Quality Programs: Hurdles and Milestones for Health Systems and Their Employed Physicians
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PYA Principal Linda ClenDening and Erlanger Health System’s Sondra McGinnis recently spoke on “Quality Programs: Hurdles and Milestones for Health Systems and Their Employed Physicians" at the Georgia Healthcare Financial Management Association’s Financial Executive One-Day.
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Quality Programs: Hurdles and Milestones for Health Systems and Their Employed Physicians
- 1. Page 0December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Quality Programs: Hurdles and Milestones for Health Systems and Their Employed Physicians 2014 Georgia HFMA Financial Executives Meeting December 12, 2014
- 2. Page 1December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Quality Program Initiatives
- 3. Page 2December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Quality Programs in the News MGMA Physician Practice Assessment Study respondents represented 48,000 physician practices nationwide and disclosed the following regarding Medicare Quality Reporting Programs: • 93% reported a negative or significant negative effect on support staff time. • 84% reported a negative or significant negative effect on practice efficiency. • 85% reported a negative or significant negative effect on clinician morale. • Most concerning, 84% of respondents do not believe these programs enhance their physicians' abilities to provide high quality patient care. http://www.mgma.com/government-affairs/advocacy/learn/legislative-and-executive-advocacy-response-network-(learn)-research-studies/mgma- physician-practice-assessment-medicare-quality-reporting-programs-research-results
- 4. Page 3December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Quality Programs in the News Advisory Board headline – November 18, 2014: Former hospital CFO faces five years in prison over EHR fraud • The former CFO of the now-shuttered Shelby Regional Medical Center in Texas has pleaded guilty to falsely attesting to the meaningful use program. • Under the 2009 federal economic stimulus package, healthcare providers who demonstrate meaningful use of certified electronic health record (EHR) systems can qualify for Medicaid and Medicare incentive payments. • 94% of CFOs at struggling hospitals blame botched IT projects . http://www.advisory.com/daily-briefing/2014/11/18/former-hospital-cfo-faces-five-years-in-prison-over-ehr- fraud?WT.mc_id=Email|Daily+Briefing+Headline|DBA|DB|Nov-18-2018|||||&elq_cid=1400065
- 5. Page 4December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Focus Areas • Quality Program Staffing • Acquisition Process • Systems • Training • Monitoring, Reporting, Audits • Next Levels
- 6. Page 5December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Staffing • Hospital quality program implementation staffing – Physician (CMO or CMIO) leadership – Nurse leadership – Quality department • Employed physician group quality program implementation staffing – Operational leadership – Physician leadership – Quality program focus by specialty Information systems/technology department staff
- 7. Page 6December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Staffing cont. • Competition for staff resources drives financial leadership to choices based on: – Comparative size of the resulting incentive or penalty dollars at risk. – Largest potential benefit for staffing resources invested. – Specialized expertise requirements may lead to outsourced staffing choices.
- 8. Page 7December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting IT Trends Biggest Organizational Impact
- 9. Page 8December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Staffing – IT-related Positions
- 10. Page 9December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Staffing Model The following staff configuration is an option to make best use of expertise and flexibility: Orientation – Systems Trainer Quality Program Team Expertise Expansion • Project Manager • Data Analyst • System Expert • New training based on new quality program implementation Positions can be internal or outsourced based on need/cost.
- 11. Page 10December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Acquisitions Develop EHR strategy for physician practice acquisitions: 1) List EHR software products you are willing/able to maintain. 2) Research likely longevity of software product by vendor. 3) Consider interfaces already in place. 4) Consider software staffing expertise in place.
- 12. Page 11December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Acquisitions cont. System considerations: No Yes Establish Practice Levels of EHR usage, such as: – Level 1: Paper charts in use, no past experience with EHR implementation. – Level 2: EHR in use, no Quality Program reporting/attestation experience. – Level 3: EHR in use, Meaningful Use (MU) attestation completed/confirmed. – Level 4: EHR in use, MU attestation completed/confirmed, additional quality reporting completed/confirmed. Has practice implemented EHR? Implement as Level 1 Practice on Established EHR Evaluate costs/benefits to maintain Practice EHR
- 13. Page 12December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting System(s) Based on recent client projects and interviews, the following summarizes the wide range of system(s) experience for health systems and their employed physician groups: Single system solution – EHR and Billing Hospital system – EHR and Billing Employed Physician Practices system - EHR and Billing Hospital system – EHR and Billing Employed Physician Practices system V2 - EHR and Billing Employed Physician Practices system V1 - EHR and Billing Employed Physician Practices system V1 – Billing and paper charts
- 14. Page 13December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting System(s) Necessary to improve collection, storage, and management of electronic health information Tracking improvement in processes and patient outcomes Better communication among providers Patient accessibility to health information Patient self-management tools E-Prescribing
- 15. Page 14December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Training • The EHR system training team needs to be prepared and have multiple training delivery methods for: 1) Individual practice new hires at all staffing levels. 2) Acquired physician groups. 3) New workflow processes in response to new quality program participation.
- 16. Page 15December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Monitoring/Reporting • Use the system-generated Meaningful Use monitoring report by eligible professional (EP). • If Quality Program team is not staffed sufficiently for monitoring, evaluate an outsourced staff solution to monitor, report deficiencies, and develop recommended workflow changes to achieve MU goals.
- 17. Page 16December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Auditing • Quality Program Staff need to be prepared for audits relating to incentive program participation. • Confirm all documentation is completed and accessible.
- 18. Page 17December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Clinical Quality Measures 2014 for Eligible Professionals http://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/2014eCQMs_EligibleProfessionalsTable_July2014.pdf Example: one page of complete document:
- 19. Page 18December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Aligning Multiple Quality Program Reporting Options
- 20. Page 19December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Next Levels
- 21. Page 20December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Next Levels • Moving from EHR usage as the ‘end’ to the means to an end. • EHR usage, staff skills, and tools for proactive patient care can lead to new reimbursement opportunities. EHR Implementation EHR usage Staff training Proactive patient care
- 22. Page 21December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Next Level: Iora Health Example Hospital Admissions – 40% Emergency Visits – 50% Net total healthcare spending – 12 to 15% “A Prescription for Primary Care,” Leadership Fall 2014: www.hfma.org/leadership, November 4, 2014. • Staffing model • System use • Proactive patient communication
- 23. Page 22December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Next Level: Patient-Centered Medical Home • Patient-Centered Medical Home (PCMH) – A model of primary care that improves clinical quality, lowers costs, and improves patient satisfaction through care coordination. – First program through NCQA started in 2003. Standards have evolved over the years to be consistent with Meaningful Use and other meaningful quality metrics.
- 24. Page 23December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting PCMH Facts • PCMH 2011 and 2014 are closely aligned with Meaningful Use reporting requirements. • Practices are not required to have a certified EMR (though a requirement for chronic care management). • Each practice location is certified versus each clinician. Clinicians are certified by way of their practice location. • Practices must report on 12 months of data. If the practice EMR has not been in place for 12 months, NCQA will accept three months of data. • Calendar year reporting is not required.
- 25. Page 24December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Next Level: Transitional Care Management (TCM) Overview • Providers are reimbursed for active follow-up with patients following discharge from an inpatient facility. • One face-to-face visit with billing provider must occur within 7 or 14 days (depending on TCM CPT code billed). • The practice must make contact with the patient within two days of discharge, educate the patient on their diagnoses, and provide resources to ensure discharge orders are fulfilled. These services must be furnished by qualified clinical staff. • Only one provider may bill for these services. • Effective transitional care management should help facilitate a reduction in hospital readmissions as well as improve patient satisfaction.
- 26. Page 25December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Practice Plan for Implementation – TCM • Assign staff to review hospital admission log on a daily basis • Inform nurse/provider of patient admission • Specify timeline for follow-up after notification (by end of day, next day, within two days, etc.) • Schedule and conduct face-to-face visit • Evaluate community and referral resources • Train staff on documentation • Spot review discharge report and documentation of follow-up on a monthly basis for compliance
- 27. Page 26December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Next Level: Chronic Care Management (CCM)
- 28. Page 27December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting CCM: Five Specified Capabilities • Provider must demonstrate following capabilities: • Submission of claim = attestation of capabilities 1. Use of certified EHR for specialized purposes 2. Electronic care plan 3. Beneficiary access to care 4. Transitions of care 5. Coordination of care Not required to be meaningful user of certified EHR technology
- 29. Page 28December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting CCM: 20+ Minutes • 20+ minutes non-face-to-face care management services per calendar month • Furnished by licensed clinical staff under physician/mid- level general supervision – No physical presence requirement – Supervisor does not have to be billing provider • 20 minutes can be aggregated but not rounded up • May be provided by different individuals, but cannot count double for two staff members providing services at the same time
- 30. Page 29December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Practice Plan for Implementation – CCM • Run a report of patients by diagnoses to identify current patients for monitoring • Assign staff with responsibility for monitoring patients and reviewing appointment schedule for no-shows • Evaluate potential outsourced resources for non face-to-face services • Train staff on management of most prevalent patient diagnosis • Evaluate community and referral resources • Evaluate educational and self-management tools • Train staff on documentation
- 31. Page 30December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting TCM/CCM: Staffing Considerations May require an increase in staff to improve workflow Diverse backgrounds to appropriately address cultural and linguistic needs of patient population May require staff with more training (LPN, RN) - especially in the clinical area to effectively assist the patients Training in evidence- based approaches to patient self- management, population management, and patient communication Effective management of staff
- 32. Page 31December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting TCM/CCM: Policy Implications Practice should consider policies for: • Structured communication between the clinician and other care team members • Educating patients on illnesses and treatment options • Identifying patients with certain conditions and monitoring improvement and/or compliance with recommended treatment • Follow-up to include newborn hearing tests, lab results, imaging results, and referrals • Notifying families of normal and abnormal results • Monitoring scheduled visits and tracking no shows
- 33. Page 32December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Summary Health systems/hospitals have opportunities to plan for quality program hurdles in staffing, policies, systems deployed, and training. Once the milestones of quality program requirements are met, additional opportunities for ‘meaningfully’ using the EHR investment can lead to improved care and reimbursement.
- 34. Page 33December 12, 2014 Prepared for Georgia HFMA Financial Executives Meeting Thank you! Linda ClenDening, FACMPE Consulting Manager Pershing Yoakley & Associates, P.C. (865) 684-2735 lclendening@pyapc.com www.pyapc.com Co-Presenter: Sondra McGinnis, RN, FACHE Erlanger Health System Sondra.McGinnis@erlanger.org
Editor's Notes
- Highlight numbers from 2013 as if printed in B&W may not be legible
- Highlight numbers from 2013 as if printed in B&W may not be legible
- In many practices, it is likely that providers and staff are providing a wide variety of CCM services through the daily course of business. With CMS’ recognition of these services, providers meeting certain criteria can now bill Medicare on a monthly basis for these activities. Based on the MGMA Cost Survey for single specialty practices, the average family medicine physician has approximately 3,200 unique patients, of which approximately 22% are covered by Medicare. (Note for this purpose that Medicare includes both traditional Medicare as well as medicare advantage patients.) In this example, the average family medicine provider has approximately 700 discrete medicare patients. Of those, the Medicare data reflects that an average of 68.6% Medicare patients have 2 or more chronic conditions. Doing that math, our average family medicine physician has approximately 500 patients that would presumably qualify for CCM services. Based on a per beneficiary per month rate of $40.39 (as finalized in the regulations), a family medicine physician can obtain approximately $238,000 in incremental collections through the provision of CCM services. Two pertinent points related to this calculation. First, patients covered via managed medicare should be eligible for coverage under their Medicare Advantage plan. However, depending on a practice’s contracts with the Medicare Advantage plan, services may be reimbursed at a rate different than the traditional medicare amount. Second, depending on practice infrastructure and staffing, it is feasible that a practice will incur some incremental costs as it seeks to provide these services. This incremental revenue should help fund the incremental costs a practice might incur.
- The rules required EPs to provide at least 20 minutes or more of non-face to face care management services per calendar month. These services may be furnished by licensed clinical staff subject to proper supervision. This includes APRNs, PAs, RNs, LSCSWs, LPNs, and what CMS refers to as “medical technical assistants” (CNAs and certified medical assistants). These services can be furnished by licensed clinical staff under the general supervision requirement. This means the physician must available by telephone to the staff but does not have to be physically present for the service to be rendered. Additionally, the individual supervising the licensed clinical staff does not have to be the billing provider. The 20+ minutes do not have to be rendered in one sitting. They can be aggregated through the month based on services provided at different times by different individuals provided they meet the criteria just described. Examples of care management include (1) performing medication reconciliation and overseeing the beneficiary’s self-management of medications; (2) ensuring receipt of all recommended preventive services; and (3) monitoring the beneficiary’s condition (physical, mental, social). If two staff members are furnishing services at the same time, only the time spent by one individual may be counted. Also, time cannot be rounded up, and cannot be carried over from one month to the next.