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Readers Write: Three Key Things Practices Should Do to Prep for MIPS/MACRA

November 30, 2017 Guest articles No Comments

Three Key Things Practices Should Do to Prep for MIPS/MACRA
By Polly Friend, RN

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Providers have had two tracks of MACRA to choose from in 2017 – the merit-based incentive payment system (MIPS) and an advanced alternative payments model (APM). Most providers were, by default, placed in the MIPS program, and they put in a lot of hard work to avoid penalties during the uncertainty of MACRA’s first year. In 2018, there will be even more changes as we transition to full implementation by 2019 and beyond. Some of the new regulations for the second year include allowing providers multiple submission mechanisms within the ACI quality and improvement categories; an exemption allowance for practices with less than $90,000 in allowed charges for up to 200 patients in Medicare Part B; and the option of participating in MIPS as an individual or a group, including a new virtual group option.

As adjustments are being made to MIPS, action needs to be taken now, so providers can stay ahead of whatever curveballs are thrown. To some degree, physician practices will need to “build the plane while flying it.” The 2018 second-year rules were finalized on November 2, giving practices lead time to position themselves for success. After months of helping practices design and execute MIPS action plans, we’ve distilled the information gathered into the top three things medical practices can do to get ready for the 2018 MIPS/MACRA landscape.

1. Choose which measures to report on wisely.

Though there are over 270 MACRA measures available, many are specialty-specific, so not all will apply to your practice. Still, narrowing down which ones you will choose to report on can be complex. There are a few ways to approach this. First, it’s important to understand the definition of each measure. When choosing which measures to report on, your practice will be expected to report only on those that are applicable or relevant to the services you provide. For an in-depth look at specific measures that your practice will need to report on, CMS provides a helpful resource library. Additionally, the Early Implementation Review: CMS’s Management of the Quality Payment Program offers valuable insights that can help your practice understand specific MACRA measures.

Once you’ve narrowed the measures down to only those that you could be eligible for, you can turn to your billing data to identify the most frequently reported procedures and diagnosis codes, and look for measures that include those. Another good way of choosing measures is through patient eligibility. Use the analytics tools in your EHR, PM, and billing systems to look at the data of your patient population and identify which measures would apply to them. It’s important to avoid those that have less than 20 eligible cases because they’ll receive an automatic minimum score, regardless of how good your performance is.

When choosing measures for your practice, it’s important to understand not just which ones are applicable to you, but also which ones you can do well with. Setting your practice up for success under the new MIPS/MACRA laws requires some upfront legwork that ultimately will help you mitigate the risk of a penalty and increase your chance of receiving an incentive.

2. Make sure your clinicians are on board.

The shift toward a value-based healthcare system addresses more than just patient satisfaction and practice revenue. There’s also a heavy, albeit indirect, focus on physician burnout. Put simply, when your physicians are overworked and spread too thin, they won’t be able to deliver the best care to their patients. This directly impacts your MIPS score. Before finalizing the measures you’ll report on, it’s important to get your clinicians on board. They will understand better than anyone else which measures are appropriate for them, and which will allow them to best demonstrate the quality of care they provide. Physicians who have gone through rounds of Meaningful Use policies may feel resentment toward this latest set of changes under MACRA.

The ability and willingness of your staff to adhere to value-based care and strive toward the final measures should be weighted heavily. To encourage engagement and ownership, consider having a brown bag lunch session and soliciting ideas for making the transition a success. Another way to engage your providers is to have them brainstorm ways to track and show progress on the measures they’ll be reporting on. For example, they may want to see weekly reports or monthly posters on the practice walls. The way in which your providers want to show progress should be amply supported as another way to encourage participation.

3. Ask your EHR or vendor for help.

Once your entire team is on board with the MIPS measures your practice will report on, you can work with your EHR vendor to determine what documentation is needed. Most will provide you with the support you need so that you can submit the minimal requirements to avoid a penalty, and prepare a plan for next year to achieve the incentive.

One of the most important things your EHR vendor can provide is a guarantee program of some kind. CareCloud offered a 2017 MIPS Guarantee, which ensured clients received full assurance of avoiding penalties during the uncertainty of MACRA’s first year. With the higher threshold of activity that will be required in 2018 and beyond, guarantees like this aren’t as easy to support. Still, you don’t want to carry a double risk by paying for a technology that can’t support your needs while you’re also trying to navigate a program that has a lot of potential for change. Though you may not be able to get a no-penalty guarantee, your EHR vendor should offer some kind of protection on the technology side.

We don’t know what’s ahead with MIPS/MACRA in the year building up to what should be full implementation. Though uncertainty exists, we can still be ready. Taking action now to prepare for pending changes can help your practice mitigate the risk of a penalty and, ideally, work toward earning an incentive.

Polly Friend, RN is senior director of clinical strategy at CareCloud in Miami.


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Readers Write: What Do Patients Want? Digital Convenience, of Course!

November 9, 2017 Guest articles No Comments

What do Patients Want? Digital Convenience, of Course!
By Kermit Randa

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The era of healthcare consumerism is here. With it, patients expect the same modern, digital conveniences they receive in other areas of their daily lives. They want easier ways to understand what they owe and convenient options to pay their balances. They also want greater freedom to choose their healthcare providers, and growing numbers of patients are increasingly comparing provider pricing. As a result, healthcare organizations are moving from antiquated payment processes to providing patients with the electronic conveniences they seek.

To that end, MGMA and Navicure collaborated to conduct our first Digital Payment Progress Report survey, where we sought to understand billing payment preferences and behaviors among provider organizations. We then compared some of these findings with Navicure’s Patient Payment Check-Up, conducted by HIMSS Analytics, to assess differences in attitudes and behaviors between patients and providers. The results were intriguing.

In particular, physician practices show some clear advantages over hospitals when it comes to the use of digital billing and payment systems. For instance:

Group practices believe patients are more comfortable sharing mobile/email contact information than do hospitals. In fact, while 64 percent of group practices claim patients are comfortable sharing their email addresses, only 56 percent of hospitals say the same. That may be because providers in smaller group practices have a more personal relationship with the patient than hospital providers. And in reality, most patients (79 percent) are perfectly comfortable providing their email address. Still, 77 percent of providers today send paper bills, which creates incredible opportunity for the industry to leverage email to deliver bills electronically, saving scads of paper, postage, and time, thereby reducing days in A/R.

Patients typically pay their physician practice bills faster. Twenty-six percent of hospital respondents say it takes patients longer than six months to pay their balance, while only 13 percent of practice respondents report it takes this long. Our survey also showed group practices having more success with patients paying at the time of service. That’s likely due to the nature of services offered in a doctor’s office being more predictable, making it easier to provide a cost estimate. And, it’s something practices should take advantage of if they aren’t already doing so.

More ambulatory organizations can provide a cost estimate than hospitals. Nearly 80 percent of ambulatory organizations can provide a cost estimate to patients, while only 69 percent of hospitals can offer one. As previously mentioned, this may be because it’s easier to put a price tag on the services provided in a doctor’s office, which translates into a simpler process for providing an estimate; whereas hospitals may not know the final cost until all procedures/services are completed and the patient is released. But, estimates will become increasingly important — our survey also showed that when patients comparatively shop for services, the results they find make a significant impact on the provider they choose. That’s especially true among younger patients: Seventy-five percent of patients comparing prices are between 18-34 years old. Practices will improve transparency, trust, and satisfaction among their patients if they offer pricing up front.

5 Ways to Put These Findings to Use

While practices may be ahead of hospitals in the areas of cost estimation and electronic billing, they’re still behind when it comes to meeting patient demand. Insights from the Digital Payment Progress Report can be helpful as practices look for ways to address patient billing and payment challenges to help bridge the gap between outdated processes that are holding back progress and patient expectations for electronic payment options.

Here are five things practice administrators can tackle to get started:

  1. Review the 5 Ps (people, processes, products, performance, and patients) to uncover where disconnects are in the payment process and develop an action plan to reduce them.
  2. Ask your patients. Conduct a short online or informal in-office survey to find out what they’re looking for in payment options.
  3. Train your teams. Provide ongoing training to help front-office teams educate patients on payment options, and cross-train the entire office to ensure everyone on the team fully understands the impact their role has on the revenue cycle process and increasing patient satisfaction.
  4. Educate your patients. Patients want a quick and easy to read, short and uncomplicated, one-page document that explains their payment options. Make sure front-office staff are able to confidently discuss financial responsibilities with patients.
  5. Establish measurable objectives for data and quality metrics. Define, collect, and respond to performance metrics to understand your practice’s revenue cycle goals and whether or not they’ve been achieved.

Ultimately, our survey showed there’s strong need for digital payment options such as patient estimates, credit card on file, online bill pay, and more. It also showed there’s agreement all around when it comes to the impact these tools can have on improving collections, reducing days in A/R, and reducing bad-debt write-offs. As healthcare consumerism continues to expand and the future of billing and payments becomes more digital, practices are well-positioned for success when they can pin-point key areas of improvement and proactively give patients what they want – electronic payments and accurate estimates.

Kermit Randa is chief growth officer of Navicure in Atlanta.


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Readers Write: “Are You Even Listening?” How Your EHR Could Be Killing Your Patient Relationships

September 7, 2017 Guest articles No Comments

“Are You Even Listening?” How Your EHR Could Be Killing Your Patient Relationships
By Jordan Miller, MD

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You’re at lunch with a close friend whom you haven’t seen in some time. It’s an opportunity to catch up, share what’s been going on, and participate in some meaningful dialogue. And yet your friend is constantly looking at his or her phone – occasionally glancing up at you as you’re talking as if they are listening. As the person speaking, you can only assume that they’re only half-listening to what you’re saying as they type away. Sound familiar?

A similar scenario is extremely common these days in physician offices. The use of EHRs has been both a blessing and a curse as it relates to patient engagement. In a recent study by Brown University and Healthcentric Advisors aptly titled, “It’s like texting at the dinner table:” A qualitative analysis of the impact of electronic health records on patient-physician interaction in hospitals,” researchers found the use of EHR systems negatively impacts the quality of physician-to-patient interactions.

The study is based on a 2014 Rhode Island Department of Health survey that asked 744 physicians open-ended questions including, “[h]ow does using an EHR affect your interaction with patients?” The increase in reporting standards and the amount of data that physicians need to report today have resulted in valuable time being diverted from the patient. Instead of the physician and patient maintaining eye contact during the examination, the computer tends to be the focal point. This tends to create an uncomfortable and often cold experience for the patient, and leaves the physician feeling unfulfilled.

This increase in demand for data also attributes to physician burnout* – where the physician works tirelessly to treat patients while keeping up with the day-to-day documentation in the EHR and subsequent reporting. Even the AMA has raised concerns about EHR usability.

While this ripple effect impacts all levels of the healthcare system, it is the patient who suffers the most. With reportedly high levels of physician burnout across the US – between 50 and 75 percent of physicians, by some reports – coupled with poor engagement due to using technology in the exam room, patients get the short end of the stick when it comes to achieving their health and wellness goals.

Shouldn’t medical professionals work as efficiently as possible while improving patient outcomes? With the shift to value-based healthcare and the focus leaning now more on patient outcomes, the answer should easily be yes. But, as we’ve seen from many studies, it’s not that simple. But it should be.

Technological advancements today have positively impacted so many industries, including healthcare (e.g. connected devices, robotic surgery), so why is some EHR technology still lagging?

As a practicing dermatologist, I can attest to the ever-increasing need to document patient information in a way that is usable. If physicians don’t have the right systems and technology in place, it could potentially take a lot time and effort to not only keep a practice up and running, but also make it successful. For years, documenting in a paper chart was the standard, and some physicians still prefer this method. Then it transitioned to what was essentially documenting in a word processing system on a desktop computer. In neither situation is the data collected in a structured way or able to be used for medical wisdom, or collecting and extracting this data to show the physician statistically what might lead to better patient outcomes. Plus, with these methods I had to frequently stay late in the office and bring work home – taking time away from the patient, and from my family.

Throughout my conversations with other healthcare providers, I’ve learned some physicians argue that improving patient relationships starts with the creation and adoption of intuitive technologies that can automate key administrative tasks and simplify documentation during patient visits. Healthcare providers should have an EHR system that improves their daily professional lives and, when it comes to usability, is intuitive and knowledgeable about my specialty, plus saves me time.

In fact, in the aforementioned survey, doctors did recognize that EHR systems can provide benefits to patient interaction related to the easy access to a patient’s history. Other physicians commented that Web-based patient portals improve communication with patients, and some shared that they will often utilize their computers to bring up and display educational illustrations of medical conditions. From the study, it can be assumed that the physicians who bring their EHR system and laptops – or iPads – into the exam room have identified ways to turn a potentially detrimental patient engagement situation into a positive one.

I like to think that I’m a perfect example of a physician who utilizes EHR technology that not only saves physicians time, but also helps improve patient outcomes. Today I use a native iPad platform that’s intuitive, automatically adapts to my preferences, collects structured data, codes patient encounters using the touch-based system and automates outputs. I can reference a longitudinal visual timeline of a patient’s diseases and treatments, allowing me to easily determine if a patient’s conditions are improving or declining over charted time periods. The mobility of the iPad allows me to show my patients exactly what I’m reviewing and use it as an educational tool. It’s technology designed to improve patient engagement and clinical outcomes. Everyone wins.

From a business standpoint, data-driven platforms help make practices more profitable and save time. Health IT systems should allow physicians to document exams while the patient is in the exam room, use that data to automate reporting, automatically generate billing codes with modifiers based on your notes, show your current billing level in real time, and assist with daily operational tasks including referring physician letters and faxes. As precision increases, so could profits. Technology should improve operational and financial outcomes, while at the same time improving patient access and outcomes – and yes, even eye contact.

*If you’re a physician or medical practitioner experiencing signs of physician burnout, there are many helpful resources on the American College of Physicians website.

Jordan Miller, MD is a dermatologist at Northern Arizona Dermatology and senior medical director of dermatology at Modernizing Medicine in Boca Raton, FL.


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Readers Write: The Importance of Technology in Ambulatory Care for Chronic Disease Management

August 30, 2017 Guest articles No Comments

The Importance of Technology in Ambulatory Care for Chronic Disease Management
By Allison Hart

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Approximately 100 million people are affected by chronic pain in the United States, and, according to the CDC, nearly half of all adults in this country are suffering from one or more chronic health conditions. Not only are healthcare providers faced with the daunting task of caring for such a large population, but care for such conditions often require multifaceted treatment protocols to address a wide range of disorders. Due to this, care management for chronic patients can be costly – demanding additional healthcare resources and extensive treatment measures beyond the clinical setting.

Financial pressures and performance demands to keep chronic patients healthy have sparked efforts to find new ways of supporting patients during ambulatory care in order to maximize revenue, reduce readmission penalties, and improve outcomes for less. Due to the complexity of most chronic cases and the sheer number of patients, it is difficult for any organization to effectively manage and engage every patient outside of a clinical setting without the right tools.

According to a recent West survey, more than half of patients struggling with chronic disease are only somewhat confident, at best, when it comes to managing their condition. And, another 35 percent of these patients were not sure what their target numbers should be for key health indicators like blood pressure, cholesterol, and weight. In order to effectively manage chronic conditions, not only does each patient need to feel confident in their understanding of treatment adherence, but both patient and provider need to have a firm grasp on the patient’s daily health status in order to avoid declining health and costly hospitalizations.

Successful chronic disease management requires continuity of care. A patient’s checkup is only a small portion of managing a chronic disease, especially when dealing with complex conditions like diabetes that require frequent monitoring and balancing of insulin levels, weight, and blood pressure. Research has shown that patients have a strong desire to improve their quality of life, but in many cases, they are unsure how to make decisions or changes that will create real improvement. Healthcare providers can support chronic patients with engaging outreach and resources that give patients the knowledge they need to better manage their condition.

The Role of Remote Technology During Ambulatory Care

The rise in value-based payment models has prompted healthcare organizations to invest in more efficient methods of patient management – including technology-enabled communications – to help improve the quality of life for patients in a cost-effective way. The rise of biometric monitoring devices, such as pulse oximeters, blood glucose meters, and heart rate monitors is making it easier for physicians to closely monitor a patient’s health status remotely. But while tracking daily analytics is key to ensuring chronic patients are maintaining good health, it is only one aspect of treatment.

In addition to collecting data on a patient’s physical health, clinicians can also leverage existing automated reminder technology to create and schedule a series of communications to support the patient’s long-term health management plan. For example, a diabetic patient might receive notifications via email or text to remind them to take medications, schedule routine eye and extremity exams, or schedule an appointment for an A1C draw. Automated communications can also be used to lend preventive support to low-risk patients to provide educational materials such as recent research on how to manage their specific ailment, videos on diet or exercises, or links to support services. Pairing biometric device data with automated support during ambulatory care can help providers establish critical touch points for intervention, or better predict negative outcomes that might escalate into a readmission.

Automated Surveys Streamline Treatment Efforts

The use of surveys in chronic care management have traditionally been reserved for recently discharged patients and offer great insight into how a patient is coping outside of the clinical setting. In fact, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys found that patients often expressed feeling disconnected from their medical team after discharge and even confused or uncertain about how to comply with care instructions after leaving the hospital. This type of information is paramount for case managers dealing with newly released patients, but could also prove invaluable for physicians caring for the long-term health of chronic patients in the ambulatory setting.

Surveys are currently underutilized by most providers as a chronic disease management tool. The same survey found that many providers monitoring the health of their chronic patients depend on in-person visits to ask questions, while only five percent stated they use survey check-ins that ask questions specifically about treatment plans. Not only is this a costly approach for both healthcare organizations and patients, but it lends itself to poor results in terms of accurately monitoring each patient’s progress on a consistent basis.

Similar to the HCAHPS, clinicians can leverage their automated reminder technology to more proactively and regularly send their chronic patients a series of questions regarding things like pain levels, medication compliance, and sleep patterns to determine if the patient is on track with treatment or if they need to intervene. Leveraging their EHR systems, care teams can also target efforts based on risk stratification – sending more in-depth questions to those more likely to develop complications. This method provides clinicians with a cost-effective method of collecting continual feedback on how each individual patient is coping during daily life. It also addresses the issue of patients feeling disconnected with their providers and makes them feel that their care team is engaged in their treatment journey.

Chronic disease management is complex and requires a multifaceted approach by providers and patients. The office visit is just the beginning of care – effective care management requires that providers and healthcare organizations incorporate the right tools and strategies in the ambulatory setting to reduce readmissions, engage patients, and prevent long-term cost deficits. Leveraging cost-effective technologies that allow patients and providers to stay connected on a day-to-day basis is changing the way doctors and patients approach chronic disease treatment.

Allison Hart is vice president of marketing for TeleVox Solutions at West in Omaha, NE.


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Readers Write: The Promise (and Pitfalls) of Greater Consumer Expectations

August 20, 2017 Guest articles No Comments

The Promise (and Pitfalls) of Greater Consumer Expectations
By Anne Weiler

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Consumer expectations are finally hitting healthcare. We’ve long become accustomed to having anything we want delivered to our homes at any time, in minutes. This level of 24/7 convenience is driving an expectation that all service delivery should be that good. And healthcare is no exception in the eyes of increasingly cost-conscious consumers. After all, rising deductibles, premiums, and copays are causing people to examine where they spend their healthcare dollars, leading them to evaluate care based on outcomes, convenience, and overall experience. We first saw indications of this on highway billboards advertising emergency room wait-times. It’s now spilling over into other areas of healthcare, like concierge medicine and direct primary care, both business models that give patients almost unlimited access to their care team. Healthcare technology is certainly aiding and abetting these expectations, with telemedicine perhaps offering the most promise in meeting expectations around convenience and up-front costs.

Virtual assistants and interactive mobile treatment plans also show huge promise. But for these burgeoning healthcare concepts to take off, their popularity with patients and physicians alike hinges on some basic tenets. First, patients need to feel supported and confident. Once they do, they can start to self-manage outside the clinic. The old way of delivering care instruction – be it verbally or on paper – is seriously lacking in providing this support and confidence. Patients forget between 40 and 80 percent of what is said to them in a face-to-face visit, while paper instructions are often lost. Virtual assistants and apps are always available, and can deliver tailored information when and how patients need it. They can alert both the patient and care team when something requires greater attention. This ability to provide actionable, personalized, and real-time care shows great promise in improving patient experience and outcomes.

However, the challenge in creating this always-connected world of healthcare – whether that’s through consumer health apps, wearables, or even those apps prescribed by healthcare organizations – is that they generate more data than physicians know what to do with. Though this data can provide extremely valuable insights to manage populations, there’s often no place for it in the medical record, which is not designed for patient-generated data.

Data without context is meaningless, which is why physicians initially balked about having device data in the EHR. While understanding how much a healthy person is active is interesting, you don’t need Fitbit data for that when there are other clinical indicators like BMI and resting heart rate. Understanding how much someone recovering from knee surgery is walking is interesting, but only if you understand other things about that person’s situation and care, such as how much they walked before surgery, pain levels, and side effects.

However, if you ignore the patient experience outside the clinic, decisions are being made with only some of the data. In Kleiner-Perkin’s State of the Internet Report, Mary Meeker estimates that the EHR collects a mere 26 data points per year on each patient. That’s not enough to make decisions about a single patient, let alone expect that AI will auto-magically find insights from aggregated information.

How do you marry this patient-generated data with current healthcare IT systems? The value of patient engagement and self-management through virtual assistants and applications is real. Current systems, however, aren’t designed for this data. To the patient, every single one of those Fitbit steps or recorded symptoms is interesting. To the physician, it’s noise. To make sense of these two worlds, we need a few things. First, we need to leverage machine-learning and big data tools to make sense of the terabytes being collected directly from patients. Next, we need to identify indicators of adverse events or negative trends. Then, we need to be able to react to and act on those indicators for patients, either with alerts and instructions delivered by an app, or by direct outreach from a clinician.

Finally, this data needs to make its way back into the patient’s medical record – but not all of it. Scores from patient-reported outcome surveys, important recorded symptoms, and trend data should be attached to the EHR. The rest should be available directly to the patient, and to clinicians and analysts to work with in BI and other tools. To make this new world a reality, patient engagement systems must be interoperable and open, and sit side-by-side with the EHR. There’s a whole world of data and learning out there to improve patient experiences and outcomes, but to capitalize on it, we need openness and interoperability.

Consumer expectations are indeed hitting healthcare – hard. Patients are no longer shy about telling physicians and payers what they want and how much they’re willing to pay for it. While these expectations can seem overwhelming to those insiders who have long become accustomed to healthcare’s glacial pace, we shouldn’t be discouraged. These greater expectations can indeed be met, provided we take the time to develop and offer physicians and patients tools that meet their needs and fit their workflows.

Anne Weiler is co-founder and CEO of Wellpepper in Seattle.


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