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How Are Ambulatory Practices Going to Compete with Health Systems?

Posted on July 9, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

We’ve all seen the stories about the explosion of data and the way healthcare is getting more personalized. However, David Chou recently pointed out how the data is one thing, but figuring out the role everyone plays in your healthcare organization is just as important as the data itself. It gets complex quickly as this graphic David shared shows:

This is a great graphic of the healthcare analytics roles and responsibilities that will be needed to make the personalized medicine future a reality. Plus, it will be key to getting a lot of the value out of our past EHR investments. Many hospitals and health systems already have these roles filled or are working to have them filled. We’ve seen this first hand when we see data jobs being posted to our healthcare IT job board.

While this work is extremely exciting and shows a lot of promise, I imagine a graphic like the one above is just completely overwhelming to consider for a small ambulatory practice. Even a large group practice would likely find the above graphic challenging to consider in their relatively small healthcare organization. How can they compete with a large health system with that kind of complexity? Do graphics like the one above just provide one other illustration of why small practices are going to soon be extinct?

I don’t think so and I hope not. However, graphics like the one above do illustrate the tremendous challenges that ambulatory practices face when they don’t have a massive health system behind them. What’s the path forward for smaller practices then?

The first thing to remember is that even though a health system is large, it doesn’t mean it’s going to do things well. In fact, it’s easy to argue how large organizations are much less efficient. It’s not hard to see how a large health system will focus all of their analytics work on the acute care environment and leaves out ambulatory practices. Smaller healthcare organizations are going to have to use this to their advantage.

While it’s unlikely that ambulatory practices will do all of the healthcare analytics work on their own, it is possible for ambulatory practices to tap into third party vendors that do the work for them and hundreds of other ambulatory practices. Smaller healthcare organizations partnering with corporate and entrepreneurial vendors is going to be the best way for these healthcare organizations to compete with the large health system. In fact, it’s a huge opportunity for them to show why patients should visit their practice instead of the large health system.

One thing that’s holding these efforts back is EHR vendors’ decision to close the doors to outside vendors. There are a few EHR vendor exceptions and areas where every EHR vendor is more open (ie. labs, pharmacy, etc), but it won’t be enough going forward. My friend Jeremy Coleman recently described why in this series of tweets:

I don’t see any healthcare future where centralization will survive. Sure, it will put up a good fight for a while, but the number and variety of applications that are coming out in healthcare are going to be so varied and dramatically important for doctors to incorporate into the care they provide that EHR vendors won’t have a choice but to create APIs that facilitate all of these applications.

An EHR vendor that embraces this approach is going to be essential for every ambulatory practice. Eventually, ambulatory practices will be stuck with the need to switch EHR systems or sell to the health system (which generally means switching EHR systems too). However, an ambulatory EHR that provides an open ecosystem for the latest and greatest in health IT will allow ambulatory practices to thrive even against the much larger health systems.

AMA Hopes To Drive Healthcare AI

Posted on July 6, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Last month, the AMA adopted a new policy setting standards for its approach to the use of AI. Now, the question is how much leverage it will actually have on the use in the practice of medicine.

In its policy statement, the trade group said it would work to set standards on how AI can improve patient outcomes and physicians’ professional satisfaction. It also hopes to see that physicians get a say-so in the development, design, validation implementation of healthcare AI tools.

More specifically, the AMA said it would promote the development of well-designed, clinically-validated standards for healthcare AI, including that they:

  • Are designed and evaluated using best-practices user-centered design
  • Address bias and avoid introducing or exacerbating healthcare disparities when testing or deploying new AI tools
  • Safeguard patients’ and other individuals’ privacy and preserve security and integrity of personal information

That being said, I find myself wondering whether the AMA will have the chance to play a significant role in the evolution of AI tools. It certainly has a fair amount of competition.

It’s certainly worth noting that the organization is knee-deep in the development of digital health solutions. Its ventures include the MATTER incubator, which brings physicians and entrepreneurs together to solve healthcare problems; biotech incubator Sling Health, which is run by medical students; Health2047, which brings helps healthcare organizations and entrepreneurs work together and Xcertia, an AMA-backed non-profit which has developed a mobile health app framework.

On the other hand, the group certainly has a lot of competition for doctors’ attention. Over the last year or two, the use of AI in healthcare has gone from a nifty idea to a practical one, and many health systems are deploying platforms that integrate AI features. These platforms include tools helping doctors collaborate with care teams, avoid errors and identify oncoming crises within the patient population.

If you’re wondering why I’m bringing all this up, here’s why. Ordinarily, I wouldn’t bother to discuss an AMA policy statement — some of them are less interesting than watching grass grow — but in this case, it’s worth thinking about for a bit.

When you look at the big picture, it matters who drive the train when it comes to healthcare AI. If physicians take the lead, as the AMA would obviously prefer, we may be able to avoid the deployment of user-hostile platforms like many of the first-generation EHRs.

If hospitals end up dictating how physicians use AI technology, it might mean that we see another round of kludgy interfaces, lousy decision-support options and time-consuming documentation extras which will give physicians an unwanted feeling of deja-vu. Not to mention doctors who refuse to use it and try to upend efforts to use AI in healthcare.

Of course, some hospitals will have learned from their mistakes, but I’m guessing that many may not, and things could go downhill from there. Regardless, let’s hope that AI tools don’t become the next albatross hung around doctors’ necks.

2017 MIPS Final Score and Performance Feedback Is Out

Posted on June 29, 2018 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 10 blogs containing over 8000 articles with John having written over 4000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 16 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit and LinkedIn.

Big news just came out for those that are participating in MACRA and MIPS. CMS Announced it on Twitter:

That’s right, you can now visit the QPP website and login to see and verify your 2017 MIPS final score and performance feedback. Interesting that they would choose to push this out late on a Friday. You’ll want to verify this information to make sure you’re paid correctly and to make sure they have the right data for you before they make all the MIPS scores public.

I looked at the Physician Compare website and unless I just didn’t look in the right places, I don’t see the MIPS Quality scores available on the website yet, but I expect they will be soon. Plus, they’re likely going to make the data available for download as a dataset. Once they do, websites like ZocDoc, Vitals, HealthGrades and the rest of the physician ratings and review websites will pull the data and incorporate it into their physician profiles. So, you’ll want to make sure your data is accurate.

I will say that when I was looking at physicians on the Physician Compare website, I was fascinated by the note they put as a popup for someone who had “Used electronic health record”:

To be fair, they did use the word “may”, but I think most doctors would say this is a far cry from what EHR software has accomplished. However, it’s clear what the intent of the legislation and CMS was when it came to adoption of EHR software.

Have you had a chance to look at your MIPS score and performance feedback? We’d love to hear about your experiences. We’ll be interested to see how these MIPS quality scores are used by doctors and patients.

Tips On Storing Patient Information In The Cloud

Posted on June 27, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

These days, it’s pretty much a given that providers will store some or all of their data in the cloud, i.e. off-site on a vendor’s servers.  For many providers, doing this is a good idea, as it allows them to avoid buying dedicated hardware or upgrade their own storage capacity.

That being said, all cloud vendors are not made equal, and it’s important to pick the right one. After all, providers can face dire consequences if their patient data is breached. Even if the vendor is at fault, providers will take most or all of the blame.

Before storing data on an outside service, it’s important to check them out carefully.  Here are some tips on evaluating vendors from David McHale of The Doctors Company:

  • Research the vendor’s security practices: Find out of they have a good reputation and strong security policies in place. Whatever time you put into the research is time well spent.
  • Make sure the vendor can handle all of your data: Bear in mind that many cloud services company charge by the amount of storage providers use, so being sure those costs are affordable is important. Also, providers should make sure the vendor can handle the amount of data they’d like to store.
  • Be sure that your data is encrypted at all times: Providers should see to it that their data is encrypted when being uploaded to or downloaded from the cloud. This includes ensuring that browsers or apps require an encrypted connection to the vendor’s server.
  • Patient data should be encrypted when stored in the cloud: Never store data protected by law in the cloud, such as medical information or personal identifiers, unless the stored data is encrypted. Also, don’t let anyone decrypt the data unless they are authorized to do so.
  • Learn how access is stored in your cloud folder: Cloud storage vendors often let providers share access to online folders stored on their servers. and it’s important to know how that sharing works. For example, find out whether data in the folder is read-only or whether users can edit the file, and whether managers can find out who last edited a file.
  • Prepare for the worst: Providers should know what they’ll do if their cloud vendor gets hacked or their data is lost. To find this out, they should read the “terms of service” provisions of their contract, which often states that users have little recourse if their data is breached or lost.

To be sure, cloud storage can be a great way for providers to save money on storage and see that their data is backed up offsite. However, it’s important they do their due diligence and see that the vendor will protect that data carefully.

Medical Practice Use Of Automated Claims Options Growing Slowly

Posted on June 25, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new study by a healthcare industry group has concluded that medical and dental practices are processing claims manually rather than going for full automation, a trend which is robbing the industry of very high levels of potential savings. While many physicians and dentists are using web portals to process claims, in most cases they haven’t reached the ”set it and forget it” level, a trend which could undercut possible savings.

The group, CAQH, tracks health plan and healthcare provider adoption of electronically-based administrative transactions for medical and dental practices. CAQH’s research estimates the time required for providers administrative transactions, including verifying a patient’s insurance coverage, sending and receiving payments, checking on the status of claims and handling prior authorization processes.

Its research concluded that despite the potential rewards, the medical and dental practices made only a modest level of progress in automating claims and related business processes over the past year. According to CAQH calculations, practices are still leaving roughly $11.1 billion in savings on the table, an estimate which has climbed by $1.8 billion over the prior year.

If these savings are realized, the majority ($9.5 billion) would end up in providers’ hands. However, many practices just haven’t gotten there yet.

A rise in portal use is certainly an improvement over paper-based claims processes. In fact, some of the increase in potential savings noted by the study is being created by a rise in online portal use.

However, providers’ adoption of fully-electronic claims is basically growing only a small amount or even declining for most transactions that can be done via a portal. For example, for prior authorizations, a big increase in portal use correlated with the decline in the adoption of fully-electronic transactions.

For CAQH, the endgame is getting all providers to automate claims processes complete, so the modest to flat growth in automated claims transactions is not exactly good news. In fact, it’s not a winning situation for medical practices either. According to the group’s estimates, each manual transaction costs practices $4.40 more than each electronic transaction and eats up five more minutes of provider time, which can create a real drag on profits.

Meanwhile, processing a single claim electronically through its lifecycle would save medical practices almost 40 minutes on average, and more than $15 in direct cost savings. Meanwhile, processing a single dental claim from start to finish could save dental practices almost 30 minutes on average and almost $11.75.

The CAQH press release doesn’t spell out what’s holding dentists and doctors back from automating the claims process completely, but it’s not hard to guess was going on. Unlike some providers, medical and dental practices typically don’t have deep pockets or large staff they can make this transition. If health plans want these providers to get on board, they’ll probably have to help them make the transition. However, even health plans haven’t invested in automated claims processing enough either.

Payers Say Value-Based Care Is Lowering Medical Costs, But Tech Isn’t Contributing Much

Posted on June 22, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

A new survey of health insurers has concluded that while value-based care seems to be lowering healthcare costs significantly, they aren’t satisfied with the tools they have to analyze value-based performance.

The report, which draws on a survey sponsored by Change Healthcare, including answers from 120 payers across several types of insurance, including managed Medicare, managed Medicaid and commercial plans.

The topline finding from the report was that value-based care (VBC) has lowered healthcare costs by 5.6% on average, with one-quarter of respondents reporting savings of more than 7.5%.

Meanwhile, the volume of fee-for-service payments has dropped dramatically as a percent of overall payments, now accounting for just 37.2% of all reimbursement among respondents. That number is expected to fall below 26% by 2021.

Not only that, 64% of payers said that provider relationships improved, and 73% said patient engagement improved. This suggests that providers have made some strides in delivering value-based care, as many had a hard time restructuring their business in the past.

That said, some payers haven’t met their own VBC goals. In particular, 66% of payers are investing administrative staffers to support episode-of-care programs given what the study terms “exceptional” medical cost savings. Also, one third to one-half said that episode-of-care models were either very or extremely effective at improving care quality.

However, payers haven’t made much progress as they’d like in rolling out episode-of-care programs. While 21% of payers said they were capable of rolling out a new episode-of-care program in 3 to 6 months, more than a third said the needed a year to launch such a program, 21% said it would take 18 months, and 13% said it would take up to 24 months or more. In other words, many payers are so far behind the curve that the programs they’re designing might be obsolete by the time they roll them out.

What’s more, they’ve had a tough time getting providers interested in episode-of-care programs. Forty-three to 58% reported that it is either very or extremely difficult to get providers to participate in these efforts. Not only that, even when they find interested providers, payers are having a hard time finding common ground with them on episode definitions, budgets, the details of risk and reward sharing and performance metrics. These disagreements could prove a major hurdle to overcome.

In addition, more than half of payers said they were not very satisfied with the current value-based analytics, automation and reporting tools, even though most of the tools were developed in-house by the payers themselves. It could be that given provider resistance, the payers aren’t quite sure about what to look for. Regardless, it seems that payers have a longer-than-expected road to travel here.

AMA Says Med Students Don’t Get Enough EHR Training

Posted on June 20, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

Whether or not doctors like it, the U.S. healthcare industry has embraced EHR technology, and in most cases, medical groups depend on it for a number of reasons. Now, the industry may be taking the next step in this direction, with the AMA deciding that it’s time to enshrine EHR use as part of medical education.

At its recent annual meeting, the AMA released a new policy embracing two somewhat contradictory notions. On the one hand, it encouraged med schools to train students on using EHR technology, while on the other, underscored the need for future doctors to get their faces out of the computer screen and engage with patients.

According to the trade group, some medical schools actually limit student access to EHRs. The AMA contends that this is a bad idea. “Medical students and residents need to learn how to ensure quality clinical documentation within an electronic health record,” said AMA board member and medical student Karthik Sarma in a prepared statement. “There is a clear need for medical students to have access to – and learn how to properly use – EHRs well before they enter practice.”

That being said, the group’s report on this subject concedes that there’s a long way to go in making this happen. For example, it notes that many med school faculty members aren’t offering students and residents much of a role model for the appropriate use of and practices in working with EHRs.

To address this problem, the new policy urges medical schools and residency programs to design clinical documentation and EHR training. It also recommends that the training be evaluated to be sure that it’s useful for future medical practice.

The AMA also suggests that med schools and residency programs provide faculty members with EHR professional development options. These lessons will help faculty serve as better role models on EHR use during interactions between physicians and patients.

That being said, there is an inherent tension between these goals and the realities of EHR use. Yes, training students to create good clinical documentation makes sense. At the same time, there are good reasons to worry about the effects of EHRs on student and resident relationships with patients. Unfortunately, this problem seems to be unavoidable as things stand today. Either you train budding physicians to be clinical documentation experts or you encourage them to use EHRs as little as possible during patient encounters.

In short, we’ve already learned that we can’t have both at the same time. So what’s the point of telling medical students that they should try to do the impossible?

Hospitals, Doctors And Patients Impacted By Unplanned EHR Downtime

Posted on June 18, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

EHRs are going to crash and go offline from time to time. But are physicians and hospitals prepared to deal with the fallout when this happens? The answer seems to be “maybe.”

Of course, physicians and hospitals have plenty of reasons to avoid EHR downtime.

For one thing, EHR crashes can have a major impact on care delivery. After all, without EHRs, physicians may have no access to patient data, which could lead to care complications or adverse events.

Also, downtime adds addition pain (and expense) to the situation. According to one estimate, unplanned system failures can cost $634 per physician per hour. Meanwhile, according to Dean Sitting of the University of Texas, a large hospital may lose as much as $1 million per hour when their EHR is down. Those are scary numbers.

Unfortunately, despite the costs, strain to the hospital operations and consumer complaints arising from downtime, many hospitals refuse to invest in preventive technologies such as a backup data center, arguing that they’re just too expensive. As a result, hospitals can be offline for a long time when their EHR system crashes, which typically has a nasty ripple effect.

One example of how EHR downtime affects hospital operations comes from Sutter Health, the largest health system in northern California, whose EHR went offline for more than 24 hours in May. The crash took place when a fire-suppression system was activated in the system’s data center.

During the shutdown, Sutter hospitals followed a series of steps often used by its peers, such as cutting elective surgeries, transporting patients to other hospitals and discharging patients who weren’t very sick. They also switched over to paper records. But despite these efforts, Sutter still faced some problems that weren’t addressed by its plans.

For one thing, younger doctors were thrown a curve ball, as many had never worked with paper charts. This alone gummed up the works during the downtime episode. There were no signs that these doctors made any mistakes due to using paper records, but the risk was there.

Then there were the effects on patients – and some were ugly. For example, when Santa Clara resident Susan Harkema’s father died, she called Sutter Health’s Hospital of the Valley to arrange for removal of his body to a crematorium. According to a story appearing in San Jose Mercury News, Harkema tried a hotline and backup numbers but couldn’t reach anyone due to the outage. It took 8 hours for a hospice nurse to arrive and collect the body, the newspaper reported.

Another patient tweeted that they had to go out of the Sutter system for critical care, which left the treating physicians without care history to review. “It was stressful and scary, and we still aren’t sure we have a successful outcome,” they said.

The net of all of this seems to be that hospital downtime policies could use more than a few tweaks, and more importantly, a better failsafe protecting EHRs from going offline in the first place. Sure, no EHR system is perfect, and crashes are inevitable, but providers can be better prepared.

Geisinger, Penn State Researchers Predict Risk Of Rehospitalization Within Three Days Of Discharge

Posted on June 15, 2018 I Written By

Anne Zieger is veteran healthcare consultant and analyst with 20 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. Contact her at @ziegerhealth on Twitter or visit her site at Zieger Healthcare.

In recent times, healthcare organizations have focused deeply on the causes of patient readmissions to the hospital. It’s a problem that affects both physicians and health systems, particularly if the two are not in synch.

To date, providers have focused on readmissions happening within 30 days, largely in an effort to avoid financial penalties imposed by Medicare and Medicaid. However, if the following research is solid, it could push the focus of care much closer to hospital discharge dates.

In an effort which could change the process of avoiding readmissions, a group of researchers has found a way to predict a patient’s risk for needing additional medical care within three days of discharge. The new approach developed jointly by Penn State and Geisinger Health Plan, relies on clinical, administrative and socio-economic data drawn from patients admitted to Geisinger over two years.

The model they created is known as REDD, an acronym which stands for readmission, emergency department or death. Using this model can help physicians target interventions effective and reduce the number of adverse events, according to Deepak Agrawal, one of the Penn State researchers.

You won’t be surprised to hear that readmissions after 30 days are often related to social determinants of health, such as a poor home environment, limited access to services and scant social support. Providers are certainly working to close these gaps, but to date, this has remained a major challenge.

However, the dynamics are different when finding patients who may be readmitted quickly. “Readmissions closer to discharge are more likely to related to factors that are actually present but are not identified at the time the patient is discharged,” said research team leader Sundar Kumara, Allen E. Pearce and Allen M. Pierce Professor of Industrial Engineering with Penn State, who was quoted in a prepared statement.

Another Penn State researcher, Cheng-Bang Chen, added another interesting observation. He noted that the more time that passes after a patient gets discharged, the less likely it is that problems will be caught in time. After all, it may be a while before treating physicians have time to review lengthy hospital records, and the patient could experience a time-sensitive event before the physician completes the review.

To test the REDD program, Geisinger ran a six-month pilot tracking high-risk patients and adding additional services designed to avoid readmissions, ED visits or death.

To treat this population effectively, physicians took a number of steps, such as scheduling appointments with patients’ primary care doctors, educating patients about their medications and post-discharge care plans,  having the inpatient clinical pharmacist review the provider’s recommendations, filling patient prescriptions before discharge and having the hospital check on patients discharged to a skilled nursing facility one day after discharge.

It’s worth noting that there was one major issue which undermined the research results. Penn State reported that because of a shortage of nurses at the hospital during the pilot, they couldn’t tell whether the REDD program met its goals.

Still, researchers are convinced they’re heading in the right direction. “If the REDD model was fully implemented and aligned with clinical workflows, it has the potential to dramatically reduce hospital readmissions,” said Eric Reich, manager of health care re-engineering at Geisinger.

Let’s hope he’s right.

Early Lessons from the Front Lines of Value-based Care: How One APM Has Impacted Community-Based Oncology Practices

Posted on June 11, 2018 I Written By

The following is a guest blog post by Dr. Charles Saunders, CEO, Integra Connect.

The Oncology Care Model (OCM) – an alternative payment model introduced in July 2016 by the Center for Medicare and Medicaid Innovation – launched with the ambitious goal to further delivery of higher quality, more coordinated cancer care at a lower cost. Participants include 184 practices representing approximately one-third of community oncologists in the US. They receive a so-called “MEOS” (monthly enhanced oncology services) payment of $160 per beneficiary per month for the duration of a qualifying 6-month chemotherapy period, plus the opportunity to earn a share of savings if they exceed a target threshold. In return, oncologists are expected to take on increasing accountability for patient outcomes and well-being, while also generating sustainable cost savings across all co-morbidities and care settings, into the patient home.

OCM Performance Period 1 Results Exposed an Unexpected Misalignment   

As part of the OCM program, CMS tracks practices during 6-month intervals – so-called “performance periods” – then shares results back about one year later. In February 2018, practices participating in the OCM program received visibility into Performance Period 1 (PP1) data, including savings achieved, aggregate quality score, and effectiveness of identifying eligible patients. While most practices were unsurprised by their performance scores, many did not anticipate the extent to which CMS would recoup MEOS payments that it deemed paid in error. The most common scenario involved patients with co-morbidities who, while receiving chemotherapy and related services, also visited other providers regularly. Therefore, the oncology practice did not represent the required plurality of E/M codes for that beneficiary. It was not uncommon for practices to be asked to return up to 30% of the sum they had been paid – a major financial hit.

Lack of Data Hinders Practices’ Ability to Accurately and Proactively Identify Beneficiaries

In May 2018, practices received their Performance Period 2 (PP2) Attribution Lists, which summarized which CMS beneficiaries met OCM eligibility criteria, which episodes were attributed to each respective practice, and episode start dates from January 1, 2017 through June 30, 2017. Unfortunately, because there is a significant lag between actual Performance Period and delivery of CMS findings – delayed up to nearly a year after each performance period has ended – OCM participants were unable to retroactively apply PP1 learnings to PP2.

Why is this especially problematic? Practices are faced not only with MEOS recoupments for erroneous payments but, with only a 1-year window to submit claims, are often unable to bill in full for patients who were missed. Indeed, there are many opportunities to miss appropriate patients, as practices needed to have an accurate view of: 1) all beneficiaries; 2) those with a qualifying diagnosis; 3) those with a new chemo episode; 4) those not only prescribed an oral agent, but those who subsequently filled it; 5) those not in a hospice; and more. Given all the dimensions to track and measure, practices without advanced tools face delivering enhanced services that they cannot correctly bill for.

Best Practices from Community-Based Oncology Practices Include Robust Data

What best practices arose to get attribution right? A vanguard of OCM practices realized that they would need to take proactive steps to enable near real-time visibility into their patient populations, embracing the tenets of population health management. Below is an example of the best practices adopted by several of these community-based oncology practices:

  • Increased transparency into oral chemotherapies: Existing practice protocols did not open an episode when oral agents were prescribed, since there was no in-office administration. To address this, the practice introduced a rule-based algorithm to identify all OCM eligible patients, including those who had been prescribed orals. In addition, they enlisted a combination of automated and personal follow-ups to validate qualification and ensure orals had been filled.
  • Avoidance of duplication: To identify missed billing opportunities while also reducing the risk of duplicated claims, practice leadership invested in a robust analytics tool that enabled personalized queries at the patient level. These reports compared eligibility against their practice management report to identify gaps, from unpaid and unbilled to denied.
  • Targeted patient intervention: To balance the practice’s financial and clinical objectives while optimizing OCM performance, the practice introduced complex care management services and employed a series of triage pathways. This approach ensured engagement with attributed beneficiaries and decreased avoidable high-cost events among at-risk patients, such as inappropriate ER visits and inpatient stays.
  • Optimized treatment choices. As part of its commitment to ensure each patient received the most effective treatment for his or her disease, the practice provided increased transparency around the availability of equally effective generic or biosimilar drugs. They also supported better end-of-life planning for patients facing second or third-line therapies not expected to provide any clinical benefits, but that could significantly degrade remaining quality of life.
  • Continuous performance improvement: To track the effectiveness of these quality improvement initiatives, the practice leveraged its analytics tool to monitor resource utilization and care management performance, then intervened to address outliers in real-time.

In short, to optimize performance under the OCM, practices are beginning to leverage the data to which they already have access – both clinical and financial – to risk-stratify their patient populations; identify OCM eligible patients; and gain near real-time visibility into quality and cost performance. Practices are also investing in better data integration and analytics that enable rules-based identification of eligible patients.

Population Health Analytics Help Practices Be Proactive and Succeed Under the OCM

Oncology is on the forefront of value-based care adoption and these early experiences from the OCM have provided a guide for other specialties. Based on their early results, what has come to the forefront is the need for a combination of comprehensive data management and robust analytics, coupled with the principles of population health management, which enable practices to step up and take control of the cost and quality for their attributed populations.