Beyond MIPS: A Look into the 90+ Clinical Improvement Activities

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Under the MACRA, providers will be reimbursed according to a composite score that reflects how well you’re providing value-based care. This composite score comprises of four key categories: the quality of care you provide, the efficiency of your resource use, meaningful use of EHR, and last but certainly not least, clinical practice improvement activities (CPIA).

 

Image - 90 Clinical Improvement Activities

A rising tide lifts all boats, right? The great part about MIPS—one of the two payment programs as part of MACRA—is that all of these metrics tie-in to improve clinical outcomes and patient engagement. This leads to cost savings, efficient resource use, and improved adoption of your EHR. Maximizing your composite score will not only affect your payments positively, but it will help you provide efficient patient care.

 

Not all activities are created equal

Certain categories are worth more than others due to their impact on patient care. High-weighted activities are worth 20 points, whereas medium-weighted activities value at 10 points. While these CPIAs only account for 15% of your total score, leveraging the highest-weighted tactics can be easy wins for your practice. Planning, completing and reporting 3 activities is much easier to pull off than 6 different initiatives. During your 90-reporting period (here’s a plan for when should start thinking about it), you must achieve 60 points by completing these clinical practice improvement activities in which there are over 90 tactics across 8 categories, in the combination of your choice.

 

Here’s a look at some of the types of activities in each category per ASCRS:

Expanded Practice Access: expanded practice hours, telehealth services, and improving access to services

Population Management: chronic care management programs, community and rural healthcare programs

Care coordination: health information sharing, timely communication and follow-up, care coordination training to handle transitions of care, and active referral management

Beneficiary Engagement: EHR to document patient-reported outcome,enhanced patient portals

Patient Safety and Practice Assessment: ongoing practice assessments and patient safety improvements, and use of tools such as the Surgical Risk Calculator

Achieving Health Equity: seeing new and follow-up Medicaid patients in a timely manner, and use of QCDR for demonstrating performance of processes for screening for social determinants

Emergency Response and Preparedness: participate in disaster medical teams or participation in domestic or international humanitarian volunteer work

Integrated Behavioral and Mental Health: tobacco intervention and smoking cessation, and integration with mental health services.

 

Choosing your activities

With several ways to maximize points in these categories, many activities may overlap and will have a bigger benefit for your patients.

Let’s take the Beneficiary Engagement and Population Management categories for example. You can implement specific programs and protocols to help patients with chronic illness like heart disease and diabetes. Helping patients manage their care at home with blood pressure testing and glucose measurements will help keep them on track and reduce the risk of readmission.

Bonus: Have a tool where patients can electronically share data and communicate with providers.

 

Convenience is king

Anything you can do to make life easier for your patients will most likely be a highly weighted CPIA. Expanding access to care with extended hours or e-visits can significantly decrease appointment cancellations or no-shows. Also, providing 24/7 real-time communication with care teams and reminders will greatly improve patient engagement and overall outcomes.

Another highly weighted activity is participation in CMS’s Transforming Clinical Practice Initiative which aims to help:

  • Exchange patient data information for the best continuity of care
  • Track patients through the entire process and integrate information from specialists to make sure care is documented
  • Coordinate phone calls, communication, navigation post-discharge
  • Communicate timely results for follow-up
  • Create individualized care plans for high-risk patients to share with other providers

 

Attaining Full Credit with Reporting

Given that the entire healthcare industry is shifting towards value-based care, reporting will be one of the most critical components within the continuum of care. If you haven’t already, begin to determine what measures you will report on and evaluate your strengths. Identify what gaps can be filled and put in the necessary plans to improve those gaps. Here at CareSkore, we envision providers getting the credit they deserve.

Through CareSkore, providers can:

  • Generate reports for measures including MACRA, PQRS, and HEDIS
  • Manage your patient population with real-time assessments
  • Understand patient data and quality metrics in order to improve outcomes

Whether it’s reporting for Clinical Improvement Activities or any of the mentioned categories, understanding your patient population through reporting is the first step to cultivating the provider-to-patient relationship.

 

Sources:

MIPS, MACRA & MU - The Next Evolution of Healthcare Payment Reform

MIPS: Clinical Practice Improvement Activities Category

MIPS Program: 2017 Clinical Practice Improvement Category Proposed Rule Guide

Federal Register - Subcategories

Medicare Program; MIPS and APM Incentive Under the Physician Fee Schedule

Transforming Clinical Practice Incentives

 

Preparing Your Practice for MACRA: A Plan for 2016 and Beyond

Header - Preparing for MACRA

Significant changes are coming to the way physicians are reimbursed through the Medicare Access and CHIP Reauthorization Act (MACRA). As part of a larger initiative to transition from fee-for-service towards value-based care, one of MACRA’s proposed payment programs, the merit-based incentive payment system (MIPS) will help providers focus on improving clinical outcomes by reducing administrative burdens. In the long run, this will offer more financial certainty and a greater potential for bonus payments. As a healthcare organization, there are action items you must take in order to receive credit for the high-quality care you’re providing.

 

Preparing for MACRA in 2016

In 2015, about 56% of physicians said they were unsure whether or not they were ready to participate in MACRA. Ready or not, the following are things you can start doing today to prepare for the newly proposed payment programs.

  • Understand the impact: Review the proposed changes and explore their implications.
  • Know yourself: There is no one-size-fits-all approach given that each and every provider is unique in their own way, so only you—alongside your administrative team—can complete an accurate self-assessment.
  • Develop a success plan: Outline your strategy with target dates to keep you on track.
  • Educate your team: Get in touch with providers and internal stakeholders to make sure everyone is on the same page.

 

What You Can Do Today

Start thinking about which payment track is most fitting for your practice. Unless you’re part of an accountable care organization (ACO), you will most likely begin with MIPS. You’ll need to review your Quality Resource and Use Report (QRUR) to get a baseline of where you can improve.

 

1. Meet Meaningful Use

If you aren’t already using an EHR or electronic health record system, now is the time. It should allow patients to access and exchange their information across the coordination of their care. Find a solution that enables you to connect with patients and will be easy to adopt.

 

2. Start Reporting

Determine which quality measures you plan to report on. Since this could differ based on specialty, you’ll want to carefully evaluate your strengths. If you’re part of a physician practice, decide whether you want to report as a group or as an individual.

 

3. Understand Resource Use

Once you dig into your data and evaluate your benchmarks, you’ll be able to understand how you’re spending your resources. Knowing which of your patient populations are keeping costs up is critical to developing a plan to improve care. Often, these groups include patients with chronic illness that require frequent visits and engagement. Strategize how your practice can deliver care more effectively to these patients.

 

4. Identify High-Performance Areas

Your practice is probably already performing well in some quality areas. Use this as an opportunity to get credit for the things you do best. Then you can develop a plan and fill in the gaps where you need to improve.

 

5. Evaluate Your Readiness for MACRA

Whether you follow a MACRA checklist or create your own success plan, gauge your progress and understand the timeline in order to set your practice up for success.

 

What You Need To Do in 2017

In January 2017, CMS (The Center for Medicare and Medicaid Services) will begin collecting data to get a baseline for the rest of your performance metrics. You’ll receive your first feedback report in July of 2017, giving you a better idea of your current quality measures. It’s also a chance to quickly adjust any measures during Q3 and Q4.

In 2017, you should decide on your 90-day reporting period. Many factors can influence your choice such as the timing of major holidays or when providers will be on vacation. Choose a time that will provide the complete, most accurate picture of your practice. Your practice will also need to decide which Clinical Practice Improvement Activities to begin. Getting a jump-start on these can help your overall composite score, and improve the patient experience. Talk with your team about which activities will be the most impactful and cost-effective to facilitate and make both short-term and long-term plans.

Make sure it’s meaningful: it won’t be enough just to meet meaningful use. Your EHR technology will be evaluated for efficacy by CMS and will want to know it’s adding value to the patient experience, not just checking off a box. The following are things to look for when evaluating an EHR:

  • Make sure it is secure
  • Make sure patients are actually using it
  • Make sure patients are using it to access health information and receive secure messages

 

Thinking About 2018

By 2018, the CMS’s goal is to have 90% of Medicare payments shifted to quality or value-based care. When you receive your second feedback report in July of 2018, you can compare your progress and understand where you can improve. From creating improvement action plans you’re positioning yourself to maximize payments.

Understanding how all practice operations work together is great if you can easily synthesize all the data and see trends. That’s where CareSkore comes in, giving healthcare providers the ability to:

  • Get a 360-degree view on patients and patient populations by accurately assessing both patient risks and needs, and improve outcomes.
  • Coordinate and manage the most appropriate and timely care through personalized follow-up with high-risk patients and understanding data that will improve quality measures.
  • Improve patient engagement by connecting with patients even after they have left the premises to reduce both no-shows and cancellation rates.

These simple, yet impactful tactics can enhance the patient experience, improve outcomes and reduce administrative and operational challenges that keep your practice from providing the best possible care to every single patient—which is ultimately what MACRA will be evaluating.

 

Sources

 

MACRA Basics: MIPS vs APM - What You Need to Know About the New Rules

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What is MACRA?

The MACRA (Medicare Access and CHIP Reauthorization Act) is the new healthcare reform poised to replace all of the different “patchwork programs” for physicians who receive Medicare payments. As part of the shift towards value-based programs proposed by CMS (Centers for Medicare & Medicaid Services), it’s purpose is to set up a new framework that rewards physicians, not on the amount, but the quality of care they provide. As a provider, you have two different options for how you want to get reimbursed: MIPS (Merit-based Incentive Payment System) and APMs (Advanced Payment Model).

 

What is MIPS?

MIPS determines your reimbursement rates by the quality of care. Payment adjustments under MIPS are based on the MIPS Composite Score, which comprises of 4 key areas:

  • Quality (Formerly Physician Quality Reporting System or PQRS)
  • Advancing Care Information (Meaningful Use)
  • Clinical Practice Improvement Activities
  • Resource Use

If your score is above the threshold, you’ll receive a positive payment adjustment. But if you’re below, you’ll have a negative payment adjustment for the following year. Scores will be compared to both year-over-year improvements and other providers.

 

Benefits of Merit-Based Payments

High performers under MIPS receive a positive payment adjustment for up to 3x the adjustment factor, but physicians still have to report on quality measures to make sure standards are being upheld. Providers can maintain a higher score by simply improving patients’ outcomes through care coordination and ensuring patients have easy electronic access to their health information. Many are already using technology to increase patient engagement. By communicating with their patients in real-time, providers can better serve patients who have a higher risks of complication and readmission to the hospital. Through patient engagement and communications, providers receive credit for helping patients through personalized reminders to take their medicines, monitor their performance, and keeping them healthy throughout the continuum of care. Tying clinical practice improvement activities such as improving patient safety, population health, and long-term outcomes together, ultimately makes your practice much more efficient.

 

What is APM?

Aside from MIPS, the other payment track is an Advanced Payment Model or APM. Currently, patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) use this model. CMS, however, anticipates that more individual providers will qualify for this option. APMs will provide a 5% lump sum bonus based on the prior year’s payment beginning in 2019 over a 6 year time period.

To be eligible for APM, participants must:

  • Have serious quality measures comparable to MIPS
  • Use EHR (Electronic Health Record) technology
  • Bear “more than a nominal financial risk” similar to an ACO or PCMH

Physicians who choose an APM have an opportunity to earn more, but run the risk of paying Medicare back if they don’t meet savings goals. Understanding these risks and determining if they outweigh the potential benefits is a decision that providers will have to make individually or with their practice management team.

 

How to Choose the Best Payment Model

Which path do you take? You and your partners can weighout both payment models under the MACRA, but first, you’ll want to get the facts to make an informed decision.

Know yourself - Dig through the quality data. Are you a high performer? Find out why or why not. Know your current quality metrics and create a plan to improve.

Know your patient population - Do you know you take on patients that have multiple health problems or things you can’t control? That could be a factor in your reimbursement rates.

Under MIPS, there are over 90 activities you can choose from to demonstrate how you’re improving your clinical practice. These tactics can give you credit for helping patients overcome challenges like making sure they’re taking their medicine or adhering to a rehab program.

 

How Meaningful is Meaningful Use Technology

Another thing to consider is your meaningful use technology. Now, you’ll be measured on how well patients are making use of their electronic health information. Is it actually providing value? The intent is that providers and patients are actually sharing information and making prevention and high-quality care more accessible to patients.

 

Start Planning Now

The good news is that the current payment programs requiring reporting on quality metrics will be absorbed into the MACRA. Physician practices have until 2019 to choose their payment track, however, it’s never too early to understand your options and have a general idea of what makes the most sense for your practice. In the meantime, you should honestly evaluate your quality metrics and how you’re meeting meaningful use. Take the time to look for ways to improve and implement tactics that can help your patients now.

 

Sources:

NPRM - Quality Payment Program Fact Sheet

CMS Quality Reporting Programs

Medicare Access and CHIP Reauthorization Act (MACRA) Preview Module

Quality Payment Program - CMS

Quality Payment Program - MIPS and APM

MIPS or APM: Which is better for your practice?

Moving toward improved care through information

MACRA Payment: APM vs MIPS

 

I Will Keep Them From Harm and Injustice (Part 2)

Part 2: Preventing No-Shows

 

Being stood up is never fun and it’s disrespectful in professional appointments. Unfortunately, it’s not a matter of if, but when patients will miss appointments. People will get stuck in traffic and priorities shifting throughout the day. No-shows will continue to occur, but there are ways to dramatically reduce patients from disappearing.

The problem with no-shows is that healthcare providers don’t get notice of a patient’s status. It could be because of time constraints, monetary constraints (e.g. insurance deductibles), or even physical constraints. The reasons behind patient no-shows may vary by individual needs.

Healthcare providers have attempted to reduce no-shows with a fee policy. One office placed “problem patients” on probation. Others simply absorb the lost time and income. While the onus ultimately rests upon the patient, doctors cannot provide proper care if the patients do not show up. It hurts a patient more than the physician.

In part two of our Population Health Management series, we explore the problem of no-shows, and how to prevent it from occurring.

 

Challenge #2: Preventing no-shows

No-shows are defined as intended appointments that are not canceled or rescheduled less than two hours before the designated time.

The worst part of patient no-shows is not knowing a patient’s condition. For doctors, this uncertainty is cause for concern because it elevates the risk of pain and suffering. Prolonging a diagnosis and treatment for a medical condition can be both physiologically and financially taxing.

Patient no-shows have been reported to be as low as 5.5% and as high as 30%. Higher rates were particularly apparent for academic practices.

No-show patients may seem harmless since it guises itself as a much-needed break for overworked physicians. But it severely hurts a hospital’s bottom line. Not only does the practice lose revenue, cost per patient increases as well as readmission rates, which may lead to hefty penalties.

 

Opportunity: Reducing Patient No-Shows

Understanding your patients is critical for reducing no-shows. It begins with observing your practice’s no-show rates. Only 63% of healthcare providers tracked missed appointments. The remaining practices are unaware of the severity of their no-show rates, and would be difficult to measure and improve on performance.

In one study, a 47% of patients are habitual no-show patients. The problem is that the 35% of the habitual no-show patients had close ties with the physicians. This makes no-show policies difficult to implement. In fact, 7% of the habitual no-shows are also 15% of the arrived visits. This makes patient management a complex and sensitive challenge.

Understanding the individual patient is as important as knowing the patient population. Each patient is unique and has different reasons for not attending an appointment. The likelihood of patient no-shows can be attributed to their clinical data, claims history, demographics, and socioeconomic status.

 

Recommendations: Nurture your Patients

There are many reasons why patients fail to appear without notice. There are ways healthcare providers can reduce no-show rates by focusing on actively engaging at-risk patients.

Traditional methods such as no-show fees, double bookings, or first come first serve practices, can marginally improve no-shows. However, these techniques can cause friction and are as unprofessional as a discount domestic airline.

To focus on the cause, rather than the symptom, healthcare providers should place more attention on long lead times. Doctor’s appointments are often made weeks in advance, which patients have to be diligent to reserve. As the appointment approaches, reminders are often necessary.

Suum cuique is the latin verb for “To each their own.” Everyone has a personal preference. Using a personalized approach encourages, rather than punishes, patients for showing up. And it’s showing results.

Patients are five times more likely to keep an appointment when they receive a call reminder. By receiving reminders, 17.3% of patients missed appointments, compared with 23.1% of patients who received no reminder call missed their appointments.

However, calling to remind each patient is laborious. Patient Relation Management technologies such as CareSkore, actively engages patients using Short Messaging Service (SMS). Texting a patient not only provides clear communication, it is automated, bidirectional, and asynchronous.

 

Automated

When an appointment is approaching messaging technologies can automatically send reminders to patients without using admin time.

 

BiDirectional

SMS technologies that leverage Artificial Intelligence (A.I.) like CareSkore engages patients in a natural conversation. Unlike push notifications, A.I. is bidirectional, which means the computer understands the language and responds accordingly.

 

Asynchronous

Unlike a phone call, text messages can be received and responded without needing the recipient to be actively engaged in real time.

 

The Patient Lifecycle

No-shows hurt both patients and caregivers. But there are ways to reduce the lost time. Nurturing patients throughout their lifecycle helps avoid no-shows. This does not require a large call center, but the careful implementation of intelligent software. Doctors are here to treat, but they are only as effective as the presence of a patient.

I Will Keep Them From Harm and Injustice (Part 1)

Part 1: Identifying and Reducing Readmissions Rates

Oliver Leung CareSkore

 

It’s no secret that America’s health care system needs intensive care. $180 billion is wasted every year on operational inefficiencies, and the condition is not improving. This is largely attributed to a fee-based system that incentivized volume over value.

In 2010, the Affordable Care Act made health care providers an offer they couldn’t refuse — a mandate to increase efficiency or feel the pain of stiff financial penalties. This ideology shifted the practice from fee for service to value-based care. Loved it or loathed it, health care providers are forced to play with the cards they were dealt with.

As with all illnesses, we begin with identifying the symptoms of a broken health care system, so we can follow through with a diagnosis and treatment. In this ten-part series, we will:

  • Identify the most pressing challenges facing our health care system
  • Address opportunities for improvements, and
  • Make recommendations for enhancements

Finding solutions to fix our health care system won’t be resolved overnight, but it is prudent to focus on the elements that are causing inefficiencies. Then implement noninvasive solutions that are quick, intelligent, and cost-effective.

 

Challenge #1: Readmission

When our vehicle breaks down, we go to the mechanic to get it fixed. We expect our vehicle to function after our visit because it is part of a mechanic’s duty of care.

Similarly, a doctor’s obligation is to treat patients with a level of care that is consistent with the Hippocratic Oath. Unlike a machine, however, humans can’t be recalled. We either heal, deteriorate or perish. Readmissions are a serious threat to not only our health but to our health care system.

By far, Medicare bears the greatest burden of readmission and is the gold standard by which health care providers measure performance on. The three greatest preventable conditions for Medicare readmissions are:

  1. Congestive heart failure (24.5%)
  2. Septicemia (21.3%)
  3. Pneumonia (17.9%)

The conditions above cost hospitals over $4.3 billion. The government (and ultimately the taxpayer) foots 43% of our national health bill. Consequently, hospital reimbursements have recently been restructured under the Hospital Readmission Reduction Program (HRRP) in October 2012. The program focuses on patients who are readmitted within 30 days for high-cost or high-volume conditions and procedures. Specifically, heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), hip/knee replacement, and coronary artery bypass graft (CABG).

The Hospital Readmissions Reduction Program is designed to improve the quality of care by incentivizing the reduction of hospital readmissions and penalizing underperforming hospitals.

 

Oliver Leung CareSkore Readmission Rates

 

Since the initiation of the program, readmission rates have declined 1%, from more than 19.0% to less than 18.0%. Although this is an improvement, 50% of hospitals received readmission penalties of up to 3% for failing to meet the national readmission benchmark.

The financial cost is merely a symptom of the problem. Readmitted patients are preventable and increase demand for doctors who already have long waitlists. It also places a hindrance on society since patients are required to take repeated time off work or home care. In short, remitted patients are not given the proper treatment, which is simply poor quality of care.

 

Opportunity: Preventing Readmission

Readmission rates are calculated using discharge data for each hospital from the three years prior to the year in which the penalty is assessed. According to the Centers for Medicare & Medicaid Services (CMS), The two criteria for evaluating the impact of readmissions are volume and costs. To understand the impact of these variables, we need to look at the data that drives the numbers.

The average readmission rate for the top ten high volume conditions among Medicare beneficiaries is 19.6%. Simply put, nearly 1 in 5 patients return for preventable retreatments.

However, the quality of care is not solely dependent on hospital care. Hospitals serve patients of varying risk profiles. External factors such as socioeconomic status and demographics come into play and should be taken into consideration.

Despite these discrepancies, there are currently no provisions in the Health care Readmissions Reduction Program to account for these external factors. This could adversely (and often unfairly) impact the perception of a health care provider. These external data sets are largely unaccounted for but have a significant impact on patient readmission.

 

Recommendations: Patient-centered care.

There are ways to mitigate the risk of patient readmission. It begins with intimately knowing your patient. This may sound daunting at first, but it can be easier than you think.

The difference between a stranger and a loved one is data. With a friend, you know what appeals to them as much as what repulses them.

In the same way, health care providers can leverage data to determine whether a patient is considered at risk of readmission. But data itself is inert. It can’t predict and won’t prevent readmissions on its own. Therefore, health care providers need to aggregating and normalizing the data in order to understand the probability of readmission. Only then can you make accurate decisions.

Finally, patients need to be nurtured throughout their medical journey. Patient engagement is like following through on your golf or tennis swing. It takes practice, but it will certainly improve your game.

It starts with asking, “How have you been?” It’s simple, but not easy. Engaging your patients is very involving and can take tremendous resources from your admin staff. So new technologies such as CareSkore actively engages patients using artificial intelligence (A.I.) to prevent readmissions from occurring.

“A spoonful of sugar helps the medicine go down…”
Reducing readmissions isn’t a trivial task, but it is one that deserves attention. Readmissions prevent doctors from seeing fresh patients, disrupts the wellbeing of a patient, and drives costs to health care providers. There are early indicators that the health care industry is adopting methods to reduce readmissions. Not only because it is mandated by the government, but because prevention is better than treatment. Solutions are available to transform hospitals from a destination to a journey.