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MACRA: A Rule Worth Learning

Introduction to MACRA

Those of us who that work closely with clinicians or simply work in healthcare have no doubt heard of the total revamping of Medicare (Part B) clinician payments from a fee-for-service to a value-based system; this sort of change hasn’t occurred in over a generation. If that isn’t incredible enough for you, how about the fact that this 892 page document was passed by Congress with a bi-partisan ‘supermajority’; that alone speaks volumes on the importance of this change. The culprit of my angst and information overload is called the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) that will go into effect 1/1/17. This rule is so complicated with so many layers, it does not even have a Wikipedia page (nobody as been so bold); so keeping that in mind this blog post is my attempt to sum up my own understanding of this proposed rule.

Courtesy of CMS.gov

Two pathways to payment. MACRA is built upon two value based pathways that eligible clinicians (physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists) must chose from: Merit-based Incentive Payment System (MIPS) or the Advanced Alternative Payment Model (Advanced APM). Which path a clinician takes depends on their patient threshold and if they are new to the Medicare. It also depends if the clinician is part of an Accountable Care Organization that is established as an APM entity. The advantage of one over the other is a 5 percent annual payment increase from CMS over 6 years if a physician decides to be grouped with their ACO APM entity. The risk is if clinicians do not meet metrics chosen and set by their ACO they will not be rewarded with their shared savings. The good news is Physicians can elect to switch between the two payment models from on year to another. This flexibility is the foundation to the MACRA proposed rule. Additional choices given to eligible clinicians are: they can report on measures that are important to them and decide if they want to report as an individual or in a group.

Courtesy of HIMMS MACRA information Webinar

Fundamental basics to the MIPS. The MIPS replaces the Physician Quality Reporting System (PQRS), Value-Based Modifier (VBM) and Meaningful Use (MU) programs with the categories: Quality, Resource Use, Clinical Practice Improvement Activities and Advancing Care Information. Quality metrics are mainly derived from PQRS, Advancing Care Information is a simplified version of MU, and Resource Use is similar to VBM. The biggest change, as far as I can tell, is clinicians can choose six quality reporting measures that are important to them. Each year HHS will publish a list of quality measures to be used in the forthcoming MIPS performance period (which is 365 days) for clinicians to choose from. Out of these measures, one must be an outcome measure of high priority measure, one must be cross-cutting (hit on several quality measures), and clinicians can choose to report a specialty measure set. Clinicians composed quality score is measured against clinicians similar to themselves; this is another significant change. If you recall previously the sustainable growth rate (SGR) “set an arbitrary aggregate spending target” not based upon individual performance or clinician peers.

Introduction to Advance APM. There is a reason why I explained in more detail the MIPS path- because I understand it better; as with many things in my life I relate it to food. MIPS takes the wholesome ingredients from MU, PQRS and VBM programs and makes it a much better appeasing entrée. Whereas the Advanced APM program doesn’t focuses so much on the recipe but on the consumer. From what I understand so far, you have to be an eligible clinician determined by CMS, and work in an organization that participates already as an APM through an agreement with CMS. Also, so far, CMS has only identified six APMs that qualify as Advanced APMs. These include Comprehensive End Stage Renal Disease care, Comprehensive Primary Care Plus, Medicare Shared Savings Program (Track 2 and 3), Next Generation ACO Model, and Oncology Care Model. The three criterion’s in order to become an Advance APM clinicians are: 50% of physicians must use Certified EHR technology; payments are based on quality measures; financial risk and nominal amount standards. I hope to dive deeper into Advanced APMs in a later blog post. For now please check out the HIMSS information deck here.

MACRA professional I am not… is anyone? Whereas I love to always learn, MACRA was difficult for me to grasp, HOWEVER I spent about 2 years in Graduate school studying Meaningful Use, so that says a lot. I am sad to say that a lot of what I learned about MU no longer applicable, but good riddance! The beginning of this year the Acting Administrator of CMS said “The Meaningful Use program as it has existed, will now be effectively over and replaced with something better.” I hope we you are right Mr. Slavitt.

Posted in: Healthcare Legislation, Healthcare Policy, Healthcare transformation, Outcomes

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Digital Health and the Influence on Healthcare: Wearables, Telehealth, & Treatment

Things are looking up in the world of digital health at least this was the view from “Digital Health and the Influence on Healthcare: Wearables, Telehealth, & Treatment.” The WBBA held their last event of the season with a panel on digital health, hosted by Russell Benaroya, CEO of Everymove, and featuring Dr. John Scott, Director of Telemedicine at UW Medicine, Davide Vigano CEO and co-founder of Sensoria, Mike Blume, independent healthcare consultant, and myself. I’d characterize the overall event as being optimistic and realistic, both from the panel and the attendees.

Digital health event

It was a dark and stormy night

No one said that the road to digital health was easy or fast, but the consensus that things like moving to the cloud, and the acceptance and adoption of patient-driven digital care is reaching a turning point.

Both Sensoria and Wellpepper’s business models are made possible by the cloud. For Sensoria this was the ability to process millions of datapoints coming from their wearable technology. For Wellpepper, this is our ability to rapidly implement solutions working with department heads facing a particular challenge in patient engagement and outcome tracking and improvement. Dr. Scott remarked on the dramatic drop in the cost of telemedicine solutions over the years he’s been an advocate and solutions due to both Moore’s Law and cloud computing over his tenure running telemedicine at UW.

Sensoria's Quantified Socks

Sensoria’s Quantified Socks

As well, although Dr. Scott highlighted how telemedicine was limited by arcane reimbursement models that did not allow for patients to receive telemedicine consults in their homes, he and other panelists discussed that they were not waiting for billing codes to do the right things in using technology to deliver better care. As usual, the Affordable Care Act was seen as a big driver as patient-centered and digital care.

Possibly because there were two ex-Microsoftees on the panel (Davide and me) a cloud-based platform approach was touted as the best way to both collect, analyze, and sort the data that came in directly from patients. In the case of Sensoria and Davide, this was to look for trends and patterns coming from sensor-integrated clothing, and in the case of Wellpepper it was to collect patient outcomes in the context of care and compare these across patients, procedures, and healthcare organizations.

This view led to a discussion about the proliferation of data, and everyone agreed that digital health has the ability to overwhelm health systems with data that they are currently not prepared for. EMRs are not set up to include sensor or patient-reported data, and as Dr. Scott pointed out, physicians are not looking for every data point on a patient, only the anomalies, like glucose out of range.

One audience member asked about whether healthcare organizations had an overall data strategy, and whether digital health data should be collected as part of that. It’s an interesting idea to consider but it seems like it’s still a long way off in healthcare. Does your organization or CIO have an overall data strategy? It seems that quality measures and the need for patient reported outcomes are introducing new requirements for data, but this is at the departmental or initiative level. Grappling with questions like this will be important as connected devices, digital, health, and patient reported outcomes enter the mainstream.

Posted in: Health Regulations, Healthcare Disruption, Healthcare Policy, Healthcare Research, Healthcare Technology, Healthcare transformation, M-health, Outcomes, Telemedicine

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Reducing Avoidable Readmissions: Care Transitions

This is the second in our series, recapping the lessons learned from the Institute for Healthcare Improvement’s Reducing Avoidable Readmissions course.

Care transitions are seen as key to improving readmission rates, and understanding that readmissions are not just the hospital’s responsibility but involve a care team that includes the patient, the patient’s caregiver, homecare, and skilled nursing depending on where the patient is discharged.

Both ensuring good care transitions to decrease readmissions, but also discharging to the right facility are crucial for lowering costs and improving care. Post-acute care shows the greatest discrepancy in costs per patient and is growing at 6% annually for Medicare patients. Today, 40% of Medicare patients discharge to a post-acute care facility, and 33% of patients in these facilities experience a care-related adverse event. By 2017, skilled nursing facilities could face penalties of up to 3% of Medicare payments for readmissions, thus there are real incentives to improve transitions, if patient safety isn’t enough to effect change.

The first step in improving care transitions is to ensure that the patient is going to the right setting, and this requires a decision by the care team that includes the patient and the patent’s caregivers. If money is not an object, many hospitals discharge to skilled nursing as a way of insuring that the patient doesn’t readmit. However, if care transitions are not handled properly, this adds costs without improving quality.

One of the biggest challenges in care transitions, is that there are no universally agreed upon assessment tools for determining the best next step for patients on hospital discharge, hence the over prescribing of skilled nursing. Beginning to track readmissions and outcomes should help organizations stratify risk and begin to be able to predict the best setting based on data. In addition to data, interview patients. Often missed care transitions are only identified by the patient him or herself as they are more aware of what was lost in transition.

Possibly because of the make-up of the attendees in the course, the transition from hospital to skilled nursing was a hot topic. Hospital attendees admitted to have little insight into how skilled nursing facilities worked. Skilled nursing attendees expressed frustration with the amount of patient information they received when admitting a patient. One attendee begged “just let me see the patient’s medical record.”

In order to facilitate better transitions, cross-functional teams need to be developed and these need to include members of the receiving facility. One skilled nursing facility reported significantly better transitions by simply placing one of their nurses in the hospital part-time to meet with patients before they were transferred.

These teams must have support at two levels: the executive level must provide resources and be open to changes recommended by the functional team that handles the care transitions. Functional teams must feel empowered to change and improve processes for care. Organizations that are pursing ACO models and bundled payments were seen as great opportunities for these types of cross-organizational and cross-discipline care teams.

The INTERACT tool is a way to ensure that the receiving organization gets the right patient care information during this transition. Unfortunately, given the lack of interoperability of medical systems, this approach requires additional paper work. There is no easy way to share patient records between EMRs or organizations, or sometimes within the same organization.

Other best practices in patient transfer include:

  • “warm handovers” that is, no patient is transferred with out a real-time conversation between physicians
  • Sending the patient with a 3-day supply of medication so there is no interruption and include pharmacy in the transfer team
  • Following up with the skilled nursing facility by phone within 24-48 hours post transfer
  • Sending information about patient preferences. One example was given of a patient who preferred to take her medication with Coke. She was greeted at the skilled nursing facility with a Coke and her medication.
  • Regular meetings between skilled nursing and hospital
  • Relationship building and storytelling for all parties to understand constraints that other side is facing
  • Creating a standard follow up and communication protocol based on patient risk of readmission

Post Acute Care Follow Up Communications

In keeping with the opening statement of the course, there is no silver bullet, just a lot of practical common sense advice, and clear and timely communication.

Next we’ll look at some best practices for discharging to home and the role of the primary care physician.

Posted in: Health Regulations, Healthcare motivation, Healthcare Policy, Healthcare Technology, Healthcare transformation

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Healthcare is part of our supply chain: The Boeing Company

The Health Innovator’s Collaborative sponsored by the University of Washington and the WBBA is entering it’s second year and continuing to gain momentum bringing together providers, payers, and health innovators from education, public sector, and industry to discuss hot topics in health. This week marked the second talk in the new season, delivered by Greg Marchand, Director of Benefits and Policy Strategy at The Boeing Company.

BoBoeing is a data-driven company that makes big bets and takes big risks to bring their products to market. This philosophy extends to how they provide employee benefits, and Marchand and team have taken a data-driven approach to healthcare benefits. In the same way that the principles of lean, data-driven decision making, and cost/risk benefit drive decisions across Boeings supply chain, the same rigor has been applied to healthcare benefits. Marchand knows that Boeing’s human resources are a key part of their success and wants to ensure they are working at optimum productivity. The best way to do that is to make sure they are healthy and that they receive the best benefits available. Quality, innovation, advocacy, and service are the influencers of Boeing’s strategy and the differentiators of their benefits.

Boeing made headlines for their “ACO” approach where they contract directly with healthcare providers and negotiate for service and Marchand came to the Health Innovator’s Collaborative to describe how they did it and why this is the model for the future.

Washington Hospitals, Boeing Strike ACO Deal

Boeing Signs Shared Savings Deal With Washington Hospitals

Boeing-Marchand2Marchand kicked off his talk with a personal example of a “defect” in the healthcare system, to his mind a result of healthcare organizations not having a consumer focus. A few years ago, his wife needed to make a doctor’s appointment for their child. She called for an appointment and was told that she could book a time two weeks from that day, which happened to be a Tuesday. Depending on whether you’re going to see a specialist, 2-weeks could be considered an acceptable wait time for an appointment, however, that wasn’t the problem. The problem was that if she wanted to book an appointment for another day, say 2 weeks from Wednesday, she’d have to call back on Wednesday to book it. Marchand asked the audience to try to imagine what might happen to a retailer like Nordstrom if they used this archane booking system for their personal shoppers. The system had a flaw, and it’s this type of flaw that Marchand and team are on a mission to correct.

boeing-marchand4To do so, they have partnered with UWMedicine and Swedish/Providence in Washington State to provide care for Boeing employees. They also rely on Cleveland Clinic as a Center of Excellence for cardiovascular care. While Marchand says that he doesn’t want employees to have to travel for care, he also wants them to have the most effective care, which is what drove the partnership. (You could tell that this statement was specifically aimed at attendees from the event’s host: the subtext being that it was possible for them to win this business for Boeing.) Boeing’s “triple aim” is quality, experience, and cost with the goal of improving the employee experience and passing any savings as a result of the new ACO model onto employees. Their expectation is that healthcare partners have these same goals and the same data-driven approach. The challenge for Marchand is the need to find partners in all states where Boeing has employees. While Boeing has a lot of clout with $2.5B in annual healthcare spend covering 500K employees, they don’t have the same economies of scale in all states based on employee number. (ACOs looking to pilot new ideas and test data-driven approaches should definitely consider reaching out to work with Boeing: they are looking for solutions.)

Finding the Defects

Marchand’s focus is on continually improving defects in the system and that includes the patient/provider relationship: making sure patients do what they are supposed to do. It also includes using the appropriate forms of communication and care for the situation. Here he gave two examples: using a house call service from Seattle-based Carena for non-emergency issues, especially with children, and being able to email or text your doctor with simple questions, like how to deal with side effects from prescribed medication. Both of these examples provided a higher level of service to the end-user and also lower costs to the entire system. A Carena house-call is 1/3 of the cost of an emergency room visit and email and texting is more efficient and less expensive than a phone call and most certainly than an office visit.

Understanding Cost Drivers

From all the data analysis, Boeing understands very well where its largest cost drivers are coming from and ways to improve, and from Marchand’s talk it was clear that they were very much in the driver seat in pushing their healthcare partners to innovate. Areas of focus include improving the usability of patient communication tools, managing population health, providing easily actionable data for the clinical team, and using the most appropriate and cost effective methods for care. Marchand gave the example of how incentives need to be better aligned to spend money on physical therapy rather than back surgery: again a situation where the patient experience is dramatically improved and costs are lowered, however incentives must be aligned because today, hospitals make more money on surgery than preventative care. Boeing and the ACO vision of the future changes that of course.

The Q&A portion of the event was quite lively and extended far beyond the allotted time. One notable question was about why other employers are not taking the same approach as The Boeing Company. Marchand wishes they would but acknowledged it’s a lot of effort and certainly the data-driven approach is in Boeing’s DNA. As well, only the largest companies have the resources for this type of undertaking.

If you’re in Seattle and interested in the massive changes coming in health and looking for a community of like-minded people plus lively debate, then we recommend you check out the series. Talks are the first Tuesday of every month. We’ll see you there!

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, Lean Healthcare, Seattle, Telemedicine

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Good, Fast, and Cheap: Demonstrating Value in Health Innovation

The goal of Triple Aim is to say that, despite what any project manager will tell you, you can have all three.

Good, Fast, Cheap

Source: http://ollmann.cc/

This provocative statement, set the tone for this third installment in Seattle’s  Health Innovator’s Collaborative, a talk called “Demonstrating Value in Health Innovation: Lessons from Comparative Effectiveness Research” by Larry Kessler, Professor and Chair, Department of Health Services, UW School of Public Health and formerly of the FDA, NIH, and NIMH. Dr. Kessler believes that the new accountable care organizations are mandated to deliver on all three and used the example of the Institute for Healthcare Improvement which was founded in 1991 on this principle and brings together leading hospitals, policy people, and researchers who are finding the best ways to deliver triple aim across many specialties.

Changes in how healthcare systems deliver care will drive innovation; however, innovation for its own sake will not win. Innovation must show evidence, cost savings, and revenue drivers. At the same time, it must satisfy a much wider group of stakeholders than previously including patients, physicians and clinicians, payers and providers. Innovative approaches and technology will take the leap past simply showing evidence of clinical outcomes to delivering value. This is a dramatically different approach from how typical NIH or FDA studies are done today. Those studies are done with a small slice of the population that is homogeneous, for example, they only have one issue and no co-morbidities. This type of study may prove outcomes with this particular population, but it doesn’t show cost or revenue based value and is no indicator of how something would work in the population at large, where the sickest patients are usually struggling with more than one issue.

Quality needs to be redefined as the best service AND the best health outcomes AND the best cost outcomes. Dr. Kessler went on to show some clear examples where solutions needed to go to the next level to be adopted and show results.

The first example provided a model that showed over a 5 year period, gastric bypass surgery proved cost effective. However, insurance plans do not include this surgery and require copious paperwork to justify it. This may make sense though, as the determinates of whether surgery is actually cost effective include a number of additional factors like the population and especially whether they will be part of your problem in 5 years. This is where the new accountable care organizations that are charged with population health will have an easier time with the cost benefit analysis as they be responsible for these patients in 5 years.

Another similar example is the new drug Solvaldi for the treatment of Hepititis C. It’s recently been in the news for its staggering price tag: $84,000 for a 12-week course. However, the drug has proved to be extremely effective, and University of Washington health economist Sean Sullivan points out “the drug is far cheaper than the alternative, which is a liver transplant and a lifetime of immunosuppressant drugs.” Again, though, whether this is a bargain or not depends on how long the payer thinks they will be responsible for the patient.

Successful business outcomes based on cost savings were shown in the example of two diagnostic tests for whether breast cancer would reoccur. The FDA-approved test MammaPrint could predict the recurrence of breast cancer. The non-FDA approved test Oncotype DX could predict the recurrence of breast cancer AND whether chemotherapy would work for the patient. This test, while not FDA-approved became far more popular as it showed very clear cost savings and quality of life for patients who did not undertake unnecessary chemotherapy.

Another study, Back Pain Outcomes Using Longitudinal Data-Extension of Research (BOLDER) was able to consider the patient experience as part of treatment. This study looked at 5,239 patients over 65 with new primary care visits for back pain across 3 integrated systems: Kaiser Permanente of Northern California, Henry Ford Health System, Harvard Vanguard/Harvard Pilgrim. The study goal was to determine the impact of early imaging as an intervention. The results are not yet published, but a couple of observations were already apparent. First, patients sent for MRIs, delay getting physical therapy and if the MRI shows they need physical therapy rather than surgery they have delayed their recovery by the time they waited for the MRI. In this case, the intervention of imaging if it was not needed produced less positive results for patients.

This study used the Roland-Morris Disability Questionnaire and it was also noted that many of the standardized testing tools do not account for what the patient actually considers a good outcome, like whether they can sleep soundly or have sex. Again, this shows that studies need to go a step further into the real world application of the patient’s situation.

These examples showed that it’s not enough to show that an intervention or new technology worked in a study, they also need to work in the real world. For payers that means lowering costs, for providers that means lowering costs or generating revenue while improving outcomes, and for patients that means delivering outcomes that are important to them, not just clinically validated.

The final lecture in this series will be June 3rd with Peter Neupert of Health Innovation Partners. See you there!
“IT can make a big difference in health:  Why hasn’t it?”

Health Innovators Collaborative
4:30 PM, W.H. Foege Building, UW Campus
Seminar: Foege Auditorium (S060)
Reception: Foege North 1st Floor Lobby

 

Posted in: Healthcare Disruption, Healthcare Technology, Healthcare transformation, Seattle

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