PYA Principal Martie Ross and Senior Consultant Aaron Elias conducted a session at the Association of Healthcare Internal Auditors (AHIA) 36th Annual Conference. The presentation was titled: “The Times, They Are A- Changin’: Alternative Payment Models Panel Presentation.”
Areas of focus included:
•Discussing new payment models available to providers, including the Merit-Based Incentive Payment System and Advanced Alternative Payment Models.
•Exploring CMS’ progress toward goals related to payment reform.
•Understanding alternative payment models and pay-for-performance programs—which components require auditing and recommendations for potential auditing processes.
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted a webinar to discuss various aspects of the Advancing Care Coordination through Episode Payment Models (EPMs); Cardiac Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model proposals on Wednesday, August 31, 2016, from noon – 1:00 p.m. EDT.
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CMS Innovation Center
http://innovation.cms.gov
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The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted an open door forum providing letter of intent overview for the 2017 Next Generation Accountable Care Organization Model. The open door forum was held on Tuesday, March 22 from 4:00pm – 5:30pm EDT.
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CMS Innovation Center
http://innovation.cms.gov
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http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The Emergency Triage, Treat, and Transport (ET3) Model Medical Triage Line Notice of Funding Opportunity (NOFO) webinar provided an overview of the application process and NOFO requirements for implementing 911 medical triage lines. This webinar was intended for those interested in learning more about the ET3 Model’s Notice of Funding Opportunity, which was released March 12.
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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
Provider participation in accountable care organizations (ACOs) is becoming the new normal. As of January 1, 2016, there are 434 ACOs
in the Medicare Shared Savings Program. More than 160,000 providers now participate in an MSSP ACO. These organizations now serve
7.7 million Medicare beneficiaries residing in 49 of the 50 states. Here’s the road to the MSSP destination of shared savings.
PYA Managing Principal David McMillan presented “Risk-Based Payment Models,” which discusses:
-The transition from fee-for-service reimbursement to value-based payments.
-Several new models, including pay-for-performance, episodic payments, shared savings arrangements, and global budgets.
CMS Innovation Center, Center for Medicaid and CHIP Services staff will be hosting a webinar that will discuss how applicants can work with States and the role of States in the Strong Start funding opportunity. A series of follow up webinars will provide more in-depth information about other aspects of this initiative.
More at: http://innovations.cms.gov/resources/Strong-Start-Webinar-State-Partnerships.html
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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
The Medicare-Medicaid Accountable Care Organization Model team hosted a webinar for states that are participating in the Medicare-Medicaid ACO Model on Thursday, June 15, 2017. Participating states have the opportunity to share in Medicare savings generated by Medicare-Medicaid ACOs in their state. This webinar covered the methodology for calculating those shared savings.
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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
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted a webinar to discuss various aspects of the Advancing Care Coordination through Episode Payment Models (EPMs); Cardiac Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model proposals on Wednesday, August 31, 2016, from noon – 1:00 p.m. EDT.
- - -
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
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted an open door forum providing letter of intent overview for the 2017 Next Generation Accountable Care Organization Model. The open door forum was held on Tuesday, March 22 from 4:00pm – 5:30pm EDT.
- - -
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
The Emergency Triage, Treat, and Transport (ET3) Model Medical Triage Line Notice of Funding Opportunity (NOFO) webinar provided an overview of the application process and NOFO requirements for implementing 911 medical triage lines. This webinar was intended for those interested in learning more about the ET3 Model’s Notice of Funding Opportunity, which was released March 12.
- - -
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
Provider participation in accountable care organizations (ACOs) is becoming the new normal. As of January 1, 2016, there are 434 ACOs
in the Medicare Shared Savings Program. More than 160,000 providers now participate in an MSSP ACO. These organizations now serve
7.7 million Medicare beneficiaries residing in 49 of the 50 states. Here’s the road to the MSSP destination of shared savings.
PYA Managing Principal David McMillan presented “Risk-Based Payment Models,” which discusses:
-The transition from fee-for-service reimbursement to value-based payments.
-Several new models, including pay-for-performance, episodic payments, shared savings arrangements, and global budgets.
CMS Innovation Center, Center for Medicaid and CHIP Services staff will be hosting a webinar that will discuss how applicants can work with States and the role of States in the Strong Start funding opportunity. A series of follow up webinars will provide more in-depth information about other aspects of this initiative.
More at: http://innovations.cms.gov/resources/Strong-Start-Webinar-State-Partnerships.html
- - -
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
The Medicare-Medicaid Accountable Care Organization Model team hosted a webinar for states that are participating in the Medicare-Medicaid ACO Model on Thursday, June 15, 2017. Participating states have the opportunity to share in Medicare savings generated by Medicare-Medicaid ACOs in their state. This webinar covered the methodology for calculating those shared savings.
- - -
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
This Accountable Health Communities Model webinar was held on Wednesday, February 10, 2016 from 3:00 – 4:00pm EST. The webinar focused on the anticipated role of state Medicaid agencies in the model.
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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
The Center for Medicare and Medicaid Innovation (CMS Innovation Center) hosted a webinar on Monday, March 23, 2015 from 12:00pm to 1:00pm EDT to provide information and answer questions regarding payer participation in the Oncology Care Model.
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CMS Innovation Center
http://innovation.cms.gov
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http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
Attributes of well_performing_utilities_mv_g_0807Water Helpdesk
This 90 minute face-to-face module presents some of the external and internal factors associated with good performance of water utilities, as well as practical tools for assessing their functioning, and past and future reform paths. The intended format is a seminar which incorporates both a lecture and question and answer period.
The Third Way--Maintaining Independence Through Interdependence PYA, P.C.
In support of our partnership with the National Rural Health Association, PYA participated in the Rural Health Clinic and Critical Access Hospital Conference, September 30 to October 3, 2014, in Kansas City, MO. One session featured PYA Principals Jeff Ellis and Martie Ross, who shared their experiences and insights in developing and operating rural network alliances as a way for providers to maintain their independence through interdependence.
Accountable Care Organizations: 4 Physician BenefitsGreenway Health
Why would physicians join an Accountable Care Oragnization (ACO)? This informative slide presentation gives a brief overview of ACOs, their benefits, and four reasons physicians may have for joining one.
Regulatory Impact Analysis - Law & Economics courseWilliam Byrnes
Regulatory Impact Analysis - Law & Economics course
Effective regulation is regulation that achieves the policy objective that led to it being made.
Efficient regulation achieves these objectives at the lowest total cost to all members of society
SIMUL8 Director of Healthcare, Claire Cordeaux, discusses her experiences of developing and implementing population health strategies in the UK National Health Service, Canada, and Australia.
This Accountable Health Communities Model webinar was held on Wednesday, February 10, 2016 from 3:00 – 4:00pm EST. The webinar focused on the anticipated role of state Medicaid agencies in the model.
- - -
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
The Center for Medicare and Medicaid Innovation (CMS Innovation Center) hosted a webinar on Monday, March 23, 2015 from 12:00pm to 1:00pm EDT to provide information and answer questions regarding payer participation in the Oncology Care Model.
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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
Attributes of well_performing_utilities_mv_g_0807Water Helpdesk
This 90 minute face-to-face module presents some of the external and internal factors associated with good performance of water utilities, as well as practical tools for assessing their functioning, and past and future reform paths. The intended format is a seminar which incorporates both a lecture and question and answer period.
The Third Way--Maintaining Independence Through Interdependence PYA, P.C.
In support of our partnership with the National Rural Health Association, PYA participated in the Rural Health Clinic and Critical Access Hospital Conference, September 30 to October 3, 2014, in Kansas City, MO. One session featured PYA Principals Jeff Ellis and Martie Ross, who shared their experiences and insights in developing and operating rural network alliances as a way for providers to maintain their independence through interdependence.
Accountable Care Organizations: 4 Physician BenefitsGreenway Health
Why would physicians join an Accountable Care Oragnization (ACO)? This informative slide presentation gives a brief overview of ACOs, their benefits, and four reasons physicians may have for joining one.
Regulatory Impact Analysis - Law & Economics courseWilliam Byrnes
Regulatory Impact Analysis - Law & Economics course
Effective regulation is regulation that achieves the policy objective that led to it being made.
Efficient regulation achieves these objectives at the lowest total cost to all members of society
SIMUL8 Director of Healthcare, Claire Cordeaux, discusses her experiences of developing and implementing population health strategies in the UK National Health Service, Canada, and Australia.
As public and private insurers move away from traditional fee-for-service payments, healthcare organizations are struggling to make the leap. Market share, regional characteristics, financial health and an organization’s mission and culture are shaping the path as the flow of money shifts and the skills to manage and measure risk are being redirected in largely untested ways.
Will New Healthcare Policy Impact Value-Based Healthcare?Health Catalyst
The final days of 2016 were fraught with uncertainty about what Congress and the new Trump Administration would do to the Affordable Care Act (ACA) and the healthcare regulatory landscape overall. So far, in 2017, we do not have much more clarity. Repeal, repeal and replace, repeal and delay, modify without repeal—there are now even more questions than answers and still no consensus Republican plan in sight. Yet healthcare executives would certainly appreciate some modicum of clarity, at least on the narrower topic of whether the shift to value-based healthcare models will continue under whatever new system is coming. This webinar attempts to add clarity by analyzing what we know so far, as reflected in the limited actual evidence that is available.
Join Dan Orenstein, General Counsel, Health Catalyst, as he analyzes these three key pieces of information:
The 21st Century Cures Act (Cures)
The Executive Order on reducing the “burden” of the Affordable Care Act (ACA)
Tom Price’s comments at his confirmation hearings
Our advanced care model fills current gaps between intensive medical management of complex chronic illness, palliative care and hospice, and promotes appropriate use of these services.
Its features include:
- Accurately identifying and segmenting the high-risk, high-need advanced illness population (3-4% of Medicare beneficiaries; 6% duals),
- Engaging the personal physician (primary care and/or specialist) as a core member of the interdisciplinary team,
- Re-tooling existing clinicians’ roles and workflows in order to maximize skill-sets through team-based care management,
- Delivering advance care planning at the person’s own pace and in the preferred setting, and
- Extending the reach of palliative care into the community and across post- acute settings.
Learn more in this presentation!
As population health management goes mainstream, providers need robust, integrated software solutions to aggregate and analyze data, coordinate care, engage patients and clinicians, and provide full administrative and financial functionality. Population Health Management is a journey, and the number of approaches to population health are varied.
Sample Report: Global Alternative Online Payment Methods: First Half 2016yStats.com
Free Report Samples for our publication "Global Alternative Online Payment Methods: First Half 2016".
Find the full report available for purchase at: https://www.ystats.com/product/global-alternative-online-payment-methods-first-half-2016/
Driving Success with Alternative Payment ModelsSarah Roberts
1. Distinguish the shift in Post-Acute Reimbursement to Alternate Payment Methods
2. Describe qualities of those high performing, successful providers who will be winners in this environment.
3. Outline what a successful transition to these new payment models looks like.
4. Specify the tools you will need to be navigate this new environment.
5. Identify how to use the tools to demonstrate evidence of success.
The 3 Must-Have Qualities of a Care Management SystemHealth Catalyst
Care management systems are defined in many ways, but the only effective system comprises three qualities:
1.) It’s comprehensive and includes a suite of tools to address all five core competencies of care management.
2.) It’s inclusive of all EMRs and other data sources to enable thorough communication and analysis.
3.) It’s analytics-driven design facilitates clinical decision making and workflow.
Ultimately, an effective system improves outcomes and becomes an indispensable tool for managing population health.
This article describes what drives successful care management, and reveals a suite of applications that aid care team members and patients through advanced algorithms and embedded analytics. Learn how technology is helping to develop appropriate interventions and improve clinical and financial outcomes.
USS Value Based—Navigating Old Obstacles in the New WorldPYA, P.C.
A proud supporter of the American Health Lawyers Association (AHLA), PYA joined legal counselors, compliance officers, government representatives, and other attendees October 4-6, at the 2017 Fraud and Compliance Institute, held at the Renaissance Harborplace Hotel, Baltimore, MD. PYA Principal Carol Carden co-presented “USS Value Based—Navigating Old Obstacles in the New World,” with Robert G. Homchick, a partner with Davis Wright Tremaine. The presentation explored: alternative payment models, value-based payments under program waivers, fraud and abuse laws, and IRS rules, as well as valuation and commercial reasonableness of value-based payments.
Deployment of the Medicare Access and CHIP Reauthorization ActPYA, P.C.
PYA Principal Martie Ross and Senior Manager Graham Fox presented, “Mastering MIPS" at the American College of Healthcare Executives’ Congress on Healthcare Leadership.
Learning objectives included:
Gaining an understanding of MIPS—why it was implemented and how it will impact reimbursement, governance, and strategic planning for healthcare organizations.
Identifying questions organizations must consider during MIPS implementation that will lead to financial and operational success.
Alternative Payment Models: The Good, the Bad, and the UglyPYA, P.C.
Real-world examples and case studies related to operationalizing, remaining compliant, valuing APMs and the evolving alternative payment models (APMs) as a catalyst for change and innovation in healthcare delivery are discussed during the presentation, “Alternative Payment Models: The Good, The Bad, and The Ugly.”
The Changing Healthcare System and Impact of MACRAPYA, P.C.
PYA Principal Lori Foley and Consulting Senior Aaron Elias co-presented “The Changing Healthcare System and Impact of MACRA” at the Physician Insurers Association of America’s CEO/COO Meeting.
The Medicare Access & CHIP Reauthorization Act (MACRA) dramatically affected Medicare reimbursements to healthcare providers, as well as provided a new framework for rewarding quality care and reporting on quality measurements. This incentive-based system has the potential not only to change how medicine is practiced, but influence patient perception of care. The presentation will provide the latest information on MACRA implementation, and will detail how the aforementioned changes will impact miscellaneous professional liability insurers.
Valuing Value: Issues Associated with the Valuation of Alternative Payment Mo...PYA, P.C.
Many providers face challenges when transitioning from fee-for-service payments to value-based reimbursement. In this presentation, existing market data and regulatory guidance will be discussed, and considerations for the determination of fair market value and commercial reasonableness for such models will be explored.
The Vicissitudes of Valuing Value--Legal and Valuation Issues Associated with...PYA, P.C.
PYA Principal Carol Carden co-presented “The Vicissitudes of Valuing Value--Legal and Valuation Issues Associated with Value-Based Payment Models” at the 2017 American Health Lawyers Association Physician and Hospitals Law Institute, February 1-3, 2017, in Orlando, Florida.
The presentation addressed:
Emerging alternative payment models (APMs)
The application of fraud and abuse laws and IRS rules to provider network payments
Existing market data and regulatory guidance
Considerations in determining fair market value and commercial reasonableness
The Need to Embrace Profit Cycle Management in Healthcare - WhitepaperGE Healthcare - IT
Executive Overview
Healthcare organizations have been operating under a fee-for-service
model for many years. As such, financial leaders have become well
versed in implementing revenue cycle management systems and
processes that primarily focus on the money that comes into an
organization. Today, a new need is emerging. Healthcare reform
and other system changes are moving the industry toward hybrid
payment models such as bundled payments, shared savings, and
capitation. To thrive in this new environment, financial leaders need
to move toward profit cycle management – an emerging model
that matches the revenues from new payment models with an
improved understanding of the true costs to deliver patient care.
The result: Positive financial performance – even in the face of
declining payments – that can be reinvested in the mission to
provide better care.
The foundation of any business or household is profit, defined as
revenue net of expenses (and applicable as such even to not-for-profit
organizations). Regardless of whether you are start-up, a Fortune 500
company, or a family of four, you need to ensure that you are bringing
in more money than you are spending. In many businesses, the
formula to determine your “profitability” is fairly straightforward.
In healthcare, however, the situation is significantly more complex,
as existing and new payment models make it difficult to determine
exactly how much revenue is going to come in the door. On the cost
side, the move to accountable care and value-based payment has
shifted the management of risk and cost onto the providers and
delivery networks, yet most providers lack the tools that would
provide a detailed understanding of the costs required to deliver
quality care, especially when that care is delivered in multiple
locations. A new model of software tools is required – representing
the next generation of revenue cycle management tools and an
emerging class of healthcare cost accounting tools. The end goal?
A solution for profit cycle management that will help organizations
generate a positive financial performance and can be reinvested
in the mission to provide better care.
This change will not happen overnight. Rather, it will be an evolution
over the next five years, as integrated delivery networks update
their revenue cycle solutions to accommodate the new payment
models, and as they deploy new activity-based costing solutions.
PYA Principal Martie Ross joined University of Kansas Medical Center’s Robert Moser, MD, and CIO Chris Hansen for the keynote presentation at the joint symposium by Heart of America Healthcare Information and Management Systems Society and Missouri Health Information Management Association, September 14, 2016, at Johnson County Community College in Overland Park, Kansas. They discussed insights related to the role of advanced analytics and technology in transforming and transitioning to new payment models.
During this webinar the Primary Care First Model Options team provided an introduction to the Primary Care First Model that is geared towards payers, presented and answered questions live on topics related to payer partnership, including the Primary Care First payer alignment framework, benefits of multi-payer partnership, and the payer solicitation elements and selection process.
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CMS Innovation Center
http://innovation.cms.gov
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Key issues in physician alignment and compensation 6 7-15Polsinelli PC
Developing and implementing effective physician alignment and compensation strategies is essential to the stability and success of any health care entity. Alignment and compensation strategies that evolve along with industry trends and follow proven "best practices" will yield dividends from both a legal and fiscal standpoint, and ensure that health care organizations and providers enjoy stable and productive relationships that reduce the probability of future challenge.
Compliance Design in a World of New Models PYA, P.C.
This presentation discusses mitigating compliance risks presented by new payment models, creating a compliance culture through human resources, leveraging new regulations to increase access to care and reduce costs, and how to educate start-ups and nontraditional facilities about integrity principles within compliance programs.
This presentation defined the disconnect between productivity-based physician compensation models and the demands of value-based payment models; identified and evaluated alternative physician compensation models; addressed the challenges in transitioning from volume-based to value-based compensation; studied how current fraud and abuse laws conflict with strategies related to value-based compensation, and explore potential solutions.
This presentation defined the disconnect between productivity-based physician compensation models and the demands of value-based payment models; identified and evaluated alternative physician compensation models; addressed the challenges in transitioning from volume-based to value-based compensation; studied how current fraud and abuse laws conflict with strategies related to value-based compensation, and exploree potential solutions.
The Bumpy Road Ahead New Challenges Facing PracticesCureMD
Insurance mergers, shift to alternative payment models, Meaningful Use stage 2, preventing data breaches, pressure to consolidate – welcome to 2016.
Your patience is not the only thing at stake when these changes kick in. Your hard earned money will become harder to collect and worse to retain. While we cannot wish these changes away, we can help you fight them.
The Evolving Role of the Compliance Officer in the Age of Accountable CarePYA, P.C.
PYA Consulting Principals Jeff Ellis and Martie Ross presented at the Health Care Compliance Association 2013 Midwest Regional Compliance Conference in Overland Park, Kansas. Ellis and Ross teamed up to explore, “The Evolving Role of the Compliance Officer in the Age of Accountable Care.”
Top Healthcare and Revenue Cycle Trends to watch for in 2019Manish Jain
2017 required healthcare organizations to respond to several new challenges – political change, growing role of technology, shift to value-based care and the increasing role of information security. While we anticipate that these issues will continue to influence through 2018, we will also see new challenges. The blurring lines between providers and payers, a refocusing on care (and more so on the patient), and a changing policy environment will occupy the center stage for 2018.
Webinar: “While You Were Sleeping…Proposed Rule Positioned to Significantly I...PYA, P.C.
You likely know from the headlines that the 2021 Medicare Physician Fee Schedule (MPFS) Proposed Rule slashes payments for surgical specialists. But the impact of the Proposed Rule is far broader, reflecting a fundamental realignment driven by the transition to value-based payments. In our webinar, “While You Were Sleeping…Proposed Rule Positioned to Significantly Impact Physician Compensation,” PYA experts addressed these proposals, helping you understand and prepare for the changes ahead.
Following this presentation, attendees were able to:
Understand how a handful of wRVU changes would alter Medicare reimbursement for nearly all physicians.
Appreciate the operational impact of these changes.
Recognize the challenges to existing physician compensation models.
Identify strategies and tactics to prepare for and manage these impacts.
Presenters include PYA Principals Angie Caldwell, Martie Ross, and Valerie Rock. The webinar took place Thursday, September 10 and was hosted in conjunction with the Florida Hospital Association.
If you have additional questions about the MPFS Proposed Rule and its impact on physician compensation or need assistance with any matter involving physician compensation, valuation, strategy and integration, or compliance, contact a PYA executive below at (800) 270-9629.
Similar to PYA to Tackle Organizational Risks, Alternative Payment Models, and HIPAA Audits at the 2017 AHIA Annual Conference (20)
“CARES Act Provider Relief Fund: Opportunities, Compliance, and Reporting”PYA, P.C.
PYA Principal Martie Ross spoke at the virtual North Carolina Healthcare Association Critical Access Hospital Statewide Meeting. The two-day event, “Quality Focus is a Finance Focus,” provided critical access hospital leaders with the opportunity to network and review data-informed strategies as well as updates to the Medicare Flexibility Program Project. It also provided guidance on federal compliance and tracking of Provider Relief Funds.
In “CARES Act Provider Relief Fund: Opportunities, Compliance, and Reporting,” Martie gave an overview of the history of distribution of those funds as well as regulations and guidelines including:
Statutory Language
Reporting Requirements
Use of Funds Calculation
Expenses
Risk Management
Martie presented Thursday, March 4, 2021.
If you would like guidance related to Provider Relief Fund regulations, or for assistance with any matter related to strategy and integration, compliance, or valuation, contact one of our PYA executives at (800) 270-9629.
PYA Presented on 2021 E/M Changes and a CARES Act Update During GHA Complianc...PYA, P.C.
The Georgia Hospital Association (GHA) Compliance Officers Roundtable, an active GHA group that meets quarterly and includes educational sessions featuring government representatives, industry experts, and other thought leaders speaking about compliance-related issues, conducted their latest meeting virtually. PYA Principals Lori Foley, Tynan Kugler, and Valerie Rock were among the presenters at this quarter’s event. In their session, they:
Described key elements associated with 2021 E/M changes, and strategies for preparation and implementation.
Explained the impact of 2021 E/M changes on physician compensation and contracting, including potential mitigation approaches.
Presented key components of Stark Law and Anti-Kickback Statute final rules.
Provided an update on the CARES Act.
The Compliance Certification Board offered CEUs for this event, which took place on Friday, December 4, 2020.
Webinar: “Trick or Treat? October 22nd Revisions to Provider Relief Fund Repo...PYA, P.C.
On October 22nd, the Department of Health and Human Services released revised Provider Relief Fund (PRF) reporting requirements. Under HHS’ September 19 directive, “lost revenue” was defined narrowly as a negative change in year-over-year patient care operating net income. Now, HHS will permit providers to use PRF funds to cover the difference between their 2019 and 2020 actual patient care revenue with some adjustments for COVID-related expenses. The October 22nd notice is available here.
PYA Principals Martie Ross and Michael Ramey hosted a complimentary 30-minute webinar, “Trick or Treat? October 22nd Revisions to Provider Relief Fund Reporting Requirements” on Thursday, October 29th.
“Regulatory Compliance Enforcement Update: Getting Results from the Guidance” PYA, P.C.
PYA Principal and Chief Compliance Officer Shannon Sumner and Consulting Senior Manager Susan Thomas presented “Regulatory Compliance Enforcement Update: Getting Results from the Guidance” at the virtual 2020 Montana Healthcare Conference. They reviewed the sources of regulatory enforcement and investigation information—guidelines, statutory updates, best practices, settlements, case studies, etc.—available to healthcare organizations. They will also discuss how to interpret and implement the guidance in order to strengthen the compliance function and protect the organization. The presentation covered:
Compliance regulatory requirements for healthcare organizations.
Guidance available for consideration in organizational compliance programs.
Internal and external reporting to ensure regulatory requirements are met.
Best practices for implementation of guidance.
Case studies for illustration of guidance implementation.
“Federal Legislative and Regulatory Update,” Webinar at DFWHCPYA, P.C.
The Dallas Fort Worth Hospital Council (DFWHC) and PYA co-hosted an exclusive complimentary webinar, “Federal Legislative and Regulatory Update,” on Wednesday, September 23.
DFWHC President/CEO Stephen Love hosted a discussion with PYA Senior Manager Kathy Reep about concerns that have dropped from the radar during the last four months of COVID-19, addressing issues for which hospitals must prepare in approaching 2021. This session focused on these key areas:
Appropriate use criteria
Transparency
Site neutral payments
The future of the Medicare Trust Fund
The federal budget
Key provisions of the final rule for the inpatient prospective payment system for FY2021 and the proposed outpatient rule for CY2021
On-Demand Webinar: Compliance With New Provider Relief Funds Reporting Requir...PYA, P.C.
On September 19, the Department of Health and Human Services (HHS) published its Post-Payment Notice of Reporting Requirements. The Notice details the reporting requirements for all Provider Relief Fund (PRF) recipients that have received $10,000 or more in aggregate payments.
Under the PRF Terms and Conditions, a recipient may use the funds only for healthcare-related expenses and lost revenue attributable to coronavirus. The Notice provides the clearest direction to date regarding permissible uses of PRF funds.
PYA offered a 45-minute complimentary webinar that explained the new reporting requirements and delved into permissible uses. While many questions remain, we provided practical advice on the next steps in the reporting process.
The webinar took place Monday, October 5 at 11 a.m. EDT.
Webinar: “Cybersecurity During COVID-19: A Look Behind the ScenesPYA, P.C.
Cybersecurity breaches have been in the news almost daily for some time now. COVID-19 has amplified the problem, as “bad actors” seize upon the opportunity to take advantage of hospitals at their most vulnerable time. Given this climate and an aging HIPAA rule, it is difficult to anticipate and prepare for the future.
PYA Principal Barry Mathis presented “Cybersecurity During COVID-19: A Look Behind the Scenes,” on Wednesday, August 12, 2020. This one-hour, complimentary webinar was hosted by PYA in conjunction with the Montana Hospital Association as Part 2 of the Frontier States Town Hall Meeting.
Barry covered information related to HIPAA, cybersecurity, and a special behind-the-scenes view into the tradecraft of bad actors. This unique presentation included:
Recent enforcement trends by the Office for Civil Rights.
The current environment for ransomware.
An opportunity to watch as Barry logs onto the Dark Web and shows you first-hand how bad actors operate.
Ideas for managing cybersecurity threats.
On Friday, August 21, 2020, a webinar co-hosted by PYA prepared hospitals for a new rule taking effect on January 1, 2021, to address price transparency in healthcare. The Centers for Medicare & Medicaid Services published a rule in November 2019 requiring hospitals to establish, update, and make public a list of their standard charges for items and services they provide. In addition to the current requirement to post standard charges on their websites, the Final Rule requires hospitals to publish online, in a machine-readable format, their payer-specific negotiated rates for 300 “shoppable” services and their standard charges for all items and services provided, defined as the gross charge, payer-specific negotiated charges, discounted cash price, and the de-identified minimum and maximum charges.
As we approach January 2021, it is vital that hospitals understand the requirements of the pricing transparency rule and options for compliance. It is unlikely that this rule will “go away”–court decisions are always subject to appeal, and there is even concern that Congress is considering action that would transform these requirements from regulation to legislation.
During the complimentary webinar, PYA Senior Manager Kathy Reep discussed hospital requirements related to pricing transparency, and Chris Kenny, Partner in the Washington, D.C., office of King & Spalding, addressed concerns related to compliance and the legal challenges associated with the final transparency rule.
This webinar was presented in conjunction with:
Dallas-Fort Worth Hospital Council
Florida Hospital Association
Georgia Hospital Association
Kansas Hospital Association
Louisiana Hospital Association
Montana Hospital Association
Not a surprise to most — healthcare is making headlines on an international level. Though not front and center, still of importance to the hospital community are issues working their way through government agencies and the legislature.
As one of the keynote speakers of this year’s virtual Florida Institute of CPAs Health Care Industry Conference, PYA Senior Manager Kathy Reep presented a “Federal Legislative and Regulatory Update.” She covered a number of current issues affecting healthcare providers, including:
Price transparency.
Congressional action on surprise billing.
The Administration’s budget for 2021.
Medicare proposed rules related to hospital inpatient payments and post-acute care for FY2021.
The virtual event took place June 23-24, 2020.
Webinar: Post-Pandemic Provider Realignment — Navigating An Uncertain MarketPYA, P.C.
The COVID-19 pandemic will materially affect U.S. provider industry structure, as financial weaknesses are exposed, risk tolerances are tested, and uncertainties persist. As a result, provider mergers-and-acquisitions (M&A) activities across industry sectors will likely spike in the short- to medium-term future. Providers of all types need to be aware of, and prepared for, the changes they will face.
In this 45-minute joint webinar, PYA Principal Brian Fuller and Juniper Advisory Managing Director Jordan Shields provided a real-time assessment of the COVID-19 pandemic, as well as shared predictions for what the extending crisis means in coming years for M&A activity in the provider space.
The webinar took place Thursday, August 6, 2020, at 11 a.m. EDT.
Since March, PYA experts have closely tracked and carefully evaluated the pandemic’s impact on employed physician compensation. During this complimentary one-hour webinar, PYA Principals Angie Caldwell and Martie Ross highlighted five immediate considerations for hospitals and health systems to manage the storm. They also explored five longer-term considerations impacting future planning.
This webinar took place Friday, July 24, 2020, at 11 a.m. EDT, and was held in conjunction with:
Dallas-Fort Worth Hospital Council
Florida Hospital Association
Kansas Hospital Association
Montana Hospital Association
The COVID-19 pandemic has exposed organizational and industry weaknesses. To build a more resilient delivery system, leaders now must engage their governing boards in re-calibrating strategic plans, re-evaluating investments, and re-imagining hospitals’ and health systems’ roles in their communities.
In this 45-minute webinar, PYA Principals Martie Ross and Brian Fuller provided a framework for these critical discussions including root-cause analysis, market assessment, new realities, guiding principles, and strategic and operational priorities.
This webinar originally took place on Wednesday, June 24, 2020.
Webinar: Free Money with Strings Attached – Cares Act Considerations for Fron...PYA, P.C.
PYA, in conjunction with the Montana Hospital Association, recently co-hosted a Frontier States Town Hall Meeting webinar, “Free Money With Strings Attached: CARES Act Considerations for Frontier States’ Healthcare Provider Organizations.” Principals Lori Foley, Martie Ross, and David McMillan introduced the CARES Act Provider Relief Fund including distribution formulas, the attestation process, the verification and application process, and ongoing recordkeeping requirement. They also answered attendees’ numerous questions regarding these matters.
Webinar: “Got a Payroll? Don’t Leave Money on the Table”PYA, P.C.
Under the CARES Act, every employer with a payroll has an opportunity to retain cash–whether they have a PPP loan or not. What employers need to know right now.
The Coronavirus Aid, Relief, and Economic Security Act (CARES Act) along with the Payroll Protection Program (PPP) offer all business owners relief, but the details can be confusing or overlooked.
Perhaps you don’t fully understand how the deferral of the employer’s share of Social Security taxes works. Maybe you wonder if the deferral even applies to you—good news, it does if you have a payroll!
Failure to fully understand your options could cost you money, at a time when “cash is king.”
As part of PYA’s ongoing commitment to sharing helpful guidance, Tax Principals Debbie Ernsberger and Mark Brumbelow outlined issues and opportunities within the CARES Act, and answered questions during a one-hour webinar that originally aired on Wednesday, May 20, 2020.
Webinar: So You Have a PPP Loan. Now What?PYA, P.C.
The CARES Act provides relief to small businesses through Paycheck Protection Program (PPP) loans, but receiving the loan is only the first part of the equation. PYA discussed what businesses need to know and do next.
Failure to fully understand the requirements for PPP loan forgiveness could cost employers money, at a time when every penny counts. Employers need to stay up-to-date on recent activities regarding the PPP loan forgiveness application, necessary documentation, and other best practices to ensure they are well-prepared for the next steps under the PPP.
As part of PYA’s ongoing commitment to sharing helpful guidance, Tax Principals Debbie Ernsberger and Mark Brumbelow outlined PPP loan forgiveness requirements and answered questions during a one-hour webinar on Wednesday, June 3, 2020.
Webinar: “Making It Work—Physician Compensation During the COVID-19 Pandemic”PYA, P.C.
What to do with your physician compensation plan in the face of the COVID-19 pandemic? It’s a question that leaves administrators searching for answers.
PYA Principal Angie Caldwell and Senior Manager Katie Culver introduced several key considerations for provider compensation during and after the COVID-19 pandemic. In PYA’s complimentary webinar, they:
Summarized the current environment impacting physician compensation associated with the pandemic.
Provided an overview of the Stark Blanket Waivers and opportunities created for physician compensation.
Described restoration and recovery strategies for physician resources.
PYA hosted this one-hour webinar Tuesday, April 28, 2020, at 11 a.m. EDT in conjunction with the Florida Hospital Association.
Webinar: “Provider Relief Fund Payments – What We Know, What We Don’t Know, W...PYA, P.C.
The federal government is now making CARES Act Relief Fund payments to Medicare providers. These payments are not loans—they do not have to be repaid or forgiven. However, this money comes with strings attached.
During PYA’s 30-minute webinar, Provider Relief Fund Payments—What We Know, What We Don’t Know, What To Do Now, PYA Principals Martie Ross and Lori Foley discussed:
The source of the funds.
The required attestation process.
Compliance, tax, and audit concerns.
The webinar took place Friday April 17, 2020.
Webinar: “Hospitals, Capital, and Cashflow Under COVID-19”PYA, P.C.
Hospitals and providers need to think creatively, strategically, and long-term about capital and cashflow under the pressures of the COVID-19 pandemic. A one-hour webinar hosted by PYA discussed the current state of capital markets for non-profit healthcare systems, and considerations for capital management, including the role of real estate assets.
PYA Principal Michael Ramey joined Realty Trust Group Senior Vice-President Michael Honeycutt and Ponder & Company Managing Director Jeffrey B. Sahrbeck to present “Hospitals, Capital, and Cashflow, Under COVID-19” In this webinar, they covered:
Hospital industry capital market updates and trends, including how the capital markets are responding to the crisis.
Access to capital under recent regulations.
Cash preservation techniques for hospitals considering real estate operations and assets.
The webinar took place Thursday, April 9, 2020, at 11 a.m. EDT.
PYA Webinar: “Additional Expansion of Medicare Telehealth Coverage During COV...PYA, P.C.
Late on March 30, CMS released an interim rule which, among other things, significantly expands Medicare telehealth coverage, even beyond the initial Section 1135 waivers. PYA’s complimentary one-hour webinar explained these changes and how they make telehealth an even more attractive option in response to the COVID-19 pandemic.
PYA Principals Martie Ross and Valerie Rock addressed the latest developments, including:
New reimbursement for telephone-only services.
Broader coverage for remote patient monitoring.
New payments for rural health clinics and federally qualified health centers.
Use of telehealth to meet supervision requirements.
New rules regarding coding and billing as well as the changed payment rates for telehealth services.
The webinar took place Friday April 3, 2020, at 11 a.m. EDT.
Webinar: “Getting Online with Telehealth: Practical Guidance for Physician Pr...PYA, P.C.
Medicare’s decision to reimburse for telehealth services, concerns for patient and staff safety, and the loss of revenue from canceled elective procedures are leading many physician practices to consider providing or expanding telehealth services.
During this webinar, PYA’s panel of heavy-hitting experts provided guidance physician practices can use to rollout, or further tap into, the telehealth opportunity. The presenters discussed:
Technology options and speed-to-implementation.
Solutions to internal process challenges.
Patient engagement in telehealth.
PYA hosted this one-hour webinar Thursday, March 26, 2020, at 4 p.m. EDT.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
We understand the unique challenges pickleball players face and are committed to helping you stay healthy and active. In this presentation, we’ll explore the three most common pickleball injuries and provide strategies for prevention and treatment.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
India Clinical Trials Market: Industry Size and Growth Trends [2030] Analyzed...Kumar Satyam
According to TechSci Research report, "India Clinical Trials Market- By Region, Competition, Forecast & Opportunities, 2030F," the India Clinical Trials Market was valued at USD 2.05 billion in 2024 and is projected to grow at a compound annual growth rate (CAGR) of 8.64% through 2030. The market is driven by a variety of factors, making India an attractive destination for pharmaceutical companies and researchers. India's vast and diverse patient population, cost-effective operational environment, and a large pool of skilled medical professionals contribute significantly to the market's growth. Additionally, increasing government support in streamlining regulations and the growing prevalence of lifestyle diseases further propel the clinical trials market.
Growing Prevalence of Lifestyle Diseases
The rising incidence of lifestyle diseases such as diabetes, cardiovascular diseases, and cancer is a major trend driving the clinical trials market in India. These conditions necessitate the development and testing of new treatment methods, creating a robust demand for clinical trials. The increasing burden of these diseases highlights the need for innovative therapies and underscores the importance of India as a key player in global clinical research.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
4. Page 3
A Movement Is Underway
Committed to having
75% of respective
businesses operating
under value-based
payments by 2020
5. Page 4
APM Framework
FEE-FOR-SERVICE
(FFS) PAYMENTS
POPULATION-BASED
APMs
ADJUSTED FFS
PAYMENTS
APMs INCORPORATING
FFS PAYMENTS
$
$
Bank
A Pay for
Reporting
B Pay for
Performance
C Foundational
Payments for
Infrastructure
and Operations
A APMs with Upside
Gainsharing
B APMs with Upside
Gainsharing /
Downside Risk
A Condition-Specific
Population-
Based
Payments
B Direct Primary Care
C Comprehensive
Population-
Based
Payments
A Traditional FFS
Source: Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework Final Whitepaper (2017)
6. Page 5
Payment Reform in Action
Source: Health Care Payment Learning & Action Network, Alternative Payment Model (APM) Framework Final Whitepaper (2017)
7. Page 6
Payment Reform in Action
One-quarter of commercial plan payments
now flow through APMs.*
* Health Care Payment Learning & Action Network 2016 Commercial Payer Survey (respondents represent over 128 million covered lives, or
nearly 44% of the combined commercial, Medicare Advantage, and Medicaid markets)
8. Page 7
FFS Care Management
Rewards the monitoring and maintenance of care plans
Other Examples:
Advance Care Planning
Behavioral Health
Integration
Chronic Care Management
Incentive: Payment for non-face-to-
face time caring for
patients
Structure: Expanded CCM
program in the 2017
Medicare Physician
Fee Schedule
Separate payment for
care plan development
Transitional Care Management
Incentive: Payment to smooth
transitions between
providers
Structure: Providers must make
contact with
beneficiaries within 7 or
14 days of discharge
9. Page 8
Spotlight: CPC+
Comprehensive Primary Care Plus
Key Features
Multi-payer
PBPM care management fee to
support infrastructure development
PBPM refundable performance
payment
Adjusted E/M payments (Track 2)
2,866 primary care practices
across 18 selected regions (by
January 1, 2018)
Includes:
Care Management Fees
Performance-Based Incentive
Payments
Care
Management
Fee (PBPM)
Performance-
Based Incentive
Payment (PBPM)
Payment
Structure
Redesign
Objective
Support augmented
staffing and training
for delivering
comprehensive
primary care
Reward practice
performance on
utilization and quality
of care
Reduce
dependence on
visit-based fee-for-
service to offer
flexibility in care
setting
Track 1 $15 average $2.50 opportunity
N/A
(Standard FFS)
Track 2
$28 average;
including $100 to
support patients with
complex needs
$4.00 opportunity
Reduce FFS with
prospective
“Comprehensive
Primary Care
Payment” (CPCP)
10. Page 9
Pay for Performance
9
Pay for reporting
Bonus payments based on quality scores
Upward/downward adjustments to fee schedule
payments
11. Page 10
Spotlight: MIPS
Merit-Based Incentive Payment System is the primary pay-for-performance
program
Quality Cost
Improvement
Activities
Advancing Care
Information
−Report quality
measures
−Scored based on
relative
performance
−“Practice
Transformation”
−Drive patient-
centered care
−Promote expanded
adoption of EHRs
−Improve utilization
and sharing of
electronic health
information
−Drive efficient care
−Providers forced to
accept risk
60%
0%
15%
25%
60%
0%
15%
25% 30%
30%
15%
25%
2017 Performance Year 2018 Performance Year 2019 Performance Year
Impacts 2019 Payments Impacts 2020 Payments Impacts 2021 Payments
12. Page 11
Shared Savings Arrangements
Rewards providers for working together to reduce payer’s cost
for an attributed population
Incentive: Portion of the savings realized, in addition to
fee-for-service payments
Structure: One- or two-sided models depending on risk
tolerance
Examples: Medicare Shared Savings Program
Next generation ACOs
Commercial payer programs
13. Page 12
Spotlight: MSSP
Medicare Shared Savings Program
▪ Rewards ACOs that lower
growth in healthcare costs
while meeting performance
standards
Medicare pays providers under
the Medicare Fee-For-Service
payment systems
ACO spending measured against
a historical financial benchmark
Shared savings are subjected to
adjustment based on quality
Tracks 1+, 2, and 3 count as
Advanced APMs under QPP
Track 1
One-sided risk
Sharing rate: Up to 50%
Performance payment limit: 10%
Track
1+
Two-sided risk
Sharing rate: Up to 50%
Performance payment limit: 10%
Shared loss rate: Fixed 30%
Prospective beneficiary assignment
Choice of MSR/MLR
Track 2
Two-sided risk
Sharing rate: Up to 60%
Performance payment limit: 15%
Shared loss rate: 40% - 60%
Track 3
Two-sided risk
Sharing rate: Up to 70%
Performance payment limit: 20%
Shared loss rate: 40% - 75%
Prospective beneficiary assignment
14. Page 13
Spotlight: MSSP
13
MSSP Waivers
ACO Pre-Participation Wavier
ACO Participation Wavier
Shared Savings Distribution Waiver
Compliance with the Stark Law Waiver
Patient Incentive Waiver
Protect financial arrangements that further the purposes
of the MSSP from challenge under the Anti-Kickback
Statute, the Stark Law, and Civil Monetary Penalties Act
15. Page 14
Episodic (Bundled) Payments
Rewards coordination and efficiency among all providers within
a specific episode of care
Incentive: Retain overage of payment if costs are managed
below target
Structure: Payment for all services furnished during an
identified cost of care, prospective or retrospective
models depending on risk tolerance
Examples: Bundled Payment for Care Improvement
Oncology Care Model
Comprehensive Care for Joint Replacement
Episodic Payment Model
16. Page 15
Spotlight: CJR
Comprehensive Care for Joint Replacement
▪ Hospitals accountable for quality and cost for hip and
knee replacement surgeries (adding hip and femur
fractures effective January 1, 2018)
▪ Incentivizes increased coordination of care among:
Hospitals
Physicians
Post-acute care providers
▪ 90-day episode of care
▪ 67 MSAs included
17. Page 16
Spotlight: EPM
Episode Payment Model
▪ Final rule released December 20, 2016
Effective January 1, 2018
▪ New models:
Acute Myocardial Infarction (AMI)
Coronary Artery Bypass Grafting (CABG)
▪ 98 MSAs included
18. Page 17
EPM Bundle Definitions
AMI, CABG, & SHFFT
AMI CABG
Services included Part A and B services
Episode start
At admission for AMI
treatment
At admission for CABG
treatment
Episode end 90 days following hospital discharge
Payment Retrospective
MS-DRGs
280, 281, 282
Contingent:
246, 247, 248, 249, 250,
251
231, 232, 233, 234, 235,
236
19. Page 18
Example: AMI Analysis
PYA performed
analytics for AMI
episodes in
Nashville, TN market
Episodes initiated at
10 different
Nashville-area
hospitals
260 different SNFs,
outpatient facilities,
and home health
agencies
KEYFINDINGS
Among these 270 organizations, there was a wide
variation in AMI-associated costs – ranging from
$5,500 to $58,000
By far, the largest drivers of cost variations were
hospital readmissions and length of SNF stays
Among the costliest 20% of episodes, the average
was $43,200 - nearly 4 times higher than the overall
average
The overall AMI readmission rate was 27%, but the
20% highest paid episodes had a rate nearly 3 times
higher: 76%
The top quintile of highest paid episodes had SNF
costs that were 3 times higher than the overall
average
20. Page 19
Gainsharing Under Cardiac EPMs
19
Three permitted financial arrangements under a Sharing
Arrangement
Sharing a Reconciliation Payment with an EPM
Collaborator--hospitals may pay all or a portion of the
reconciliation payment for a given performance year
Sharing Internal Cost Savings with an EPM Collaborator--
hospitals may share measurable and actual cost savings
with EPM collaborators
Sharing a Repayment Obligation with an EPM
Collaborator--hospitals may pay all or a portion of the
repayment obligation to CMS
21. Page 20
Global Budgets
Rewards provider network for managing a defined patient
population within a single budget
Incentive: Reduce unnecessary and avoidable services to
remain within budget
Structure: Advance payment for network to assume full
responsibility for defined population
Examples: Comprehensive ESRD Care Model
Provider-led Medicare Advantage plans
28. Page 27
Thank You
27
Aaron Elias
Senior Consultant
PYA
aelias@pyapc.com
(319) 560-0716
Martie Ross
Principal
PYA
mross@pyapc.com
(913) 232-5145
Susan Thomas
Senior Manager
PYA
sthomas@pyapc.com
(913) 232-5145
Editor's Notes
Mississippi is NOT a selected region
Only a handful of counties in MS are part of an MSA for CCJR, in the Northwest
AMI
MS-DRG 280 (Acute myocardial infarction, discharged alive with MCC),
MS-DRG 281 (Acute myocardial infarction, discharged alive with CC),
MS-DRG 282 (Acute myocardial infarction, discharged alive without CC/MCC).
Percutaneous catheter insertion including an AMI ICD-10-CM diagnosis code in the principal or secondary position on the IPPS claim
MS-DRG 246 (Percutaneous cardiovascular procedures with drug-eluting stent with MCC or 4+ vessels/stents),
MS-DRG 247 (Percutaneous cardiovascular procedures with drug-eluting stent without MCC),
MS-DRG 248 (Percutaneous cardiovascular procedures with non-drug-eluting stent with MCC or 4+ vessels/stents),
MS-DRG 249 (Percutaneous cardiovascular procedures with non-drug-eluting stent without MCC),
MS-DRG 250 Percutaneous cardiovascular procedures without coronary artery stent with MCC), and
MS-DRG 251 (Percutaneous cardiovascular procedures without coronary artery stent without MCC).
CABG
MS-DRG 231 (Coronary bypass with percutaneous transluminal coronary angioplasty (PTCA) with MCC),
MS-DRG 232 (Coronary bypass with PTCA without MCC),
MS-DRG 233 (Coronary bypass with cardiac catheterization with MCC),
MS-DRG 234 (Coronary bypass with cardiac catheterization without MCC),
MS-DRG 235 (Coronary bypass without cardiac catheterization with MCC), or
MS-DRG 236 (Coronary bypass without cardiac catheterization without MCC).
SHFFT:
MS-DRG 480 (Hip and femur procedures except major joint with major complication or comorbidity - CC),
MS-DRG 481 (Hip and femur procedures except major joint with complication or comorbidity - MCC), or
MS-DRG 482 (Hip and femur procedures except major joint without CC or MCC).