CMS Chronic Care Management Medicare Reimbursement: Sizeable Revenue, Health Outcome Opportunities

November 21st, 2014 by Cheryl Miller

Beginning January 2015, Medicare will pay a flat, monthly chronic care management (CCM) fee to providers coordinating care for beneficiaries with more than one chronic condition. This change will expand the current Medicare payment policy to include non face-to-face management services previously included within payments for evaluation and management (EM) services, amount to about $40 a beneficiary, a sizeable new source of revenue for eligible providers.

The targeted population is also substantial; as recent news story reported by the Healthcare Intelligence Network (HIN), 87 percent of U.S. adults ages 65 and older have at least one chronic illness, and 68 percent have two or more, the highest rates in a new 11-country Commonwealth Fund survey.

But healthcare organizations do not have that much time to prepare for the newly released 2015 Medicare Physician Fee schedule, which finalized the CCM reimbursement. Who can bill for CCM, what constitutes a chronic condition, which patients are eligible to receive CCM services, and the scope of services required were among the issues discussed during Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care Coordination, a November 19th webinar, now available for replay. Rick Hindmand, an attorney with McDonald Hopkins, a law firm that advises a nationwide client base extensively on healthcare reimbursement, shared insight on these issues and how to best prepare for this reimbursement opportunity.

Those allowed to bill for CCM reimbursement fall into one of five categories: physicians, advanced practice registered nurses (APRNs), physician assistants (PAs), clinical nurse specialists and certified nurse midwives. If these practitioners are part of a practice entity, that entity can bill for it as well.

Beneficiary requirements are not as clear cut, Mr. Hindman continued. Eligible patients must have at least two chronic conditions that are expected to last at least 12 months or until death, and those conditions need to create a significant risk of death, acute exacerbation/decomposition or functional decline. Specific definitions of conditions can be found at CMS’s Web site.

And because CMS does not want to pay for duplicative services, CCM is not allowed for beneficiaries who receive services for transitional care management, home healthcare supervision, hospice supervision, and various end stage renal disease (ESRD) conditions. Patients attributed under the Multi-payer Advanced Primary Care Practice Demonstration (MAPCP) and the Comprehensive Primary Care (CPC) Initiative are also excluded.

Once these requirements are satisfied, providers must offer and document 20 minutes of CCM services a month, which enhance access and continuity of care, care management, transition management, and coordination, Mr. Hindman continues.

The CCM fee comes to about $40 a beneficiary, a significant revenue source once applied to all patients within a practice. Why the change now? Mr. Hindman speculates that CMS is finally realizing that care management is a crucial component of primary care. But questions and details await future guidance from CMS, and satisfying and documenting compliance with the CCM reimbursement requirements is going to present a challenge for many practices.

But the time and effort is worth it, he says. "With careful structuring, chronic care management can provide the potential to improve the health of their patients, while also providing some significant financial benefits for the practice."

To listen to an interview with Mr. Hindman, click here.

Infographic: Getting Paid for the New Chronic Care Management Code

November 21st, 2014 by Melanie Matthews

Under CMS' new Chronic Care Management (CCM) program, which takes effect in 2015, physician practices can receive reimbursement for non-encounter based follow up care to coordinate care for those with chronic conditions.

A new infographic by HealthFusion provides details on the physician practice and patient responsibilities for practices to be eligible for this reimbursement.

Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care CoordinationStarting January 2015, physician practices will be eligible to receive reimbursement for chronic care management services provided by physicians, advanced practice nurses, physician assistants, clinical nurse specialists and certified midwives to Medicare beneficiaries with multiple chronic conditions. The 2015 Medicare Physician Fee schedule, which finalized the Chronic Care Management reimbursement, was just released, leaving healthcare organizations with little time to prepare for the final aspects of this new reimbursement opportunity.

During Chronic Care Management Medicare Reimbursement: New Revenue Opportunities for Care Coordination a November 19th webinar, now available for replay, Rick Hindmand, attorney with McDonald Hopkins, will share critical insight into how physician practices can best structure their practice to receive this additional reimbursement. The McDonald Hopkins law firm advises a nation-wide client base extensively on healthcare reimbursement.

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11 Statistics about Stratifying High-Risk Patients

November 20th, 2014 by Cheryl Miller

Healthcare organizations use a range of tools and practices to identify and stratify high-risk, high-cost patients and determine appropriate interventions. Most critical to the stratification process is clinical patient data, say an overwhelming 87 percent of respondents to the Healthcare Intelligence Network’s (HIN) inaugural survey on Stratifying High-Risk Patients. However, obtaining and verifying patient data remain major challenges for many respondents. Following are 10 more statistics from our survey.

  • „„Hospital readmissions is the metric most favorably impacted by risk stratification tools, according to a majority of respondents.
  • „„In addition to high utilization, clinical diagnosis is considered a key factor in stratifying high-risk patients, according to 16 percent of respondents.
  • „„Case management as a post-stratification intervention is offered by 83 percent of respondents; health coaching by 56 percent.
  • Reducing heart failure (HF), pneumonia (PN), and atrial myocardial infarction (AMI) are among the greatest successes of risk stratification programs.
  • Diabetes is considered the prominent health condition among high-risk populations, according to 37 percent of respondents; other prominent conditions include hypertension (20 percent) and mental health/psychological issues (15 percent).
  • Physician referrals are cited by 76 percent of respondents as an important input for stratification, followed by case/care manager referrals (71 percent).
  • „„Home health and/or home visits are available to risk-stratified populations of 56 percent of respondents.
  • „„LACE (Length of stay, Acute admission, Charleston Comorbidity score, ED visits) is considered the primary indice and screen to assess health risk, according to 33 percent of respondents.
  • Nearly half of respondents (45 percent) cite high utilization of the emergency department (ED) or hospital as the most critical attribute of high-risk patients.
  • „„While more than half of respondents have a program in place to identify and risk-stratify complex cases, the majority admit it is too early to tell the ROI achieved.

Source: 2014 Healthcare Benchmarks: Stratifying High-Risk Patients

http://hin.3dcartstores.com/2014-Healthcare-Benchmarks-Stratifying-High-Risk-Patients_p_4963.html

2014 Healthcare Benchmarks: Stratifying High-Risk Patients captures the tools and practices employed by dozens of organizations in this prerequisite for care management and jumping-off point for population health improvement — data analytics that will ultimately enhance quality ratings and improve reimbursement in the industry's value-focused climate.

Healthcare Trends 2015: Transparency, New Players Narrow Payor-Provider Divide

November 20th, 2014 by Patricia Donovan

Trends 2015
To paraphrase Bob Dylan: Healthcare roles, they are a' changin:'

For example:

  • Providers are moving into payor spaces, assuming care coordination roles.
  • Payors are expanding into provider businesses.
  • Hospitals are being repurposed as post-acute care centers.
  • Empowered consumers are diving into data analytics for cost and quality information.
  • Innovators launching new care models abroad are poised to test them on U.S. soil, turning healthcare into a global market.

Given these role reversals and emerging players, the challenge of distinguishing oneself organizationally in the marketplace is a formidable one. Healthcare payors and providers received targeted advice for achieving this goal during Healthcare Trends and Forecasts 2015: A Strategic Planning Session.

And as Dorothy Moller, a managing director at Navigant, and Steven Valentine, president of The Camden Group, both attested to during the eleventh annual planning session from the Healthcare Intelligence Network, the biggest threat may come from outside the industry.

"Payors are experiencing new threats to their core business from new market entrants and competitors," noted Ms. Moller, who offered the payor perspective. "Those could be anything from new health plans to new technology companies or companies chipping away at components of their core business, offering new services or decision-making tools to their existing customers."

Walgreen's retail clinics were on Ms. Moller's list of nine such companies to watch in 2015. Similarly, Walmart's venture into Direct Health is one example of a 'disruptive strategy,' contributed Valentine, representing the providers' viewpoint. "We begin to see what direct health is doing. Walmart is getting people in their stores because they still sell goods. What happens when Walmart acquires a health plan or starts to offer its own healthcare products? If we think of some disruptive strategy, you might look at what a Walmart would do."

Within the marketplace, Vivity, Anthem Blue Cross's new, low-cost, patient-centered Southern California health plan that targets employers, is challenging Kaiser Health Plan for market share, added Valentine. Similarly, health plans are also threatened by 'disintermediation,' offered Ms. Moller— the movement of payors out of the value exchange, such as in the case of direct primary care.

Both thought leaders analyzed factors driving healthcare change, including the steady shift toward value-based reimbursement, changing healthcare delivery models and the increasing reliance on remote patient monitoring, then outlined areas ripe for potential innovation and growth.

While each proposed sector-specific coping strategies, payor-provider integration, collaboration and partnerships were also strongly encouraged.

Pressure for increased transparency also is taking its toll, with myriad sites and sources offering healthcare cost and quality data. "Healthcare systems can look at their competitors. They can get a sense of pricing in their market," said Valentine, who advised providers to focus on pricing now in anticipation of increased awareness by 2016 and 2017, when he expects more states to include claims and pricing in exchanges.

"We used to say that healthcare was recession-proof; we now know healthcare is price-sensitive," he said. "People's copays and deductibles have grown enough that consumers will shop price."

Ms. Moller advises payors to proceed carefully when considering new development. Her suggestions include collaborations with non-traditional industries, conducting long-term strategizing, and monitoring the global market.

In the closing Q&A, Ms. Moller and Mr. Valentine addressed more 2015 concerns, including the anticipated impact of Chronic Care Management reimbursement. Hospice and palliative care will likely be affected by the updated 2015 Physician Medicare Fee Schedule, predicted Valentine, who views chronic care management as a critical focus for healthcare providers in the year ahead.

"The area in which we see the most growth, and where we'll see continued growth in 2015, is in the center for chronic care management. For example, we identify a diabetes care team, which is the diabetes center for chronic care. We find this is better in terms of using a multi-disciplinary team and it improves throughput for the primary care patient-centered medical home (PCMH)."

Commenting on impact from the numbers of newly insured on the system, Ms. Moller responded it is still too early to see the true effect, due to slow implementation and a claims lag.

For more provider predictions from Steven Valentine, including a surge in telehealth, e-visits and physician-hospital organizations, click here.

To listen to Ms. Moller's expectations for payors in the year ahead, including co-located care management and progress by safety net payors, click here.

Have predictions of your own? Our 10 Questions on 2015 Healthcare Trends Survey runs through December 13. One winner who completes the survey will be eligible to win an on-demand recording of the 2015 strategic healthcare planning session described in this post.

Infographic: Motivational Interviewing

November 19th, 2014 by Melanie Matthews

Motivational interviewing (MI) is a standardized, evidence-based approach for facilitating behavior change, according to a new infographic by Health Sciences Institute.

The infographic explores the four key phases of MI and evidence to support MI's impact.

Evidence-Based Health Coaching: Patient-Centered Competencies for Population HealthTo succeed in a value-driven system, healthcare organizations will need to shift primary responsibility for health management to the individuals it serves. Evidence-based health coaching supports these population health goals by aligning best practice care with patients' needs and values.

Evidence-Based Health Coaching: Patient-Centered Competencies for Population Health presents a template for evidence-based coaching that emphasizes clinical competencies, along with real-life applications from a health system already utilizing clinical health coaches within its value-based healthcare network.

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Humana Remote Monitoring Tools Assess Frail Elderly with Functional Limitations

November 18th, 2014 by Patricia Donovan

In nine separate pilots of remote patient monitoring, Humana is testing technologies to keep the frail elderly safe and healthy within their homes for as long as possible. Here, Gail Miller, vice president of telephonic clinical operations in Humana's care management organization, Humana Cares/SeniorBridge, reviews some of the tools and challenges of remote care management of individuals experiencing difficulties with activities of daily living (ADL).

Question: What assessment tools do you use to measure functional limitations and ADLs?

(Gail Miller): Besides the Charleston Frailty Index, we have a proprietarily developed tool that was started with Green Ribbon Health that manages all of the functional capabilities. That is the one that we use to help scale people. We also use the PH12 and the Subjective Global Assessment (SGA), as well as a couple of other assessment tools. It will often depend on how the person is presenting, but our primary assessment tool for functionality is the mDAT, which we developed internally.

Question: How does Humana define ‘frail’?

(Gail Miller): We use the clinical definition of frail — people more likely to fall, unable to keep their balance, on various medications, etc.

Question: How do you coordinate care for the functionally challenged?

(Gail Miller): If someone is having problems falling in their home, we will send our care managers into the home to do a fall and safety assessment, and then we will work with that member to complete the actions on the plan and to try and make their home safer for them to be able to move around in. If the person is having issues with their balance for example, and it isn’t due to the construction of their home or the way items are placed there, then we will get them to the appropriate provider so that they can be assessed, and see if there are things that we can do to improve on that.

In that case, we would not only be taking them to one of our providers, but also getting them enrolled in one of our Silver Sneakers classes, which is a class we offer that focuses specifically on balance and core strengths.

remote patient monitoring
Gail Miller is vice president of clinical telephonic operations for Humana Cares, the complex care and chronic management arm of Humana, Inc. Her responsibilities include the oversight of the complex and chronic care programs provided telephonically to members of Humana.

Source: Remote Patient Monitoring for Enhanced Care Coordination: Technology to Manage an Aging Population

Infographic: A Platform-Oriented Approach to Healthcare IT

November 17th, 2014 by Melanie Matthews

Traditional IT adoption models such as building solutions from the ground up and/or sourcing third party services results in inefficiency, complexity and unpredictability, according to a new infographic by Infosys.

The infographic examines the benefits of a platform-based approach to health IT.

Interoperability in Healthcare Information Systems: Standards, Management, and TechnologyAlthough the standards in electronic health records and general healthcare services continue to evolve, many organizations push to connect interoperability with public service and basic citizenship rights. This poses significant technical and organizational challenges that are the focus of many research and standardization efforts.

Interoperability in Healthcare Information Systems: Standards, Management and Technology provides a comprehensive collection on the overview of electronic health records and health services interoperability and the different aspects representing its outlook in a framework that is useful for practitioners, researchers, and decision-makers.

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Infographic: Healthcare Quality Reporting

November 14th, 2014 by Melanie Matthews

Healthcare quality reporting initiatives have revealed the state of healthcare quality in the United States, according to a new infographic by Caradigm.

In the infographic, Caradigm explores the impact of quality on patients and providers.

Healthcare Quality Reporting

Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care While widespread adoption of electronic health records has generated new streams of actionable patient data, John C. Lincoln has taken data mining to new levels to enhance performance of its accountable care organization (ACO).

Beyond the EMR: Mining Population Health Analytics to Elevate Accountable Care reviews the concentrated data dig undertaken by John C. Lincoln to prepare for participation in the CMS Medicare Shared Savings Program (MSSP).

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Sentara Home Visits for High-Risk ‘VIPs’ Drive Hybrid Case Management Outcomes

November 13th, 2014 by Cheryl Miller

When the Sentara Medical Group evolved to a hybrid embedded case management model in 2012, case managers spent time in the practice, but also managed care through other touch points, including home visits, explains Mary M. Morin, RN, NEA-BC, RN-BC, vice president, nurse executive with Sentara Medical Group. How to identify high-risk patients for case management, and home visits in particular? Here, Ms. Morin addresses that question posed by The Healthcare Intelligence Network during a recent webinar.

Question: How does Sentara identify high-risk patients for case management in general and for home visits in particular? Do all patients in the case management program receive home visits?

Response: (Mary M. Morin) This program started as a pilot in 2012. It was targeted at patients that we called very important patients — high-cost, high-utilizers, the top of the pyramid. There are about 2,300 patients within 11 of our primary care sites. We kept it small, with five RN care managers. That population included all payors, most importantly our health plan patients. Because of our health plan, we were able to really study whether RN care management had an impact on the total cost of care — not unlike other organizations, if you can find a cost savings and justify the expense of having RN care managers, it makes the case much more solid moving forward with formalizing the program.

We sorted those patients by high-risk, high-cost or high-cost, high-utilizers because of chronic diseases. We looked at patient with congestive heart failure (CHF), chronic obstructive pulmonary disorder (COPD), asthma, renal failure and diabetes. We excluded patients that had any traumatic event like a car accident or something that led to high-cost, or they had cancer or they were a transplant patient.

The purpose was to engage that population. It is voluntary. We studied that population for three years. It allowed us to measure our outcomes over time because we weren’t sure if there was seasonality to the patients with chronic disease: did they just not use services because of seasonal issues or because it’s a cycle issue within the chronic disease phase? After three years of data, we determined there is definitely a difference in the outcomes of this patient population and their utilization.

Home visits was one of the big differences in the model. The main reason to do home visits is not to do patient care, but to do an assessment of the patient’s environment. A lot of times, patients don’t share with us their actual living situation. They tell you that they’re walking, and then you find out they walk within a five-foot radius. The real emphasis for home visits was to get in and meet the patient in their environment.

We found that RN care managers in the home facilitated advance care planning. That is best done in the patient’s home with a family member present, not in the doctor’s office or waiting until the patient is admitted to the hospital. We found that patients appreciated the visits. The RN care managers who went in really cleaned up the medications. Patients will hold on to medications.

value-based reimbursement
Mary M. Morin, RN, NEA-BC, RN-BC, is a nurse executive with Sentara Medical Group, where she is responsible and accountable for non-physician clinical practice within the Sentara Medical Group (160 clinics/practices) to ensure integration and alignment with Sentara Healthcare, regulatory compliance, standardization of nursing practice/care, and patient safety.

Source: Hybrid Embedded Case Management: New Model for Cross-Continuum Care Coordination

Infographic: Medication Non-Adherence’s Impact

November 12th, 2014 by Melanie Matthews

Medication Adherence

Medication Adherence

Medication non-adherence negatively impacts patient health and drives increases in healthcare costs, according to an infographic by NextIT.

The infographic examines one of the top reasons for medication non-adherence, eliminating health risk factors, and the role of virtual health assistants in helping patient manage chronic conditions.

What's the cost of medication non-adherence? As high as $290 billion annually, according to one frequently cited estimate. An equally bitter pill to swallow is the dismal C+ grade in medication adherence earned in 2013 by Americans with chronic medical conditions, according to the first National Report Card on Adherence from the National Community Pharmacists Association (NCPA). Fortunately, the healthcare industry is striving to improve performance in this area.

42 Metrics for Improving Medication Adherence42 Metrics for Improving Medication Adherence provides convincing evidence of the impact of nine key interventions on medication non-adherence— from the presence of pharmacists in patient-centered medical homes to medication reconciliation conducted during home visits.

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