Transitioning from Fee-for-Service to Value-Based Care: How to Manage Your Revenue

It’s no secret that the shift to value-based is leading more physicians and nurses to be employed by hospitals. Patients feel the height of these effects because Medicare reimbursement rates have not yet kept pace with inflation. So how can physicians and nursing facilities manage their bottom line while losing money caring for this growing group of patients? Some will simply take care of fewer patients, which will reduce overall revenue in an effort to minimize the financial impact. However, there are things doctors and nurses can do to balance out the loss and actually improve margins during the slow transition to value-based care.


Overcome the Obstacles

First things first, you’ll need the right infrastructure and tools to make sure you’re accurately tracking all patients, so you can measure your performance and revenue. While this happens annually or quarterly, hospital CEOs and CFOs should be regularly accessing and evaluating this data in order to make continuous adjustments. Once you’ve synthesized all this information, you’ll want to rethink your traditional KPI’s (key performance indicators) associated with fee-for-service. Rather than focusing on traditional, one-dimensional metrics like headcount in beds or number of surgeries, you’ll need to get the full picture of your quality metrics. Instead, focus on metrics like:

  • Cost per case
  • Readmission rates
  • Length of stay
  • Complication rates

When you dive deeper into the data, you will probably find there are plenty of areas you can improve. Are there specific diagnoses codes that you struggle with? Are there other factors that contribute to readmission rates that might not be happening at your hospital?


Improve Care Coordination

Readmission rates are a major metric that is evaluated by CMS. However, even if you provide the best care, a patient could still be readmitted because they aren’t following up with their primary care provider. Skilled nursing facilities and home health solutions are also important factors to evaluate the quality of a patient’s care after they leave your hospital. Choosing the right partners and holding them to a high standard will help lessen readmissions and provide better continuity of care.


Become More Efficient

In come cases, you might find that the length-of-stay is longer for patients that receive an MRI, for example. If you only have one MRI for both inpatients and outpatients, your teams may be prioritizing outpatient diagnostic tests simply to accommodate business hours. But that leaves inpatients to wait until evening (around 8 pm) to get their MRI, which increases overall length-of-stay.


Other Strategies to Optimize


1. Expand access points

Free-standing ERs; outpatient diagnostic centers and urgent care facilities can all increase your volume of services you provide without the additional costs and potential penalties from inpatient stays.


2. Telehealth technology

Physicians or nurses that travel between hospitals, practice offices, and outreach. Clinics can reduce travel time and see more patients through virtual visits. Offering convenient telemedicine services can also be a market differentiator and attract more patients with commercial insurance that prefer the convenience of virtual visits.


3. Focus on specialization

By developing signature services you can focus on recruiting top-notch physicians and creating centers of excellence. Especially for procedures like joint replacement and bariatric surgery, you will draw patients that are potentially willing to pay more for a unique, high-quality experience. Ultimately, all of these efforts will result in better access to high-quality care for your patients, which will improve your composite scores and increase reimbursement potential.


Understanding Population Health: Why It’s a Reflection of Your Patients

Improving population health begins with focusing on the health of each one of your patients. To do so, we in the healthcare community—nurses and physicians alike, need to identify and engage patients—particularly those of high risk—throughout the continuum of care. These are individuals most likely to be readmitted, miss an appointment, skip medications or unable to pay their bill.


But how can we pinpoint these individuals efficiently when we’re often looking at multiple databases and EHRs, examining enormous quantities of unstructured data—from multiple notes fields and categories, pathology reports, radiology notes, to admission notes and everything in between—containing invaluable historical information, all entered at different times, in different ways by different people?


Standard EHR systems do not currently provide a way to easily synthesize and summarize patient information on the changing risk factors recorded in different EHRs to support clinical decision-making. In addition, EHRs do not capture all the data points to understand the risks patients face, nor does it prioritize care for those at high risk for readmissions or infections. Imagine then how much we could do to identify, treat and engage patients if we had a way to analyze unstructured data!


The primary benefit of normalizing and aggregating unstructured data is attaining a cohesive picture of the patient’s history, diagnosis, treatment, and outcome. If details around the pathology of a patient’s tumor are only recorded within the pathology note for example, then analysis cannot include such things as genomics, margin reports, laterality, size, shape or even perhaps the stage of the tumor. Including that information along with trends for an individual patient or an entire population could be valuable. Additionally, combining that information with data about the treatment and outcome of a patient—which is possibly available within textual notes fields—can provide a rich field for research and results-driven treatment.


Here at CareSkore, we thrive to compile—and where applicable—translate data from hospitals electronically. Through our Personalized Population Management™ platform, we’re able to identify patients at high risk of readmission and hospitalization by combining clinical and 3rd party data. We put in place standard care plans so everyone on the team knows the steps they should be taking to manage the patients. CareSkore also allows our partners to reach out to patients even after they have left the nursing facility, using our Iris module, and document the follow-up care to provide them resources as needed.


Fundamentally, integrated care management, leveraged by data and predictive analytics, helps nursing home administrators to:

  1. Identify and engage patient populations at-risk for poor outcomes or unnecessary intervention at a time of need and opportunity for impact
  2. Perform assessments and respond to changes in patients’ conditions to uncover problems that, if addressed through effective interventions, will improve care and reduce the need for expensive services—particularly ER visits and hospitalizations
  3. Collaborate with patients and their caregivers as well as primary care, specialty, behavioral health, and social service providers and show hospital partners they can perform proper follow-up care
  4. Have an integrated system that provides a complete picture of expenditures and combines risk prediction software, chronic disease criteria, or utilization thresholds with patient-to-provider referrals or assessments
  5. Combines the strengths of both quantitative and qualitative approaches and brings data together from multiple sources


All in all, benefits extend beyond medical issues to address, to the extent possible, how patients’ psychosocial circumstances affect their ability to follow treatment recommendations and achieve a healthy lifestyle. The goals are to maintain or improve patients’ functional status, increase their capacity to self-manage their condition, eliminate unnecessary clinical testing, and reduce the need for acute care services.


The result? Fewer nursing visits, shorter hospital stays, better intra-office communication, faster and efficient communication between primary physician and nursing facilities, and cost savings that could pay for the expansion of EMR use in those facilities.


This post is an edited version originally published on McKnights.


A Moment of Truth: Population Health Management Myths Debunked

What is population management? At its core, it is the assemblage of strategies and tactics providers use to identify, measure, and improve the health of your at-risk patient populations. And under the umbrella of population management efforts are:

  1. Predictions; predicting future risks across your populations
  2. Engagement; communicating with patients
  3. Reporting; performance and regulatory measures reporting

With population health management still in its infancy, it can be easy to misinterpret what it actually entails. To shed some light on the subject, we’ll address the most common myths around population health management, both as a strategic initiative and technology component.


1. “Population Management is a People- and Strategy-Only Initiative”

Without best-of-breed health IT, population health management can be challenging. To be successful, population management requires a uniformed effort from both a talented team—doctors, administration, IT, to operations and everything inbetween—and an ensemble of robust, clinician-centric technology. You need modern, up-to-date platforms that don’t get in between you and your patients, but instead, amplifies your workflows. Such processes include intimately knowing risk factors and what to do about them, communicating with patients even after they’ve left the premises, and in tandem, measuring all doctor-to-patient activities for actionable insights on how you can improve them.


2. “Population Management is a Software-Only Initiative”

On the other hand, software itself can’t tackle population health management alone. While population management software itself brings merit to the table, your team—in partnership with the right population health management vendor committed to helping you and your patients—guiding the reins can only be favorable towards your population health initiatives. Without one or the other (people or technology), your path to improved health and financial outcomes could be filled with uncertainty.


3. “Population Management Can Be Addressed by an EHR System Alone”

We’ve discussed how EHRs are critical to the care continuum, yet falls short on providing you complete guidance over your populations. For instance, a hospital system may have multiple EHRs that are unable to communicate, resulting in unnecessary silos for patient data. Chaos aside, providers run the risk of having critical information on a patient in one EHR, while in another is nowhere to be found. EHRs also lack the complete picture on your patient populations falling short on all the information you need (clinical, demographics, economic, behavioral, and social data for example) into one aggregated source. More importantly, EHRs don’t enable you to take action, whereas population management platforms allow you to take initiative and address any concerns across your patients. The ultimate takeaway is that providers must unify their EHR systems with a population management platform. But to clarify another myth: one system does not replace the other. Instead, they work together in parallel to further improve how you provide quality care to your patients.


4. “Population Management is Unnecessary”

With MACRA (The Medicare and CHIP Reauthorization Act) becoming a reality, measuring care quality will be more table stakes than ever before. This seed change to how providers are reimbursed is one of the many reasons providers should start thinking about population health management. It demands providers be forward-thinking, collaborative, and to be able to deeply know the health of their populations. Knowing the past and present in order to plan for the future, requires providers to include population health management as part of the equation.


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.




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

Header - MACRA MIPS vs APM (1)

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.



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


Where EHRs Fall Short: 3 Reasons Doctors Need Personalized Population Management


Look into the center of a hospital’s information technology stack, and you’re bound to find electronic health record systems (EHRs) to be the cream of the crop, costing healthcare providers tens to hundreds of millions of dollars for implementation and use. As the core system of record within a healthcare organization, when it comes to providing the 360-degree view on any given patient or patient population, EHRs fall short on giving the complete picture.


The State of Electronic Health Record Systems

It’s no doubt that EHRs are critical to a hospital or health practice. An EHRs’ core capability rests on being able to store significant amounts of patient data records and is used across multiple functions—care quality, finance, and operations—within a health organization. Whether it’s capturing notes on patient encounters, insurance claim information, or data on historical visits, you name it—EHRs are effective in that regard. This, however, is what EHRs were designed to do, and nothing more; to operate as silos of unstructured data.

Storing data and interpreting data are two independent undertakings. It’s important for doctors to be able to distinguish between the two without overspending on time and resources. In order to capture the complete picture on a patient population, clinical and financial departments need a dedicated system that allows for seamless interpretation of patient data, predictability, and personalized patient communication at will. Keep an eye out for the following when looking into a population management solution:


 1. Predicting no-shows and patient risks

Tracking historical patient data is fundamental. But what about predicting and planning for the future? As healthcare providers continue to amass increasingly large amounts of patient data from socioeconomic to demographic inputs, not leveraging that data is an opportunity missed. Where EHRs lack, a Personalized Population Management™ can make up in value, as EHRs were not designed to predict future occurrences from their stored data. Doctors need a solution that not only enables them to manage no-show and cancellation rates but addresses dire questions like, Which patients within my population are at-risk? What are the leading factors for my patients’ risks? How can I improve the health of my patient population?


 2. The need to engage patients

Doctors and physicians want to spend more time doing what they do best: caring for their patients, not trying to make sense of high volumes of unstructured data. When relying on EHRs for patient engagement, physicians and nurse practitioners can face barriers; meeting personalized demands, usability issues, unnecessary workload. What doctors and physicians seek is a tool that not only gives back lost time from using EHRs but a tool that enables bi-directional patient communication even when patients leave the premise. This calls for a communication medium to be put in place dedicated to engaging patients and helping doctors get what patients need when they need it.


 3. Meeting regulatory reporting requirements

One thing is true. It’s becoming much more difficult for doctors to focus on their population. While the rise of the health IT landscape was meant to automate certain tasks, the reality is it’s taking up more and more of a doctor’s time. With new reporting and payment regulations underway, doctors must have a solution fixated to handling this department. EHRs alone aren’t enough and extracting data from these systems can be a daunting task. Orchestrated in alignment, however, EHRs and predictive analytics make a formidable pair. Together as the bread-and-butter of the health IT stack, EHRs and predictive analytics empower healthcare providers to capture data, interpret it for actionable insights—regardless of complexity or magnitude—and help providers with their patients in the continuum of care.


Personalized Population Management does not replace an EHR. Rather, Personalized Population Management complements a robust EHR system. In this new era of healthcare, predictability tied with communication and reporting gives doctors the ability to ultimately improve their financial and clinical outcomes and focus on what matters most, the patient.


The Medicare Access and CHIP Reauthorization Act (MACRA) is underway to completely change how healthcare providers approach medicare payments. Are you ready? Join us as we discuss how to approach MACRA in our upcoming webinar, MACRA: Addressing the Transition.