EHR Optimization Among Seniors May Need Improvement
Wednesday, August 26th, 2020
A Journal of the American Medical Informatics Association (JAMIA) study reveals acute care hospital EHR optimization may not be meeting rigid healthcare standards when it comes to older patients. Current optimization for this demographic is not reaching the standards of the “4Ms” Framework, implemented back in 2017 as a way to boost healthcare for seniors. The 4Ms are a series of healthcare preferences and goals: What Matters, Medication, Mentation, and Mobility. 

EHRs could be modified, for instance, to integrate features that tackle the 4Ms by incorporating reminders and fields in the EHR for clinicians to implement standardized treatment, target documentation, or revisit medicines known to affect mobility and mentation (the prevention, identification, and management of mental illnesses like delirium and depression). According to the JAMIA study, however, there may be a lack of awareness among clinicians on ways to integrate certain needs for older adults.

 

The JAMIA findings may suggest that hospitals do not rely on EHR optimization to improve older adult care, while the bulk of the inpatient population is actually older adults. Applying policy and realistic initiatives that concentrate on improving care for this age group may help tackle this problem.

To read more, please visit https://ehrintelligence.com/news/older-population-often-overlooked-during-ehr-optimization.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

Transitioning to Full-Risk Capitation
Monday, August 24th, 2020

Healthcare’s “value movement” is a concept just about everyone comprehends. It’s easier to compensate someone for the value they’re making versus simply doing the job. A situation of affordability sparked value-based care, with the Affordable Care Act contributing heavily. Today, among the few programs that have near-universal political support, value-based care is one. When efficaciously enforced, clinicians are spurred to care for the entire person and tackle the risk factors so essential to the quality of life of patients.

Many value systems are still developed on a fee-for-service basis, where doctors are constrained in what they can do with the conventional method of billing and coding. What’s more, these programs too often measure processes rather than results (for example, checking blood pressure versus improving it and cutting down on hospitalizations). It’s not clear whether calculated actions would result in the true desired outcome of less expensive, more sustainable healthcare, and those acts say little about the experiences of actual patients.

A typical primary care doctor sees about thirty patients daily, generating around $600,000 in a year at $80 a visit. This individual is trying to keep patient visits short, there is a ton of paperwork they need to take care of, and, after covering the costs of running the practice, they are hoping to take home a portion of what specialists earn. There is minimal benefit resulting from value-based care payouts, regardless of their PCP skills.

What if the individual assumed “full” risk for these patients? If the doctor took the reins and was responsible for everything about their patients? Things shift radically. Presuming the payor negotiations have been taken care of, this same doctor may have somewhere around $12 million (average $500 per patient per month), about twenty times the money. There is the danger the $12 million is expended, and the doctor incurs a loss. But primary care is worth more than five percent ($600,000 of the $12 million) of overall costs collected by the doctor in the fee-for-service environment because PCPs will redefine the “downstream” treatment use. To stop wasting the other 95 percent of preventable, avoidable, and wasteful treatment, everything now becomes how to maximize patient health. It’s about working with patients, encouraging them to do what’s needed to have a positive effect.

To read more, visit https://www.linkedin.com/pulse/full-risk-capitation-model-why-make-change-christopher-chen/.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

COVID-19 Shines a Strong Light on Medicare Advantage
Wednesday, August 19th, 2020

The strength and versatility of Medicare Advantage has become increasingly evident in the age of COVID-19. When the pandemic began spreading across the country this spring, Medicare Advantage plans responded quickly and were among the first to take charge, identifying and introducing changes to policies and benefits.

Many Medicare Advantage programs quickly identified an exhaustive list of supplemental benefits addressing health social determinants, crucial in the response to COVID-19. Member outreach including meal deliveries, free masks, and regular communication were instituted to help address anxieties made evident early on.

By the time June was over, Medicare Advantage membership reached almost four million, an increase of more than ten percent from the first half of 2019 and up to eight percent from enrollment by the end of the same year. In the first half of the year, insurer Humana added well over 250,000 Medicare Advantage members and predicts more than 330,000 will join before the end of the year. Humana’s success in Q2 mirrors that of many payers as a result of lower utilization during the pandemic. That number is expected to rise in the last half of the year with rising utilization including an expected increase in elective surgeries.

Seniors have recognized the value in Medicare Advantage, as demonstrated by rising enrollment, which has almost doubled during the past years. Close to forty percent of the Medicare population are now enrolled in an Medicare Advantage plan. That number is anticipated only to increase as more seniors become old enough to qualify for Medicare.

To read more, please visit https://www.fiercehealthcare.com/payer/humana-posts-1-8b-q2-profit-as-insurers-continue-to-show-strong-financial-performance-amid.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

Value-Based Care May Help Practices Remain Afloat
Wednesday, August 12th, 2020

Primary care practices have had to contend with the possibility of closure due to the pandemic. The conundrum comes in figuring out the best way for physicians to save their practices while still providing patients optimum care. The answer may lie in value-based care.

Primary care is arguably more important than ever, yet it has become increasingly evident that the traditional fee-for-service model, based solely upon actual practice visits, has become untenable. The safest option for many patients is to stay at home to stay healthy, so these physicians and healthcare practices now find themselves facing an uphill battle to remain in operation.

Value-based practices have managed to keep their doors open, take care of their patients, and even prosper in these challenging times. Instead of concentrating solely on patients that walk into the practice, value-based care is more about ensuring patients remain healthy and out of the hospital. With value-based care, practices can, for example, reach out to a patient to contact them and evaluate their care beyond the doors of the practice as well as keep in touch in the event the patient does have to go to the hospital emergency room.

The key is breaking the misconception that fee-for-service is the perfect way to pay for primary care. Primary care should be about the value created, where care is more person-based than transactional.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

COVID-19 Waivers Boost Medicare Telehealth Access
Monday, August 10th, 2020

Per a recent study, Medicare Advantage Plans and other stakeholders indicated that during the coronavirus pandemic, CMS exemptions proved successful in allowing access to Medicare and Medicare Advantage telehealth. However, there are still hurdles to overcome.

After reviewing the data from 2017, the researchers discovered that, particularly in metropolitan areas, internet coverage was primarily targeted towards younger Medicare beneficiaries with income deemed medium to high. Standard Medicare beneficiaries were more likely to use the internet than beneficiaries of Medicare Advantage, in all the groups analyzed.

CMS provided several telehealth flexibility plans for Medicare and Medicare Advantage, including broadening coverage to Medicare telehealth visits, virtual check-ins, and e-visits, and finally, audio-only services.

Policies that shared risk-bearing payment structures assisted with the rapid adjustments of plans and providers to the pandemic. These models let Medicare Advantage plans employ telehealth services and grow in a brief time to current platforms.

Fee-for-service payment programs proved trickier for both traditional Medicare and Medicare Advantage patients as they navigated the adoption and expansion of telehealth.

Certain factors that increased the adoption and growth of virtual care included promoting home-based telehealth, removing the requirement for providers to have a previous relationship, and increasing the eligibility requirements for provider and service reimbursement.

To read more, visit https://healthpayerintelligence.com/news/covid-19-waivers-improved-medicare-advantage-telehealth-access.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

Appropriate Use Criteria Guidelines In Effect January 1, 2021
Monday, August 3rd, 2020
As of January 1, 2021, providers who serve Medicare patients will be required to consult a Clinical Decision Support Mechanism (CDSM) and obtain a determination as to whether the test conforms to the Appropriate Use Criteria (AUC) before the test can be administered.

Advanced diagnostic imaging services are crucial tools for ensuring accurate diagnoses and planning suitable treatment. Examples of CDSM imaging services are CT (Computed Tomography), PET (Positron Emission Tomography), Nuclear Medicine, and MRI (Magnetic Resonance Imaging). Any time any of these services are ordered, providers are required to consult the CDSM and receive a determination whether or not the order follows AUC guidelines.
All physicians and other providers who treat Medicare patients and any facility that furnishes those services in a physician’s office, hospital outpatient department, ambulatory services department, or independent diagnostic testing facility will be required to adhere to the regulation. The program is now in the educational and operational testing phase, so no payment consequences will result from not following the recommended workflow. Providers should take this time to familiarize themselves with the process, however, as any practitioner who treats Medicare Part B beneficiaries will be required to abide by this rule from January 1, 2021 on.
The CDSM is a tool within your certified EHR. (All CEHRT systems should be on the 2015 certified version.) This tool must be enabled to be incorporated into the workflow. Ideally, this consult should be done at time of ordering, so the test will not be denied later. Embedding the AUC requirement into your workflow will ensure you are following prescribed guidelines and avoiding any payment penalties.
CareOptimize is ready to help any practitioner with any questions about this new rule. Our value-based experts can assist with:
• Ensuring your workflow is adjusted to accommodate the AUC requirement

• Enabling the tool within your EHR

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.