HIStalk Interviews Clinigence Client, Rick MacCornack, CEO of Northwest Physicians Network

Rick MacCornack is CEO of Northwest Physicians Network, a Washington-based independent practice association and multispecialty provider network that has experienced record growth in the last 12 months.

 

NPN has seen an 80-percent increase in membership over the last year – a statistic that highlights the fact that independent physicians want to stay that way. What are the biggest obstacles private practices face when it comes to remaining independent? 
The largest obstacle facing private practice today is the increasing administrative burden associated with so-called value-based payer contracts. Performing well on quality metrics, which are now required by all public and private payer contracts, is a challenge when the payment methodology is predominantly fee-for-service within PPO products. Patients are permitted to not have a primary provider, which flies in the face of a practice’s attempt to be actively “accountable” for an individual’s health. Technology cannot solve this issue. This is an adaptive, behavioral issue. Payment methods and consumer incentives are currently not in alignment with policy attempts to achieve the goal of population health.

How does NPN help them to overcome these challenges? 
In the NPN network of 1,000 providers, there are 49 different EHR platforms in use. NPN staff supports the primary care providers by collecting and handling their clinical data for reporting and management purposes. This is done through remote access as well as in-clinic, manual abstraction of records. NPN supports a cloud-base registry, warehouse, and analytics platform, which serves as the aggregator and processing center for all reporting for each provider. Both clinical care gap reporting at the practice and patient level and managed care analytics (total cost of care and cost and utilization broken out by service category, per member per month) is provided to each clinician on a scheduled basis. Both sets of reports provide the clinic staff with a means of managing defined populations of patients. Reports to the provider are payer agnostic.

What role does healthcare technology play in this predicament? 
Healthcare technology used by NPN is all cloud-based. NPN provides a comprehensive referral and care coordination platform to ease the administrative burden of referral processing, patient tracking, and care coordination. NPN also provides secure messaging via smartphone and desktop. And quality, utilization, and cost analytics are provided to all providers. The cost of providing these services is subsidized by NPN for all primary care providers, who are the least able to afford these technical services on their own.

What type of healthcare technology seems poised to best help private practices keep their doors open and patients satisfied? 
All cloud-based solutions used by NPN have been developed and are provided by small startups who are experienced working in heterogeneous care delivery environments like IPAs. The private practice environment is a non-standard environment. True collaboration between vendor and the client in developing and delivering the service is required. NPN has even served as both an alpha and beta site for some of the technology services it uses.

How does NPN plan to help its network prepare for and work through MACRA? What resources do you feel practices are most in need of to make it through this transition? 
MACRA adoption is a process of education and learning which track is most appropriate for each practice. One size doesn’t fit all. Across all tracks, data reporting by the practice and performance feedback to the practice are essential to participate under MACRA guidelines. NPN’s approach to supporting private practices under MACRA is to relieve the administrative burden of data collection from the EHR, uploading it into an analytics environment in combination with claims data, and returning results to practices on a scheduled basis for assessment and action. NPN staff serve to educate and support work flow changes in a practice to enable them to reach designated performance targets.

That said, until the payment system in the US is fully converted to “value-based” payment that is attached to administrative requirements that support performance- (cost and quality) based payment, it will be difficult for providers in any delivery system structure to consume practice-level data in a way that achieves better management of resources, one patient at a time. Population health is an unreachable goal when patients are not tied to a primary care provider who has the responsibility and the resources to manage each patient’s individual clinical needs over time.

About Clinigence
Clinigence, LLC, in Atlanta, GA, is a health information technology company that develops, publishes and delivers collaborative software-as-a-service (SaaS) to help healthcare providers derive business value from clinical data and quality patient care. The Clinigence solution is tailored to the emerging needs of healthcare providers due to the shift of the U.S. healthcare system from volume- to value-based purchasing and the growing demand for quality patient care.

About Northwest Physicians Health Network

Franciscan Northwest Physicians Health Network became the second approved Accountable Care Organization (ACO) in Washington State, responsible for 27,000 Medicare patients. The organization represents a collaboration of a hospital-based delivery system and an association of independent physicians through the partnership of Northwest Physicians Network and Franciscan Health System. The ACO’s goal is to reduce costs through the delivery of coordinated, managed care.

CPC+ and MSSP – The Odd Couple?

By Kobi Margolin

In an update fact sheet released May 27, 2016, the Centers for Medicare and Medicaid Services (CMS) announced that as many as 1,500 primary care practices will be eligible to participate in both the Medicare Shared Savings Program (MSSP) and the new Comprehensive Primary Care Plus (CPC+) program.

The announcement was a reversal of CMS’ previous position that precluded such dual eligibility. Explaining the reversal, CMS stated that this dual participation “may enhance the coordination of care for Medicare beneficiaries and help to achieve our aims of better care, smarter spending, and healthier people”.

For practices in the MSSP program, or ones applying to join the program in 2017 that are also eligible for CPC+, the question becomes: “Should I apply to CPC+? Can I make both programs work together?”. Let’s tackle these two questions one by one.

Should I apply to CPC+?

You are already more or less familiar with how the MSSP works. In a number of ways, CPC+ addresses the challenges of MSSP:

1.       Upfront Payment – Under CPC+, all payments are made upfront. This is in stark contrast to the MSSP model, where shared savings (if any) are paid in arrears and about 9 months after the end of the performance year for which they are due.

2.       Guaranteed Payment – Under CPC+, a portion of your payment (the “Care Management Fee”, or CMF) is guaranteed and paid to you on a quarterly basis. The amount will vary based on the risk profile of your patients, but CMS estimates an average of $15 per patient per month in Track 1 and $28 in Track 2. This is very different from payments under MSSP, which are entirely dependent on your ACO’s ability to generate substantial savings to CMS.

3.       Low Minimum Size – You can be a solo primary care practitioner. As long as you see at least 150 Medicare beneficiaries, you are eligible to apply. Compare that with the 5,000 beneficiary minimum under MSSP. Moreover, CPC+ is especially designed for individual primary care practices. No need to align yourself with other practices, a hospital or any other entity.

4.       Multi-payer Participation - CPC+ is a multi-payer program with specific commercial payers already committed to extend the program to their members by 2019. This will increase your payments and allow you to offer enhanced services to these commercial patient population in addition to your Medicare patients.

These are some compelling benefits. CPC+ is designed to help practices invest in the staffing and technology they need to accomplish the larger goal of value-based healthcare. For those already taking steps in that direction, it just means that the return on the investment may finally be here.

For others, this may be a way to start the process. Looking at similar programs, such as Meaningful Use (MU) and the Physician Quality Reporting System (PQRS) over the past few years, tells us that when CMS offers “carrots”, the “stick” is never too far away. CPC+ may be your last opportunity to get CMS to pay for transforming your practice to the patient-centered medical home model before you see your reimbursement shrink if you don’t.

Conclusion: You should absolutely consider applying to CPC+!

Can I make both programs work together?

There are 4 unique rules with respect to MSSP members applying to or participating in CPC+:

1.       ACO Letter: You must provide a signed letter by your ACO leadership that commits to segregate funds paid as a result of participation in CPC+. In other words, you cannot apply to CPC+ without getting your ACO to approve.

2.       Higher ACO Expenses: The amounts you get paid under CPC+ will be counted “against” your ACO (i.e. they are included in the calculation of the ACO’s total expenditures). This may put you at odds with your ACO unless you can convince them that you can make up for the increased CPC+ payments by generating even higher savings to Medicare.

3.       Shared Savings instead of Performance-based Incentives: You will not be paid the CPC+ performance-based incentives. CMS considers your share of the shared savings generated under the MSSP to be your performance-based incentive for both programs. This of course may put you again at odds with your ACO. This time the onus is on them to convince you that you can indeed make as much as $30 or $48 per patient per year (the full performance incentive under CPC+ Track 1 and Track 2 respectively) in shared savings. Not an easy feat considering that only about 25% of MSSPs historically have made any shared savings at all.

4.       No Advanced APM Incentive for MSSP Track 1: If your ACO is in Track 1 of the MSSP, your participation in CPC+ will not exempt you from MIPS and you will not be eligible for the 5% Medicare Part B bonus otherwise available to all participants of CPC+ (payable starting in 2019). According to CMS, the eligibility for this bonus will be determined based on your MSSP Track and independent of your CPC+ participation. Since MSSP Track 1 is not eligible, you won’t be either. This may be the most painful strike against dual participants. Unless your ACO converts to Track 2 or 3 in subsequent years (it’s too late to do so for 2017), it will be hard to make up for this 5% bonus through either shared savings or MIPS incentives (that are generally limited to 4% for high performers).  

These are some serious challenges for dual participation. But while they may put you at odds with your ACO, they also give you some leverage to ensure your interests are aligned. After all, your participation in the MSSP is voluntary and ACOs still have time through 10/26/2016 to remove members from their Medicare roster.

 

Conclusion: CPC+ participation can increase your power to make the ACO work to your advantage and a contingency plan in case it doesn’t.

The Bottom Line

It is easy to calculate your estimated payments under CPC+. Note in particular the CMF component of these payments. As noted above, these are guaranteed funds that you can invest in exactly the kind of care coordination and management activities your ACO should be implementing anyway. Whether you do it in the practice or through shared ACO resources (or, as oftentimes is the case – a combination of both), you can only gain from having the additional funds to invest in these activities. One caveat: you need to get buy-in from your ACO leadership. Moreover, you must get their signed letter of support before the application deadline of September 15th.

What if your ACO leadership does not agree or cannot produce a support letter fast enough? Well, then, you have a choice: compare your potential benefits (i.e. your share of potential shared savings, incentives through commercial contracts, any services/resources provided to you by the ACO, etc.) against your CPC+ estimated payout and choose the program that offers you more benefits. If your ACO is in MSSP Track 1, don’t forget to include the 5% Advanced APM bonus you will receive if you decide to opt out of the MSSP. Getting your ACO leadership to agree may be easier than you think… It’s your decision whether you’d like to move in or move out as the case may be!

MEDENT Partners With Clinigence to Deliver Qualitative Information to Health Systems and Practices

AUBURN, NY and ATLANTA, GA--(Marketwired - May 11, 2016) - MEDENT and Clinigence announced today that Clinigence's next-generation technology, which includes clinical data analytics, data mining, predictive modeling and business intelligence, has been integrated into MEDENT's comprehensive EMR/EHR solution.

MEDENT is a software development and services company focused on automating medical practices. The company offers an "All-In-One" EMR/EHR, Patient Portal and Practice Management system providing a high level of interoperability and automation. The MEDENT system is available in the cloud as a service or as a server-based system in the medical practice.

"With the changing landscape in healthcare, it's vital that practices and healthcare systems have the ability to obtain and report on quality measures," said Gary S. Cuthbert, President of MEDENT. "By partnering with Clinigence, our customers can take advantage of advanced enterprise-wide reporting capabilities presented in a visual manner that will help them succeed in today's environment. We selected Clinigence based upon their capabilities and the ease of integration with our system."

The collaboration is already paying dividends for MEDENT customer The Greater Buffalo United Accountable Healthcare Network (GBUAHN). The organization is a Health Home created under the Affordable Care Act to coordinate care for people with Medicaid who have chronic conditions. GBUAHN operates under New York State's Delivery System Reform Incentive Payment (DSRIP) Program.

Raul Vazquez, MD, FAAFP, is the President of GBUAHN; the organization's 140 physician members use the MEDENT solution with the quality measurement enhancements delivered by Clinigence.

"We use Clinigence within our EMR in two ways," said Dr. Vazquez. "First, we are able to see clinical information at an individual and enterprise level. This is critical as we move toward becoming an Accountable Care Organization (ACO). Second, we are able to pull information into the system and use it to provide better care coordination throughout our Network."

Clinigence is a next-generation clinical business intelligence technology provider. Leveraging cloud-based semantic collaboration, Clinigence's solution fuels a continuous cycle of improvement in staff performance and process effectiveness while accelerating the creation of best practices.

"Improving both individual and population health is greatly dependent on the ability to access and leverage data to create insights that drive better healthcare coordination and outcomes, while lowering costs," said Kobi Margolin, CEO of Clinigence. "We are pleased to support organizations like GBUAHN that are successfully demonstrating that value-based reimbursement and quality patient care for fragile populations go hand-in-hand."

About Clinigence
Clinigence, LLC, in Atlanta, GA, is a health information technology company that develops, publishes and delivers collaborative software-as-a-service (SaaS) to help healthcare providers derive business value from clinical data and quality patient care. The Clinigence solution is tailored to the emerging needs of healthcare providers due to the shift of the U.S. healthcare system from volume- to value-based purchasing and the growing demand for quality patient care.

About MEDENT
MEDENT is a software development and services company focused on automating medical practices. We offer an All-In-One EMR/EHR, Patient Portal and Practice Management system providing a high level of interoperability and automation. A recent Medical Economics survey ranked MEDENT EHR the #1 EHR system in the nation for the second year in a row. The MEDENT system is available in the cloud as a service or as a server-based system in the medical practice. For more information, visit www.medent.com.

 

ACO Collaborative Employs Clinical Data in Population Health

A Selected Case Study in Healthcare Innovation and Transformation

Program Objectives:

   Create a streamlined process for accountable care organizations’ (ACOs) annual mandatory reporting to the Centers for Medicare & Medicaid Services (CMS) on 33 nationally recognized clinical quality measures.

   Maintain status as an ACO, while gaining valuable insights from clinical data obtained.

   Map clinical data from multiple electronic medical records (EMRs) into a single cloud-based dashboard providing real- time outcomes for clinical quality measures across the ACO.

   Obtain powerful information from a dashboard to promote population health management (PHM).

Program Description:

Although the Affordable Care Act (ACA) does not formally define the term “population health,” CMS defined it within the context of ACOs. While it is still unclear how ACO care delivery systems will intersect with a broader community definition of PHM, what has become clear is the value of clinical data to connect the dots in integrating, measuring and improving the health of a population.

This is reflected by the mandatory ACO reporting to CMS on 33 nationally recognized clinical quality measures in the domains of patient/caregiver experience; care coordination/patient safety; preventive health; and at-risk populations for diabetes, hypertension, ischemic vascular disease, heart failure and coronary artery disease.1 Thus, ACOs have come face to face with employing clinical data in PHM.

Three Medicare Shared Savings Program (MSSP) ACOs in distinct settings—Indiana Lakes Quality Partners (ILQP), Northwest Physicians Network/Rainier Health Network in Washington State (NPN) and Cumberland Center for Healthcare Innovation in Tennessee (CCHI)—found innovative ways of leveraging clinical data for PHM.

The collaboration of these three ACOs began due to their shared use of an ACO vendor, Clinigence, to achieve the mandatory annual ACO quality measure reporting.  The three ACOs represent a diverse collection of hospital, health system and primary care ACOs and at the time of their introduction to one another in the fall of 2013, they represented more than 50,000 MSSP ACO lives, with an additional 50,000 commercially and self-insured beneficiaries.

From a population health perspective, the ACOs’ stories were much the same in that they were each starting at ground zero. For example, the ambulatory care physicians had no idea how many diabetics were in their practices, much less a registry of who these patients were and their respective outcomes. In addition, each of the ACOs had multiple different outpatient EMRs across both owned and independent practices, which greatly complicated the task of compiling clinical quality metric reports.

Adding to the mayhem were physicians in the ACOs who did not have a clear understanding of the ACO reporting measures by which their quality would be scored. Underpinning the confusion was inaccurate patient attribution logic utilized by CMS, which made it difficult to assign the correct patient to the correct primary care provider.

To develop a streamlined reporting process, the Clinigence tool ingested the list of randomly selected annual reporting beneficiaries as provided by CMS, populated each beneficiary’s profile with the measures that applied to them and consumed claims data for the same beneficiaries in order to pre-populate the tool with as much data as possible and reduce the time and burden of ACO reporting.

After CCHI adopted the strategy, the other two ACOs followed suit by achieving 100% submission of data for all 616 assigned beneficiaries per measure (the minimum requirement is 411) in their first years of reporting—an accomplishment they credited to the ACO reporting tool. This is a valuable achievement in light of the fact that five MSSP ACOs were unable to complete the mandatory reporting in 2013, and two of the five forfeited shared savings as a result of their inability to complete reporting.2

CCHI found an additional benefit of the reporting tool by using it to gauge quality improvement throughout the year— something the ACO accomplished by populating the tool with the same ACO patients that were required for CMS reporting and resubmitting it to providers for attesting to updated clinical data part way through the reporting year.

This semi-annual reporting strategy identified deficiencies in clinical documentation processes, as well as detected practices that were falling behind in terms of quality improvement. It also reminded the practices of ACO measures that CMS would be using for quality scoring. Both CCHI and ILQP found that engaging the practices in reporting for their own populations had tremendous value in alerting practices to areas of quality improvement.

The new strategy also mapped clinical data from multiple EMRs into a cloud-based dashboard that provided real-time outcomes for the clinical quality measures across the ACO. This relieved the pain point of inaccurate patient attribution because logic was supplemented with the EMR location in which the greatest amount of clinical data was found. In other words, clinical data could trump claims data in assigning a patient to a specific primary care physician.

“The result was a dashboard of real- time clinical data that allowed the ACO to view how each of the practices were performing on the ACO measures.”

ILQP began the mapping process by identifying practices most likely to benefit from automated data extraction, practices with a locally hosted EMR and those with more complete clinical documentation methods. A clinical data extraction application was installed on the EMR servers and ran at regularly scheduled intervals to automatically extract clinical data that applied to the ACO measures, including vital signs, lab test results, immunizations, diagnoses codes, allergies and medications.

The result was a dashboard of real-time clinical data that allowed the ACO to view how each of the practices were performing on the ACO measures. Ross Family Medicine of CCHI, who began the EMR mapping process one year prior to ILQP, found that for 2013 ACO reporting 18 of the 22 clinical measures were automatically extracted and thus populating the CMS reporting registry. This greatly decreased the time required for the ACO reporting process.

Results: Once the ACOs were able to pull clinical data into a dashboard from multiple practices and across various EMRs, they had powerful information to promote PHM. Examples of how this data was leveraged included physicians using the diabetes composite measure data as a registry of not-to-goal diabetic patients to coordinate with both onsite and centralized practice care teams for outreach and follow up.

In terms of broadening the onsite practice care teams, Ross Family Medicine found that it could easily pay for a full-time embedded care coordinator based on using the dashboard to identify and follow up on gaps in care. Shipshewana Family Medicine of ILQP employed a full-time registered nurse health coach to coordinate a team-based approach that used the dashboard to supplement identifying gaps in care for both chronic and preventive measures. The practice simultaneously applied standing orders for preventive care, such as mammograms, flu shots and colonoscopies. This off-loaded the burden of care coordination from the physician and engaged multiple practice team members in PHM.

ILQP provided each of its primary care providers with access to the dashboard clinical data, which resulted in improved engagement of the physicians in PHM. For example, a physician work group at ILQP created an ACO-wide strategy for quality improvement of known hypertension patients. ILQP found that 40% of its diagnosed hypertensive patients were not to goal, meaning that their most recently obtained blood pressure readings were above normal. Measuring patients’ blood pressure at both the beginning and the end of every patient appointment, a pilot practice increased its performance from 58% to 67%—the ACO set a goal of 66%—between April and November of 2014 by implementing this strategy alone.

Since the inception of the ACO collaborative, it has grown from three initial ACOs to 10, and represents more than five million beneficiaries across nine states. In terms of decreasing costs, one of the initial three ACOs achieved more than $4.5 million in savings in 2013. Two of the ACOs were recently awarded lucrative commercial payer contracts. On target for 2015, the ACOs plan to leverage the clinical data in the dashboard to identify patients most likely to benefit from the new CMS Chronic Care Management Medicare Physician Fee Schedule for 2015, outlined on Oct. 31, 2014.3

Lessons Learned:

·      One hundred percent automation of EMR clinical data for PHM is impossible; ACOs must have a backup tool in place for manual attestation.

·      Engaging practices in reporting for their own populations promotes innovation and quality improvement.

·      Assessing all the determinants of health for a given population is at the intersection of accurate clinical and claims data.

·      Patient attribution logic can be supplemented with EMR data to assign patients to the correct provider.

·      Automating the aggregation of the greatest amount of clinical data possible identifies trending and promotes physician engagement.

 

1 “Guide to Quality Performance Scoring Methods for Accountable Care Organizations.” Medicare Program; Medicare Shared Savings Program: Accountable Care Organizations; Final Rule, 76 Fed. Reg. 67802. Nov. 2, 2011.

2 Petersen M, Muhlestein D. “ACO Results: What We Know So Far.” HealthAffairs Blog. May 30, 2014.

3 “Fact Sheets: Policy and Payment Changes to the Medicare Physician Fee Schedule for 2015.” CMS.gov. Oct. 31, 2014.