It provides an example from a pilot program in Maryland where costs have been capped and prices set in an effort to cut Medicare spending. The document outlines some of the key areas health systems need to address in both acute and post-acute care settings, such as optimizing patient mix and readmission rates, in order to successfully meet budget targets and quality measures. It provides details on specific strategies used by one Maryland health system to improve performance, such as reducing readmission rates from over 23% to less than 7%.
The Evolution of Physician Group from Patient Centric Medical HomesVitreosHealth
A Quest to Achieve Higher Quality and Bend the Employers Health Care Cost Curves. Medical Clinic of North Texas (MCNT) enjoys a stellar FY 2010 performance with Total Medical Cost trend for their managed population 2.4% better than market. We tried to understand the journey and the drivers behind the success of Medical Clinic of North Texas from its early years and its future direction.
The document provides information about the Academy of Managed Care Pharmacy (AMCP). It discusses:
1) AMCP was founded in 1989 and is a national professional society dedicated to promoting pharmaceutical care in managed healthcare environments.
2) AMCP's mission is to empower its over 5,700 members to improve healthcare for all individuals through the appropriate use of medications within managed care systems.
3) Key players in managed care include health plans, pharmacy benefit managers, the pharmaceutical industry, specialty pharmacy providers, retail pharmacies, and consulting firms. Pharmacists work in various roles across these organizations.
Chronic diseases are the leading cause of death in the US. Managed care organizations implement disease management programs like smoking cessation programs to help prevent chronic diseases and lower costs. These programs aim to eliminate risk factors for disease such as smoking and provide incentives, care management, and access to services to help patients quit smoking. Quality of care is evaluated through structure, process and outcomes to ensure these programs are effective.
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
1. The document discusses issues with the current healthcare system including lack of coordination between institutions, dehumanization of care, and rising costs.
2. It introduces case management as a promising solution, defined as a method that aims for continuity of services and quality clinical outcomes through efficient management of available resources for specific clientele.
3. Case management relies on thorough knowledge of client needs, estimating patient stay lengths, and planning coordinated treatment processes to improve care quality while controlling costs.
This document provides an overview of a study on implementing total quality management (TQM) in the healthcare sector in India. It includes an abstract that describes the rising costs and pressures in healthcare that have led organizations to adopt quality management approaches like TQM. The introduction discusses issues in healthcare quality and the need for reforms. The document then proposes a model for TQM implementation that identifies key factors like leadership, momentum, teamwork, training, focus on core processes, and measures.
The document discusses New York State's efforts to promote the patient-centered medical home model. It notes that while New York spends a lot on healthcare, the quality and health outcomes are only middle of the pack. The Commissioner of Health believes the PCMH model can help strengthen primary care, improve chronic care management, and reduce avoidable costs. New York has promoted multipayer PCMH initiatives through legislation and programs. Initial PCMH pilot programs showed promising results, and the state has seen significant uptake of PCMH recognition across practices. Evaluations are still early, but results so far are encouraging regarding patient experience and quality measures.
This document discusses strategies that clinically integrated networks (CINs) can use to ensure patients stay within their network. It identifies five key areas of focus: 1) extending access beyond traditional models such as physician offices by partnering with urgent care and retail clinics, 2) managing patient migration outside the network through partnerships and narrow network contracts, 3) making it easy for patients to access care through optimized scheduling and expanded hours, 4) building engagement into clinical care through education and protocols, and 5) exploring innovative technologies like smartphone apps and social media to engage patients. The document emphasizes that keeping patients within the network is important for CINs to effectively manage patient care, costs, and outcomes under value-based payment models.
The document discusses challenges that health systems face in managing costs under new bundled payment programs and global budgets. It provides an example from a pilot program in Maryland where costs have been capped and prices set in an effort to cut Medicare spending. The document outlines some of the key areas health systems need to address in both acute and post-acute care settings, such as optimizing patient mix and readmission rates, in order to successfully meet budget targets and quality measures. It provides details on specific strategies used by one Maryland health system to improve performance, such as reducing readmission rates from over 23% to less than 7%.
The Evolution of Physician Group from Patient Centric Medical HomesVitreosHealth
A Quest to Achieve Higher Quality and Bend the Employers Health Care Cost Curves. Medical Clinic of North Texas (MCNT) enjoys a stellar FY 2010 performance with Total Medical Cost trend for their managed population 2.4% better than market. We tried to understand the journey and the drivers behind the success of Medical Clinic of North Texas from its early years and its future direction.
The document provides information about the Academy of Managed Care Pharmacy (AMCP). It discusses:
1) AMCP was founded in 1989 and is a national professional society dedicated to promoting pharmaceutical care in managed healthcare environments.
2) AMCP's mission is to empower its over 5,700 members to improve healthcare for all individuals through the appropriate use of medications within managed care systems.
3) Key players in managed care include health plans, pharmacy benefit managers, the pharmaceutical industry, specialty pharmacy providers, retail pharmacies, and consulting firms. Pharmacists work in various roles across these organizations.
Chronic diseases are the leading cause of death in the US. Managed care organizations implement disease management programs like smoking cessation programs to help prevent chronic diseases and lower costs. These programs aim to eliminate risk factors for disease such as smoking and provide incentives, care management, and access to services to help patients quit smoking. Quality of care is evaluated through structure, process and outcomes to ensure these programs are effective.
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
1. The document discusses issues with the current healthcare system including lack of coordination between institutions, dehumanization of care, and rising costs.
2. It introduces case management as a promising solution, defined as a method that aims for continuity of services and quality clinical outcomes through efficient management of available resources for specific clientele.
3. Case management relies on thorough knowledge of client needs, estimating patient stay lengths, and planning coordinated treatment processes to improve care quality while controlling costs.
This document provides an overview of a study on implementing total quality management (TQM) in the healthcare sector in India. It includes an abstract that describes the rising costs and pressures in healthcare that have led organizations to adopt quality management approaches like TQM. The introduction discusses issues in healthcare quality and the need for reforms. The document then proposes a model for TQM implementation that identifies key factors like leadership, momentum, teamwork, training, focus on core processes, and measures.
The document discusses New York State's efforts to promote the patient-centered medical home model. It notes that while New York spends a lot on healthcare, the quality and health outcomes are only middle of the pack. The Commissioner of Health believes the PCMH model can help strengthen primary care, improve chronic care management, and reduce avoidable costs. New York has promoted multipayer PCMH initiatives through legislation and programs. Initial PCMH pilot programs showed promising results, and the state has seen significant uptake of PCMH recognition across practices. Evaluations are still early, but results so far are encouraging regarding patient experience and quality measures.
This document discusses strategies that clinically integrated networks (CINs) can use to ensure patients stay within their network. It identifies five key areas of focus: 1) extending access beyond traditional models such as physician offices by partnering with urgent care and retail clinics, 2) managing patient migration outside the network through partnerships and narrow network contracts, 3) making it easy for patients to access care through optimized scheduling and expanded hours, 4) building engagement into clinical care through education and protocols, and 5) exploring innovative technologies like smartphone apps and social media to engage patients. The document emphasizes that keeping patients within the network is important for CINs to effectively manage patient care, costs, and outcomes under value-based payment models.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
This document discusses team-based care in the context of the patient-centered medical home (PCMH) model. It outlines six key qualities of effective team-based care: 1) a physician servant leader, 2) a clear mission and goals, 3) defined roles, 4) strong communication, 5) optimized systems, and 6) enhanced training. The article then provides strategies for implementing team-based care in small practices, noting they have limited resources but are adaptable, and in larger practices with multiple locations. Overall, the document emphasizes that developing the right team is essential before practices can transform to the patient-centered medical home model.
Michigan Hospital Association Governance meetingMary Beth Bolton
Patient centered medical home activities in MI and Nationally and the opportunity to improve quality outcomes by increased access to primary care doctors who outreach members who are missing preventive and chronic care services.
Drhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
This document discusses new models of healthcare delivery that aim to improve care coordination. It describes two prominent models - patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) - that are working to eliminate fragmented care through coordinated care. The case manager plays a key role in coordinating care across settings and providers in these new models, as their role in care coordination is becoming increasingly important with growing care complexity. The document uses Geisinger Health Plan as an example of an ACO that has successfully implemented a medical home program with embedded case managers to coordinate care.
This document discusses several topics related to healthcare finance and quality reporting systems:
1) It summarizes the goals of the Physician Quality Reporting System (PQRS) and Value-Based Purchasing System (VBPS), including improving quality of care and tying reimbursement to quality metrics.
2) It outlines the roles of Health Information Management professionals in supporting these programs through data analytics and quality reporting.
3) It describes the roles of Quality Improvement Organizations in ensuring accurate medical coding and documentation for reimbursement.
4) It provides an overview of several laws and acts aimed at reducing healthcare fraud, including the Anti-Kickback statute and their effects on providers.
- Ascension Health, the largest nonprofit health system in the US, has two systems participating in the CMS Pioneer ACO program - Seton Health Alliance in Texas and Genesys Physician Hospital Organization (PHO) in Michigan.
- The goal is for these organizations to develop population health strategies and engage providers not employed by Ascension in financial risk-taking models.
- Seton Health Alliance and Genesys PHO chose different payment models from CMS - Genesys PHO selecting a fully population-based model in year 3 while Seton chose a model with no downside risk in the first year.
Population Health Management White Paper, Spring 2015Edward Pierce
Population health management (PHM) aims to improve health outcomes for groups of individuals through coordinated care and patient engagement. Key components of PHM include leadership from primary care physicians to develop customized care plans for each patient. Data analysis is used to identify at-risk patients and care gaps, while automation and technology help disseminate information to patients. Referral networks and payment structures incentivize physicians to focus on outcomes over volume. Hospitals are developing PHM strategies starting with their own employees to coordinate benefits, replicate the model, and expand it community-wide to improve affordability.
Drhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
This document outlines case management guidelines for workers' compensation cases in Oklahoma. It was developed by the Physician Advisory Committee and adopted by the Administrator of the Oklahoma Workers' Compensation Court. The guidelines define case management, describe the benefits and role of case managers, and outline the case management process. They provide criteria for when a case should be referred to case management, including catastrophic injuries, noncompliance with treatment plans, frequent changes in providers, and issues that require in-person evaluation like language barriers. The guidelines are intended to help case managers provide coordinated, quality care to injured workers.
This article analyzes annual cost profiles and consumption patterns of Medicare beneficiaries with diabetes from 2000 to 2006. It finds that while the percentages of beneficiaries and expenditures in different consumption clusters (ranging from "crisis consumers" to "low consumers") remained generally constant year to year, there was significant movement of individuals between clusters over time. Notably, a large proportion of those in the lowest clusters in one year transitioned to the highest clusters in subsequent years, representing a significant portion of inpatient costs. This dynamic migration between clusters, with individuals moving from low to high usage, was a previously unrecognized trend with important implications for targeting of disease management programs.
Improving Patients’ Health Acute Care FinalmHealth2015
mHealth strategies have the potential to improve patient health and outcomes before, during, and after emergency department visits. By facilitating patient triage and decision making before visits, improving communication during visits, and enhancing health literacy and behavior change support after visits, mHealth can help emergency departments improve throughput and post-discharge outcomes. This can increase revenue, avoid penalties, and improve patient satisfaction. Two case studies show that text messaging improved satisfaction scores and appointment adherence for discharged patients from emergency departments.
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
The document summarizes a report about the use of embedded case managers in healthcare organizations. It finds that about half of healthcare organizations embed or co-locate case managers at points of care. The report provides metrics and benchmarks on the prevalence and impact of embedded case management programs. It finds that embedded case management results in more efficient care coordination of high-risk patients and those with chronic illnesses. The metrics are derived from a survey of healthcare organizations that currently embed case managers.
The Physician Task Force's How-to Guide will help both clinicians and C-suite executives identify which mobile tools are needed and worth investing in.
DeMarco and Associates and Pendulum HealthCare Corporation provide services to help organizations develop accountable care organizations (ACOs). They assist with infrastructure development, care coordination, and data analytics. Pendulum also designs, develops, and manages ACOs. An ACO aims to deliver coordinated, efficient care to a defined patient population through provider collaboration and accountability for costs and quality outcomes. Requirements include agreements between primary care physicians, specialists, and hospitals to be responsible for a minimum number of Medicare beneficiaries.
Drhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
This document provides an overview of case management programs and evaluations in long-term care. It defines case management as a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates services to meet individual needs. The goals of case management can be client-oriented, such as improving access to services, administrative, such as improving efficiency, or system-oriented, such as promoting a high-quality service system. Common models of case management include traditional models within long-term care, brokerage models, managed care models, and integrated models. Quality is evaluated based on structure, process, and outcomes. Current ongoing evaluations of case management programs seek to assess outcomes and costs. The document concludes that case management shows promise but more
Delivering value based_care_with_e_health_services.5Greg Bauer
The document discusses how value-based care requires new approaches to engage patients and improve outcomes while lowering costs. It argues that e-health tools can help by enabling better care coordination, remote patient monitoring, social support for patients, and customized care programs. These e-health disciplines are important for engaging patients in their care in new ways to support value-based models.
Ammonoosuc Community Health Services EMR Medical Record Case StudyGE Healthcare - IT
For Ammonoosuc Community Health Services, an Electronic Medical Record proves essential in delivering award-winning care and achieving Level 3 recognition as a patient-centered medical home
Co-located or embedded case management is a critical component of value-based care. The role of case managers has changed significantly over the past 25 years as the healthcare system has shifted from fee-for-service to value-based. Case managers are now seen as integral members of care teams in primary care offices, hospitals, and other settings. Having case managers embedded directly in these settings, rather than just co-located, has been shown to lead to more successful programs and better patient outcomes. As value-based programs and medical home models have expanded, the need for embedded case managers has grown substantially.
Meritage ACO developed a care transitions program with three elements: care transitions coaching, complex care management, and care coordination between care settings. The program aims to reduce preventable hospital readmissions, which cost the healthcare system an estimated $25 billion per year. Care transitions coaches visit patients before discharge to educate them and plan for their needs. Complex care management involves using tools like the Coleman Care Transitions Intervention and motivational interviewing. Care coordinators help with non-clinical needs. The program seeks to shift clinicians' thinking to a team-based approach focused on continuous care between settings and patient care goals.
A New Payer Model for Medical Management ExecutionCognizant
To combat rising costs and inefficient use of resources, payers can streamline utilization management and optimize care management through medical management delivered as a service.
Partnering with Patients, Families and Communities for Health: A Global Imper...EngagingPatients
Engagement is an essential tool to improving global health. This report introduces a new framework for engagement to help countries assess current programs and think strategically about future engagement opportunities. It spotlights barriers to engagement and offers concrete examples of effective engagement from around the globe.
This document discusses team-based care in the context of the patient-centered medical home (PCMH) model. It outlines six key qualities of effective team-based care: 1) a physician servant leader, 2) a clear mission and goals, 3) defined roles, 4) strong communication, 5) optimized systems, and 6) enhanced training. The article then provides strategies for implementing team-based care in small practices, noting they have limited resources but are adaptable, and in larger practices with multiple locations. Overall, the document emphasizes that developing the right team is essential before practices can transform to the patient-centered medical home model.
Michigan Hospital Association Governance meetingMary Beth Bolton
Patient centered medical home activities in MI and Nationally and the opportunity to improve quality outcomes by increased access to primary care doctors who outreach members who are missing preventive and chronic care services.
Drhatemelbitar (2)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
This document discusses new models of healthcare delivery that aim to improve care coordination. It describes two prominent models - patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) - that are working to eliminate fragmented care through coordinated care. The case manager plays a key role in coordinating care across settings and providers in these new models, as their role in care coordination is becoming increasingly important with growing care complexity. The document uses Geisinger Health Plan as an example of an ACO that has successfully implemented a medical home program with embedded case managers to coordinate care.
This document discusses several topics related to healthcare finance and quality reporting systems:
1) It summarizes the goals of the Physician Quality Reporting System (PQRS) and Value-Based Purchasing System (VBPS), including improving quality of care and tying reimbursement to quality metrics.
2) It outlines the roles of Health Information Management professionals in supporting these programs through data analytics and quality reporting.
3) It describes the roles of Quality Improvement Organizations in ensuring accurate medical coding and documentation for reimbursement.
4) It provides an overview of several laws and acts aimed at reducing healthcare fraud, including the Anti-Kickback statute and their effects on providers.
- Ascension Health, the largest nonprofit health system in the US, has two systems participating in the CMS Pioneer ACO program - Seton Health Alliance in Texas and Genesys Physician Hospital Organization (PHO) in Michigan.
- The goal is for these organizations to develop population health strategies and engage providers not employed by Ascension in financial risk-taking models.
- Seton Health Alliance and Genesys PHO chose different payment models from CMS - Genesys PHO selecting a fully population-based model in year 3 while Seton chose a model with no downside risk in the first year.
Population Health Management White Paper, Spring 2015Edward Pierce
Population health management (PHM) aims to improve health outcomes for groups of individuals through coordinated care and patient engagement. Key components of PHM include leadership from primary care physicians to develop customized care plans for each patient. Data analysis is used to identify at-risk patients and care gaps, while automation and technology help disseminate information to patients. Referral networks and payment structures incentivize physicians to focus on outcomes over volume. Hospitals are developing PHM strategies starting with their own employees to coordinate benefits, replicate the model, and expand it community-wide to improve affordability.
Drhatemelbitar (3)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
This document outlines case management guidelines for workers' compensation cases in Oklahoma. It was developed by the Physician Advisory Committee and adopted by the Administrator of the Oklahoma Workers' Compensation Court. The guidelines define case management, describe the benefits and role of case managers, and outline the case management process. They provide criteria for when a case should be referred to case management, including catastrophic injuries, noncompliance with treatment plans, frequent changes in providers, and issues that require in-person evaluation like language barriers. The guidelines are intended to help case managers provide coordinated, quality care to injured workers.
This article analyzes annual cost profiles and consumption patterns of Medicare beneficiaries with diabetes from 2000 to 2006. It finds that while the percentages of beneficiaries and expenditures in different consumption clusters (ranging from "crisis consumers" to "low consumers") remained generally constant year to year, there was significant movement of individuals between clusters over time. Notably, a large proportion of those in the lowest clusters in one year transitioned to the highest clusters in subsequent years, representing a significant portion of inpatient costs. This dynamic migration between clusters, with individuals moving from low to high usage, was a previously unrecognized trend with important implications for targeting of disease management programs.
Improving Patients’ Health Acute Care FinalmHealth2015
mHealth strategies have the potential to improve patient health and outcomes before, during, and after emergency department visits. By facilitating patient triage and decision making before visits, improving communication during visits, and enhancing health literacy and behavior change support after visits, mHealth can help emergency departments improve throughput and post-discharge outcomes. This can increase revenue, avoid penalties, and improve patient satisfaction. Two case studies show that text messaging improved satisfaction scores and appointment adherence for discharged patients from emergency departments.
Drhatemelbitar (1)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
The document summarizes a report about the use of embedded case managers in healthcare organizations. It finds that about half of healthcare organizations embed or co-locate case managers at points of care. The report provides metrics and benchmarks on the prevalence and impact of embedded case management programs. It finds that embedded case management results in more efficient care coordination of high-risk patients and those with chronic illnesses. The metrics are derived from a survey of healthcare organizations that currently embed case managers.
The Physician Task Force's How-to Guide will help both clinicians and C-suite executives identify which mobile tools are needed and worth investing in.
DeMarco and Associates and Pendulum HealthCare Corporation provide services to help organizations develop accountable care organizations (ACOs). They assist with infrastructure development, care coordination, and data analytics. Pendulum also designs, develops, and manages ACOs. An ACO aims to deliver coordinated, efficient care to a defined patient population through provider collaboration and accountability for costs and quality outcomes. Requirements include agreements between primary care physicians, specialists, and hospitals to be responsible for a minimum number of Medicare beneficiaries.
Drhatemelbitar (4)MEDICAL CASE MANAGEMENTد حاتم البيطارد حاتم البيطار
This document provides an overview of case management programs and evaluations in long-term care. It defines case management as a collaborative process that assesses, plans, implements, coordinates, monitors and evaluates services to meet individual needs. The goals of case management can be client-oriented, such as improving access to services, administrative, such as improving efficiency, or system-oriented, such as promoting a high-quality service system. Common models of case management include traditional models within long-term care, brokerage models, managed care models, and integrated models. Quality is evaluated based on structure, process, and outcomes. Current ongoing evaluations of case management programs seek to assess outcomes and costs. The document concludes that case management shows promise but more
Delivering value based_care_with_e_health_services.5Greg Bauer
The document discusses how value-based care requires new approaches to engage patients and improve outcomes while lowering costs. It argues that e-health tools can help by enabling better care coordination, remote patient monitoring, social support for patients, and customized care programs. These e-health disciplines are important for engaging patients in their care in new ways to support value-based models.
Ammonoosuc Community Health Services EMR Medical Record Case StudyGE Healthcare - IT
For Ammonoosuc Community Health Services, an Electronic Medical Record proves essential in delivering award-winning care and achieving Level 3 recognition as a patient-centered medical home
Co-located or embedded case management is a critical component of value-based care. The role of case managers has changed significantly over the past 25 years as the healthcare system has shifted from fee-for-service to value-based. Case managers are now seen as integral members of care teams in primary care offices, hospitals, and other settings. Having case managers embedded directly in these settings, rather than just co-located, has been shown to lead to more successful programs and better patient outcomes. As value-based programs and medical home models have expanded, the need for embedded case managers has grown substantially.
Meritage ACO developed a care transitions program with three elements: care transitions coaching, complex care management, and care coordination between care settings. The program aims to reduce preventable hospital readmissions, which cost the healthcare system an estimated $25 billion per year. Care transitions coaches visit patients before discharge to educate them and plan for their needs. Complex care management involves using tools like the Coleman Care Transitions Intervention and motivational interviewing. Care coordinators help with non-clinical needs. The program seeks to shift clinicians' thinking to a team-based approach focused on continuous care between settings and patient care goals.
A New Payer Model for Medical Management ExecutionCognizant
To combat rising costs and inefficient use of resources, payers can streamline utilization management and optimize care management through medical management delivered as a service.
This document discusses how a community paramedic program supports the goals of accountable care organizations (ACOs) in achieving the "Triple Aim" of improving patient care, improving population health, and reducing costs. It provides examples of how community paramedics can coordinate care between primary care, hospitals, and other partners to reduce emergency department visits and hospital readmissions. The document also outlines various payment models that reimburse for services like care coordination that community paramedic programs provide.
How Providers Can Reshape their Operations to Master Value-Based ReimbursementsCognizant
Healthcare providers must make sweeping system, process and operational changes to thrive under the inevitable move to value-based payments. Here are our recommendations on how to get started.
Read the scenario that you will use for the Individual Projects in ea.pdfashokarians
Read the scenario that you will use for the Individual Projects in each week of the course. The
Centers for Medicare and Medicaid Services (CMS) has taken on a more visible role in health
care delivery. Many changes have transpired to improve patient safety along with the
implementation of additional quality metrics, and these changes impact reimbursement rates
Likewise, the Patient Protection and Affordable Care Act has changed the reimbursement fee
structure of Medicare and Medicaid reimbursement for health care services. Other legislation
including the HITECH Act and the Medicare Authorization and CHIP Reactivation Act of 2015
(MACRA) all impact how healthcare organizations receive reimbursement and demonstrate use
of data to improve quality and delivery of patient care Mr. Magone, CEO of Healing Hands
Hospital, has asked you to join the \"Future of Healing Hands Task Force, and your first
assignment is to work with the Hospital Chief Financial Officer, Mr. Johnson, and provide a
summary of the current regulations regarding Medicare reimbursement including how MACR
impact reimbursement if/when Healing Hands coordinates delivery of services by affiliating with
physician practices For this assignment, write a 2-3 page report that you will deliver to Mr.
Magone on how the new CMS initiatives and regulations impact the organization\'s revenue
structure. In your presentation, address the following questions: Why did CMS become more
involved in the reimbursement component of health care? How does CMS\'s involvement impact
the reimbursement model for Healing Hands Hospital and other health care organizations If
CMS reimbursement regulations for Medicare and Medicaid change, does it follow that other
insurance providers change heir policies on reimbursement? What tools can be implemented to
ensure organizations such as Healing Hands Hospital and physician practices are meeting the
policies and procedures set forth by CMS? Identify 3 tools from the CMS Web site that are
helpful in meeting the requirements for Medicare reimbursement set forth by CMS
Solution
Part-a & part-b:
The physician’s work, practice expense, and malpractice, RVU values, CMS (centers for
Medicare and Medicaid services) is required to control overall expenditures in health care
organization. Therefore, CMS become highly involved in the reimbursement component of
health care to patients as per their \"insurance packages\". The CMS\' involvement in “budget
Neutrality” & the reimbursement model at Healing Hand hospital & other health care
organizations is mainly for physician RVU based payments from Medicare & Medicare that can
control its physician costs by adjusting physician payment rates based on “previous periods in a
calendar year” as per federal acts and regulations. The Medicare is going to control physicians
costs according to “medical procedures and medical visits of their record” in a Jan- 1 ending Dec
31. Conversion Factor is main basis to control the physician costs ac.
Employer Sponsored Medical Clinics white paperTom Pascuzzi
Employer-sponsored medical clinics have evolved from providing only basic convenience care to playing a larger role in actively managing chronic conditions to help control employers' health care costs. Successful clinics are integrated into the employer's data-driven health strategy and hold the clinic accountable for meeting cost and productivity goals. Different clinic models provide varying levels of services from basic care to full primary care management. For an on-site clinic to be effective, employers need to analyze their claims data to identify conditions driving costs and those amenable to improved management. The Affordable Care Act has prompted some employers to reconsider clinics to help manage costs and improve access to care.
Hospitalist programs are increasingly used by hospitals to manage the shift to value-based care and reduce costs. The use of hospitalists has grown significantly, with approximately 75% of hospitals now utilizing hospitalists. Hospitalist programs can improve outcomes, drive cost efficiencies, and increase reimbursements by reducing lengths of stay and readmission rates. While hospitalists provide benefits, there is debate around their impact on overall patient health and outcomes. As value-based payments increase, demand for hospitalists is expected to continue growing as they help hospitals achieve quality metrics and financial targets.
The document describes the Comprehensive Primary Care Plus (CPC+) initiative, which aims to strengthen primary care through multi-payer partnerships and alternative payment models. It has three main goals: 1) allow practices to provide more comprehensive care, 2) accommodate practices at different transformation levels, and 3) achieve better care, smarter spending and healthier people. CPC+ will run in up to 20 regions over 5 years, selecting practices to participate in one of two tracks. It emphasizes the importance of aligning Medicare, Medicaid, and commercial payers to support practice transformation.
This document summarizes discussions from a series of panel discussions on the future of post-acute healthcare. Key concerns discussed include the need for better coordination and pathways between acute and post-acute care to reduce hospital readmissions, ensuring clinical staff in skilled nursing facilities have sufficient skills and training, understanding new models like Accountable Care Organizations, managing increased utilization of managed care plans with lower reimbursement rates, and navigating changes to state Medicaid systems. Potential solutions focus on developing partnerships across settings, sharing clinical information, participating in advocacy, and using technology and analytics to improve coordination and decision making.
The Healthcare Quality Coalition wrote to CMS Administrator Berwick to provide feedback on the proposed Medicare Shared Savings Program and ACO regulations. The coalition supports the goals of improved care coordination and reduced costs through alternative payment models like ACOs. However, the letter outlines several concerns with the proposed rule, including that it requires reporting on too many quality measures in year one, does not adequately account for patient acuity, and may not provide sufficient incentives for high-quality organizations to participate. The coalition urges CMS to address these issues in the final rule.
AAPC Local chapter Presentation by Venkatesh Srinivas-Vee TechnologiesVee Technologies
The value of clinical documentation improvement in a value-based reimbursement model is discussed. Physicians play a critical role in supporting the transition to value-based care through improved documentation. Value-based care combined with CDI can help achieve the goal of improved population health. CDI ensures accurate reimbursement under various models like IPPS, OPPS, FFS, and risk-adjusted models by capturing the right codes. It also impacts quality reporting programs like MIPS and helps achieve better health outcomes and cost savings. Examples are provided showing the impact of CDI on reimbursement through correcting coding at the outpatient level under different models.
A Clinically Integrated Network (CIN) is a selective partnership of physicians collaborating with
hospital(s) and other providers to deliver evidence-based care, improve quality and efficiency,
manage populations and demonstrate value to the market. Once these objectives are met, the network may contract on behalf of participants
This document provides a roadmap for clinical integration as healthcare transitions from fee-for-service to value-based payment. It outlines three phases of integration - asset aggregation, functional integration, and system optimization. True clinical integration requires optimization across clinical, financial, and operational areas through shared governance, financial alignment, and clinical/business integration. Following this roadmap by focusing on vision, governance, alignment, and culture can help cardiovascular groups successfully balance the current and future healthcare worlds.
The document discusses emerging value-based healthcare payment models in the US and provides recommendations for stakeholders. It outlines recent legislation like MACRA that aims to shift Medicare payments from fee-for-service to value-based models. MACRA establishes the MIPS program which combines existing quality programs and the APM program which incentivizes participation in alternative payment models. It also describes various CMS pay-for-performance programs focused on readmissions, hospital value, and hospital-acquired conditions. The document concludes with recommendations for stakeholders to collaborate across the healthcare system to effectively transition to value-based models.
What quality measures does the MCO have in placeSolutionManag.pdfformicreation
What quality measures does the MCO have in place?
Solution
Managed care organizations (MCOs) are responsible for ensuring that persons enrolled in their
plans receive quality health care. In addition, MCOs publicly funded through the Medicare and
Medicaid programs are required by State and Federal governments to meet certain quality
standards.
To fulfill their responsibilities, MCOs need ready access to a comprehensive array of evidence-
based clinical information and other clinical performance measures to enable them to evaluate
their providers\' performance and identify areas where improvement is needed. They also need to
know how their members feel about the care they receive and the way they are treated. Finally,
they need to ensure that both their providers and members are aware of the most recent
preventive care recommendations.
Valid, reliable, and cost-effective measurement tools must be available to make such
determinations, but these tools have not always been available. Furthermore, because the science
of performance measurement is relatively new, additional measures need to be developed and
those that have been developed can be improved. Therefore, to ensure that their enrollees in
MCOs receive high-quality care, MCOs need a reliable source to provide the most current and
scientifically sound tools.
In response to this need, the Agency for Healthcare Research and Quality (AHRQ) has funded
research to compile a database of evidence-based clinical guidelines and to develop clinical
performance measures, member satisfaction surveys, and preventive care recommendations that
can help MCOs meet their responsibilities. Additionally, AHRQ funds research and develops
performance measures and guidelines that MCOs, insurers, providers, and consumers can trust.
This report describes these tools and how they have been used and provides information on
where to learn more about them.
Background
Around one-half of insured Americans are enrolled in some form of managed care. However, as
the number of persons enrolled in MCOs increased in the 1990s, health care purchasers,
policymakers, and other stakeholders became concerned about the potential for health care
quality to diminish. In their view, the policies and practices imposed by MCOs to reduce what
MCOs define as unnecessary care might result in patients not receiving needed care. Therefore,
MCOs faced accreditation systems and other requirements to ensure that patients were receiving
the most appropriate care.
More recently, MCOs have had to address other emerging concerns such as: Rapid introduction
of new technologies, Data showing unexplained variations in the provision of care, Severe cost
pressures.
These factors have provided additional motivation to MCOs to develop systematic ways of
preserving and enhancing health care quality and cost-effectiveness.
Evidence-based practice guidelines and performance measures were developed to help ensure
that patients always receive the most appropri.
The Center for Medicare & Medicaid Services hosted a webinar on Thursday, April 14, 2016. During this webinar staff provided an overview of the model. A repeat of the webinar was held on Tuesday, April 19.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
White Paper - Building Your ACO and Healthcare IT’s RoleNextGen Healthcare
The tools needed to capture, organize, and share healthcare data are truly evolving at the speed of light. Patient Centered Medical Homes play a vital role in the path toward accountable care and technology, staff, and workflow transformation are necessary to achieve PCMH recognition. This transformation allows healthcare providers to deliver higher quality coordinated care by streamlining and rationalizing the patient experience.
Healthcare by Any Other Name - Centricity Business WhitepaperGE Healthcare - IT
This document discusses new models of healthcare delivery such as accountable care organizations and integrated health organizations that aim to improve outcomes and reduce costs through greater coordination and integration of care. It summarizes that these models seek to address long-standing issues with the traditional fragmented healthcare system such as its focus on episodic treatment rather than prevention. Critical to enabling these new models is developing an information technology infrastructure that includes electronic medical records, revenue cycle management systems, clinical decision support, and health information exchange capabilities to facilitate data sharing and population health management.
- Parkview Medical Group participated in the Maryland Multi-Payer Plan (MMPP), a program that provided financial incentives for practices that improved care coordination and achieved savings through reduced hospital admissions and specialist referrals. For the first time in 2014, Parkview received shared savings payments through the MMPP.
- Parkview worked to achieve NCQA Patient-Centered Medical Home Level 3 recognition, requiring collaboration between administration, providers, and staff. After over a year of preparation, Parkview received Level 3 recognition in 2015.
- Parkview has enhanced access for patients by adding services and expanded hours. They launched an online patient portal in 2014 and are working to integrate behavioral health services and move towards more integrated "whole patient
Similar to NCQA_Future Vision for Medicare Value-Based Payments Final (20)
The document outlines 12 disruptive forces in healthcare that will provide challenges in 2016, including the transition from fee-for-service to value-based reimbursement, shifting volumes and lower reimbursements, increasing oversight and focus on quality and compliance, and the growing need for care management and team-based models of care delivery amid shrinking financial resources and coming shortages of healthcare providers.
Anthony Fanelli is an experienced sales and business development professional with over 20 years of experience in clinical diagnostics and healthcare services industries. He has a proven track record of consistently exceeding sales quotas and objectives, including increasing sales revenues by over $11 million in just 5 years at one position. Fanelli is seeking a new position where he can utilize his leadership skills and experience managing large sales teams and client relationships.
This pharmacogenomic report summarizes genetic test results for a patient. It finds the patient has various genetic variants that impact drug metabolism for certain medications like warfarin and antidepressants. For warfarin, it recommends a lower starting dose due to increased sensitivity. It also provides risk assessments and recommendations for conditions like thrombosis and hyperhomocysteinemia based on the patient's genetic results.
The document provides an overview of Anthony Faneli's experience and qualifications for leadership in healthcare. It discusses his commitment to quality, integrity, innovation, accountability, collaboration, and leadership. It outlines his experience with integrated delivery networks, managed care organizations, health information technology, and perspectives on trends in healthcare reform and personalized medicine. The document promotes Faneli's expertise across multiple areas of the healthcare industry.
The document outlines 12 disruptive forces in healthcare that will provide challenges in 2016, including the transition from fee-for-service to value-based reimbursement, shifting volumes and lower reimbursements, increasing oversight and focus on quality and compliance, and the growing need for care management and team-based models of care delivery amid shrinking financial resources and coming shortages of healthcare providers.
The document discusses trends in mobile usage and expectations in 2016. It predicts that user expectations for mobile experiences will increase greatly, forcing companies to better integrate mobile into their overall strategies. Specifically, it forecasts that a quarter of companies will fully integrate mobile, treating it not just as a channel but as core to the customer experience. It also predicts that mobile success will be a key factor in the vendor landscape, with digital platforms seeking to own more mobile moments and consolidation among enterprise mobile vendors. Contextual data and next-generation mobile technologies will be important to fueling these new mobile experiences.
1) The payment models in healthcare are shifting from fee-for-service to value-based models that tie reimbursement to quality outcomes and cost savings. This transition is being driven by rising healthcare costs, the Affordable Care Act, and commercial insurers.
2) Providers now need to accelerate preparations for managing clinical and financial risk through value-based contracts. This requires changes to business models, physician alignment, and supporting patients through the transition.
3) For organizations to succeed under value-based contracts, they must define population health strategies, implement coordinated care delivery models, and carefully sequence clinical and financial transformations to capture savings while maintaining stability.
This document summarizes a study conducted by Forrester Consulting on behalf of Phunware regarding mobile application development among midsize companies. The key findings were: 1) Providing basic mobile app features is not enough, customers expect new value-adding features; 2) Many midsize businesses lack tools to customize mobile experiences; 3) Most midsize businesses face challenges building a business case for mobile app investment due to inability to measure usage and decide on features. The document also provides recommendations for companies to focus on meeting specific customer needs with mobile apps and designing a strategic roadmap.
The document describes an integrated delivery network community that provides a continuum of both mental health and chemical dependency care. This includes outpatient and inpatient substance abuse treatment, mental health treatment, pain management, and partnerships with emergency rooms, specialists, and managed care organizations to coordinate care. The network aims to comprehensively address both physical and behavioral healthcare needs within a community.
This document discusses several models for integrated healthcare delivery systems called Integrated Delivery Network Community (IDNC). An IDNC aims to provide seamless care from "Womb to Tomb" through coordination between various providers. The goal is for primary care practices to act as hubs that connect patients to specialists, hospitals, labs, and community resources. Coordinating primary care and behavioral health is also emphasized. Examples provided include a wellness center that integrates various services under one roof, and a health home program that links patients to needed care through care coordinators. The Affordable Care Act and other policies aim to improve access to behavioral health services and their integration with primary care through provisions like increased Medicaid eligibility and parity in insurance
The document discusses how the Affordable Care Act (ACA) has changed the US health insurance landscape and the challenges facing healthcare enrollment in 2015. It outlines how the ACA aimed to make quality health insurance affordable and accessible for all Americans. While the number of uninsured Americans has dropped since 2010, tens of millions remain uninsured. The upcoming open enrollment period faces challenges in engaging populations like young adults, Latinos, low-income households, and those in rural areas. Mobile technologies like text messaging are effective ways for healthcare organizations to reach these diverse groups and drive enrollment due to the widespread adoption of mobile phones.
This document discusses 5 elements of a successful patient engagement strategy:
1. Define your organization's vision for patient engagement.
2. Create a culture of engagement within the practice.
3. Employ the right technology and services like patient portals.
4. Empower patients to become collaborators in their care.
5. Continuously evaluate progress and be ready to adapt the strategy.
True patient engagement involves patients managing their own health, a practice culture that prioritizes engagement, and collaboration between patients and providers.
Mobile health technology is becoming increasingly important in healthcare. Clinicians now use mobile devices extensively to access patient information, clinical references, and communicate with colleagues. Integrating mobile effectively presents challenges around selecting appropriate apps, maintaining data security, and ensuring interoperability with electronic health records. To maximize benefits, healthcare organizations should focus on supporting clinical decisions with vetted apps, enhancing workflows, enabling care coordination through secure messaging, and engaging patients through their mobile devices. Done thoughtfully, integrating mobile can improve patient care, outcomes and practice efficiency.
This document provides an overview of Tony Fanelli's career in health information technology leadership. It summarizes his 20+ years of experience in various roles within healthcare organizations, implementing electronic medical record systems. It also outlines some common issues and needs expressed by key stakeholders in healthcare such as primary care physicians, administrators, and C-suite executives regarding EMR systems like ensuring data quality, interoperability, and support for value-based care initiatives.
Florence Grant is a 68-year-old female with a history of arthritis, congestive heart failure, COPD, diabetes, hypertension, osteoporosis, shingles, and urinary incontinence. She takes 11 medications and sees 20 different providers. Her most recent appointments were in February and April 2015 for follow-ups related to her congestive heart failure and diabetes.
To provide chronic care management (CCM) services and bill Medicare, several requirements must be met:
1) Written consent from the beneficiary is required before services begin.
2) The care plan must be electronically accessible 24/7 to all providers on the care team, as well as the beneficiary.
3) At least 20 minutes per month of non face-to-face care coordination is required, including tracking time spent and services provided.
CareSync provides chronic care management services to help providers meet Medicare's requirements for billing code 99490. Some key details include:
1) CareSync's health assistants provide 24/7 access to clinical staff and help coordinate care among providers and caregivers.
2) They create comprehensive care plans and ensure continuity of care by updating care plans based on new information from appointments.
3) CareSync tracks care coordination minutes and will provide a monthly report with billing details, but will not charge if the 20-minute minimum is not met for a patient.
Chronic Care Management (CCM) involves coordinating care between patient visits to improve health outcomes and reduce costs for patients with chronic conditions. Medicare now reimburses providers for CCM services, defined as at least 20 minutes per month of care coordination. To bill for CCM, providers must meet requirements such as developing comprehensive care plans, ensuring 24/7 access to care teams, and using certified EHR technology. CCM has the potential to improve chronic disease management but providers must implement services carefully to comply with Medicare's billing criteria.
The document discusses readmissions as a major problem in U.S. healthcare, costing billions annually. It outlines various causes of readmissions including systemic failures in care transitions from hospitals to outpatient settings. These failures include inadequate preparation at discharge, poor patient education, lack of follow-up care, and poor communication between inpatient and outpatient providers. New government programs and regulations are putting pressure on hospitals to reduce preventable readmissions. The document reviews best practices for addressing readmissions, including programs that focus on patient-centered care, care coordination, and care management for high-risk patients.
NCQA_Future Vision for Medicare Value-Based Payments Final
1. 1
October 14, 2015
A Future Vision of Medicare Value-Based Payment
Medicare will soon begin paying physicians and other clinicians for the value rather than volume of care
they provide. This transition is advancing through the Medicare Access & CHIP Reauthorization Act
(MACRA), a law recently enacted with broad bipartisan and multi-stakeholder support. MACRA includes
a Merit-Based Incentive Payment System (MIPS) that will adjust fee-for-service (FFS) payment based on
performance. MACRA also encourages clinicians to develop and participate in Alternative Payment
Models (APMs) that move toward greater compensation for value instead of volume. Current quality
measurement abilities can help to start this important advancement. However, the optimal future state
of measurement to support performance-based clinician pay requires more work that must begin now.
This paper suggests for discussion potential principles for achieving that optimal future state:
PRINCIPLE A: Every Medicare enrollee needs a dedicated and well-organized primary care team.
PRINCIPLE B: Measurement must be specified appropriately for each different unit of accountability.
PRINCIPLE C: Measurement should support rapid improvement and clinical decision making.
PRINCIPLE D: A core set of measures will let all stakeholders make comparisons across programs.
PRINCIPLE E: Quality measure results should be easy for consumers and payers to get and use.
PRINCIPLE A: Every patient should have a dedicated and well-organized primary care team.
A dedicated primary care team that coordinates all care for each enrollee by organizing and interpreting
care from all other clinicians and includes the patient as a full partner is essential. Dedicated primary
care teams engage patients and/or family caregivers as partners in their own health and care, support
population management and improve quality, cost and experience of care. They also, importantly,
mitigate fractured care that makes it exceedingly difficult to assign, or hold clinicians accountable, for
the quality of care delivered to individual or groups of patients. Assigning accountability is essential for
meaningful and actionable performance-based payment.
The current dispersion of care among many disconnected clinicians and sites must be addressed.
Medicare enrollees usually see two primary care clinicians and five specialists each year.1
1
Pham et al, Care Patterns in Medicare and their Implications for Pay for Performance, NEJM, March 2007.
2. 2
Over one in five enrollees do not see one clinician enough to assign accountability for their care to any
clinician. For another third, assignment would change from year to year. The typical primary care
clinician coordinates with 229 other clinicians in 117 practices, equivalent to an additional 99 physicians
and 53 practices for every 100 Medicare beneficiaries they manage.2
Patient-Centered Medical Homes (PCMHs) are specifically designed to create dedicated primary care
teams to address this challenge. A growing body of evidence documents that PCMHs improve the
quality, cost and experience of care while also reducing socioeconomic disparities in care.3
PCMHs
provide significantly greater continuity of care and substantial reductions in Medicare payments.4
Increased continuity of care from the same clinician lowers use of high-cost services.5
Patient-Centered
Specialty Practices (PCSP), in turn, are specifically designed to help specialists meet their important
responsibility to communicate effectively with primary care teams.
MACRA actively promotes PCMHs and PCSPs by giving them automatic credit under MIPS, and by giving
successful PCMH demonstration sites automatic APM status. MACRA thus intentionally provides a solid
foundation for helping more practices become PCMHs and PCSPs and getting more enrollees PCMH and
PCSP care. It is important for Medicare to have robust requirements for PCMHs and PCSPs to provide
patient- and family-centered care, as in NCQA’s programs.
However, to get the most benefit from dedicated primary care teams, patients need a strong allegiance
to these teams so they do not seek uncoordinated care from multiple clinicians. Medicare and other
stakeholders should explore ways to encourage patients to rely on dedicated primary care teams.
PRINCIPLE B: Measurement must be specified appropriately for each different unit of accountability.
Clinicians in different payment models, from uncoordinated FFS to more coordinated APMs,
Accountable Care Organizations (ACOs) and Medicare Advantage (MA) plans have differing abilities to
measure and improve quality. Measures therefore must be specified for each payment model, or unit of
accountability, yet still facilitate comparison between and among all payment models. Measures also
must be tailored for the different types of care furnished by clinicians in different payment models. For
example, clinicians in MIPS will have less ability to coordinate care across settings than clinicians in
APMs, ACOs or Medicare Advantage plans.
Population-based measures, such as preventable hospital admissions, readmissions, emergency
department visits and mortality rates, are particularly important. They can be used to calculate
benchmarks and facilitate quality comparisons within and across payment models both nationally and
within specific geographic regions. However, the specifications for population-based measures must be
appropriate for each unit of accountability in order to work effectively.
2
Pham et al, Primary Care Physicians' Links to Other Physicians through Medicare Patients: The Scope of Care
Coordination, AIM, February 2009.
3
NCQA, Latest Evidence: Benefits of the Patient-Centered Medical Home, June 2015.
4
Perry et al, Examining the Impact of Continuity of Care on Medicare Payments in the Medical Home Context, RTI
International, 2012
5
Romaire et al, Primary Care and Specialty Providers: An Assessment of Continuity of Care, Utilization and
Expenditures, Med Care 2014.
3. 3
Population-based measures are generally not appropriate for individual clinicians in MIPS who have little
ability to influence population outcomes. Holding individual clinicians responsible for such outcomes
when they lack shared accountability frameworks may create adverse incentives to avoid vulnerable
and complex patients.
The Medicare Payment Advisory Commission suggested aggregating clinicians in a community or
geographic region for measures that have limited meaning for individual clinicians.6
While individual clinicians might wonder about their contribution to a geographic region’s performance,
stakeholders need to understand the performance among the large number of clinicians outside
coherent accountable entities. Local aggregation would allow comparisons of population-based
measures among clinicians in a region under MIPS versus those in APMs, ACOs and MA plans. For non-
aggregated assessments of individual clinicians, measures of processes proven to improve outcomes,
like cancer screenings and good chronic care management, are appropriate.
Appropriate physician level measures are essential for patient decision-making, accountability and care
improvement. For all clinicians, measures must rely on credible electronic clinical data sources, including
claims whenever possible for the most reliable, robust information, and ease in reporting. Measure
collection from both clinicians and patients must increasingly be built into care delivery workflows, and
provide real-time actionable data for care improvement. All measures, whether from electronic or other
sources, must be audited and appropriately risk-adjusted to ensure that results are accurate and
appropriate to use for comparisons and payment purposes. Measurement must include reliable, valid
patient experience measures and leverage patient-generated data as much as possible as measurement
science and data collection evolve. Existing patient experience surveys and measures must be improved
to increase response rates and utility to clinicians.
PRINCIPLE C: Measurement should support rapid improvement and clinical decision making.
Beyond assessing and paying for value, measurement also needs to help clinicians rapidly identify gaps
in quality in order to improve their performance. Feedback must be much faster than the current lag of
months or years. Quality information also can help to inform and strengthen shared decision-making
tools that help patients and clinicians together make more informed treatment choices based on
patients’ own priorities.
Health information technology can be enhanced and embedded in clinical workflows to capture data for
measurement and rapid feedback that supports care management and other functions that clinicians
want. The EHR “Meaningful Use” program that MACRA incorporates into MIPS already encourages use
of data for population health, decision support, and measuring quality. Meaningful Use requirements
must include accurate, prompt reports for clinician quality improvement efforts. Ideally clinicians will get
the data at the point of care, a goal that will be difficult for physicians under MIPS and more likely
achieved by well-organized systems.
6
Medicare Payment Advisory Commission, Report to Congress: Medicare and the Health Care Delivery System,
Chapter 3, Measuring Quality of Care in Medicare, June 2014.
4. 4
For example, patient-reported outcome measures (PROMs) can be collected at the point of care for
many purposes. PROMs can inform care planning, support patient self-management, provide data
needed for rapid-cycle improvement and measure performance. It therefore will be helpful to develop
workflows that facilitate widespread use of PROMs in clinical care.
PRINCIPLE D: A core set of measures should let all stakeholders make comparisons across programs.
A core measure set will allow comparison across MIPS, APMs, ACOs and MA. Core measures will be
specified appropriately for the differing situations for individual clinicians, practice teams, ACOs and MA
plans, yet aligned in concept and intent to allow meaningful comparisons. The measures will draw from
data in claims, electronic health records (EHRs) and patient surveys to aggregate up to levels that matter
most to consumers, clinicians, plans, the community or state. They should maximize use of patient-
generated data about experience and outcomes. They must be relevant and meaningful to patients,
clinicians and other stakeholders alike. Measures also must continually evolve for advances in clinical
evidence, progress on measures that top out with little room for improvement, and improvements in
measurement science and methods of data collection.
Core set measures will address a common set of domains, identified with multi-stakeholder input, such
as those identified by the National Quality Strategy.7
Many existing measures address possible core
domains, such as preventive and evidence based care, and could facilitate cross-program comparison.
The core set can then support nesting of measures needed for other purposes. For example, groups of
measures can be used as building blocks that are aggregated for each core quality domain. Domain
scores meet the needs of consumers who prefer higher-level quality data, and other stakeholders
seeking to focus on a reduced measure set.
Measures also are needed outside the core set for certain sub-sets of populations and types of
clinicians. These include measures that specifically address the unique needs of vulnerable populations,
including patients with functional and cognitive limitations and serious mental illness. They also include
measures for specific medical specialties providing unique services not addressed in the core set. It is
essential to have measures appropriate for all needed purposes, and to not discard measures that help
clinicians improve value for the simplistic purpose of parsimony or fewer measures overall. The desire to
reduce burden should focus on selecting high-value, high-impact measures and efficient data collection,
not arbitrarily limiting the number of measures.
PRINCIPLE E: Quality measure results should be easy for consumers and payers to get and use.
All stakeholders need user-friendly information to make meaningful comparisons across all payment
models. However, formats and level of detail will likely differ among stakeholders. Translating complex
quality data into user-friendly information for each type of stakeholder is particularly important.
Consumers usually want cost information along with quality information, but it is a challenge to present
such complex information in a manner suitable to all levels of health literacy and numeracy. Current
efforts often hinder consumers’ ability to use value data effectively.
7
http://www.ahrq.gov/workingforquality/
5. 5
Many consumers may prefer to have quality information rolled up into composite scores, such as star
ratings. Other consumers will want more details on the multiple dimensions of clinical quality and how
they compare across different clinicians and payment arrangements. Those who want deeper
understanding will need plain-language explanations of how the information might affect care and guide
choices. To ensure that information genuinely facilitates consumers’ ability to make value-based
decisions, consumer and patient advocates need to be included throughout the process, from measure
selection to information display.
Measurement must account for the move toward bundled payments that Medicare already is making
and that APMs may accelerate. Bundled payments, which cover all clinicians and facilities participating
in care for a specific condition or episode, should be packaged in ways that make sense to patients, and
not be clinician-centric.
Salient messages are essential for making value data actionable and useful to consumers.
Clinicians need more specific data about how they compare to local and national peers to identify
improvement opportunities and achieve value-based payment rewards. They need timely, actionable
feedback as close as possible to delivery of care. Embedding results in clinical care workflow, as
described above, is essential. Policymakers, employers and insurers need even broader data to set
payments, focus improvement efforts and assess networks.
Conclusion
The powerful consensus and legislative mandate to move away from volume-driven fee-for-service
payment to instead reward value provides an historic opportunity to improve the quality, cost and
experience of health care. Groundbreaking efforts over the last quarter century to use performance
measurement to improve care are an excellent beginning, but not at all sufficient.
Now is the time for all stakeholders to again join together to advance the breadth and depth of
measurement that this opportunity requires. We hope the principles we have outlined in this paper help
to promote a robust dialogue on what is needed to move forward. We look forward to working with all
our colleagues to develop a clear plan of action for achieving the best value-based payment results.