The pMD Blog

Welcome to the
pMD Blog...

where we cover interesting and relevant news, insights, events, and more related to the health care industry and pMD. Most importantly, this blog is a fun, engaging way to learn about developments in an ever-changing field that is heavily influenced by technology.

POSTS BY TAG | Alternative Payment Model

Increasing medical practice revenue


As health care organizations in the U.S. move towards electronic systems to manage their patient records, data collection and analysis on health care information has become easier for entities like the Centers for Medicare and Medicaid Services (CMS). As a result of this, trends in patient outcomes and patient health history can provide useful information. This has given way to a new format of hospital reimbursement in health care, which is called value-based care.

VALUE-BASED CARE AND ALTERNATIVE PAYMENT MODELS


Value-based care is a broad term for a reimbursement model for health care organizations (HCOs) in which CMS or other insurance institutions will reimburse based on the quality of care provided and the quality of patient outcomes. This means that providing efficient and quality care to a patient will result in a higher reimbursement for the HCO, while inefficient care will result in a lower reimbursement to the organization. This differs from the traditional fee-for-service model, where providers are reimbursed based on the service provided to a patient, regardless of quality of care or outcome.

One way that CMS has begun to implement value-based care models in the U.S. is by offering certain HCOs the opportunity to participate in Alternative Payment Models (APMs), which is their version of value-based care. There are nearly 100 APMs offered by CMS that organizations can participate in, each of which has different participation requirements and different quality measures by which patient outcomes are measured. The Bundled Payment for Care Improvement (BPCI) Advanced model is a great example of an APM.

BUNDLED PAYMENT FOR CARE IMPROVEMENT (BPCI) ADVANCED MODEL


The BPCI Advanced model is just one example of a value-based payment model, and it’s one that pMD can largely accommodate today. The quality measures tracked by this payment model are: 

1. Unexpected hospital readmission for the patient in question within 30 days of discharge
2. Existence of an Advanced Care Plan
3. Quality of care based on a list of 26 CMS-defined Patient Safety Indicators  

How are BPCI Advanced quality measures reported and tracked?


With HCOs' profits on the line, most would not want to participate in a reimbursement model that could lose them money if they’re unprepared. Fortunately, with the BPCI Advanced model, and many of the other models offered by CMS, these quality measures can be completely tracked through electronic means, providing a more streamlined way to submit that information to CMS. The additional work required here, however, would be the time it takes to complete some advanced care planning with your patients, a practice that may not have been standard but has been shown in data to have a positive impact on patient outcomes in health care.

pMD Helps Practices Participating in Alternative Payments Models


Not only does pMD, a MIPS registry, have the capability to accurately submit claims electronically but we also provide the tools to help organizations better navigate patient care. Our comprehensive platform offers customizations to accommodate the growing needs of practices participating in alternative payments models. pMD’s functionality is constantly evolving to support customers looking to participate in value-based care payment models, improve patient outcomes, and maximize reimbursement.

 

To find out more about pMD's suite of products, which includes our charge capture and MIPS registrybilling servicestelehealthsecure messagingclinical communication, and care navigation software and services, please contact pMD.
With the growth of CMS’s Alternative Payment Models, the moments when physicians directly care for patients - the points of care - are getting vastly more complicated and information-needy. Let’s take a look at why and how this is happening!

The Environment
Recently, CMS set a clear path to creating new risk sharing programs for providers through alternative payment models such as Bundled Payments for Care Improvement (BPCI), which my colleague Tracy outlined well in this terrific post. The broad based BPCI program gave way to more specialty specific programs such as the Oncology Care Management Model, Nephrology’s ESRD Care Model, and Orthopedics’ Comprehensive Care for Joint Replacement model.

Collectively these programs signal a new era where previously disparate episodes of care are financially bound together. The new twist is that the payments, and hence risk, cover multiple providers and multiple sites of care. Now providers in different businesses are wrapped together in common financial risk, where before they operated independently. This new dependence asks more of each patient encounter and as a result, communication and coordination needs are growing exponentially.

These new alternative payment programs have a common general structure. First, each requires a risk period that includes all patient costs over a period ranging from 30 to 90 days. Second, each requires certain quality metrics be met. Third, each requires certain financial outcomes usually obligating an organization to operate at lower than its historical cost over the risk period. The organization can earn bonuses if the cost performance is below historical cost, or they must repay CMS for any costs that run above historical cost.

The first two elements trigger a need to work collaboratively with other caregivers given that most patients receive care from a variety of providers over such time periods. The last element, financial outcomes, acts to incentivize broad engagement since it can reward physicians with bonuses. Organizations can theoretically make up to a 50% bonus on their Medicare reimbursements occurring within the program. Taken together, these elements: risk, quality, and financial performance, require providers to be particularly attentive to the decision-making around patients in these programs. Each decision made at the point of care by an individual provider affects risk, quality, and finances not only for themselves, but also for every provider involved in the program.

On the Ground
Given this new importance of decision making at the point of care, there is a lot of new information to consider. Each risk period starts in the hospital and follows the patient into their post acute outpatient settings, which are typically owned by a different entity than the hospital. Thus, doctors at the point of care need to evaluate information such as:

• What is the site of care best suited for the patient’s condition: a skilled nursing facility, Home Health, inpatient rehab, or acute long term care?
• What site of care promises the best outcomes?
• Which particular provider will do the best job with that particular patient’s diagnosis and needs?
• How do we discuss this with the family and their particular dynamics and medical literacy?
• What quality measures are unmet for that patient?

How to get all of this information to the provider at the point of care - where decisions about the best, most effective care path for the patient must be made - is a growing problem. Further complicating matters are:

• The availability and continuity of the hospital case managers who have a primary responsibility to get patients discharged from the hospital in a timely manner;
• The many physicians who may be on the case with their demanding caseload;
• The frequent uncertainty of who would follow the patient post discharge and the families’ desire to have the patient’s needs fit into their busy lives.

All in all, this is a lot of new information to address at the point of care, and some of it quite complex with many different and diverse audiences. These data points highlight the very real question of who will be consistently available to deliver the information needed.

So therein lies the challenges for success in any of these Alternative Payment Models. There are new outcomes to consider spanning up to 90 days of care across all care settings, many beyond your walls, with a quality scorecard to meet. All of this impacts financial risk if the goals aren’t met. It seems inevitable that technology must rise to the task of delivering this data at the point of care, if alternative payment programs are to ever succeed. However, the challenge for those who seek to enable with technology is how well they can understand this thicket of needs and help you build the right care network, around each patient, extending to all the places you need it to go, and to all the people you need involved. I came to pMD to tackle such complex issues. Here, we love your difficult challenges.