It’s All About Revenue…
Best Practices to Successfully
Navigate the Future of Healthcare
JUSTIN T. BARNES
CHAIRMAN EMERITUS, EHR ASSOCIATION
CO-CHAIR, ACCOUNTABLE CARE COMMUNITY OF PRACTICE
About Justin T. Barnes
Justin is a nationally recognized business and policy advisor who also
serves as Chairman Emeritus of the HIMSS EHR Association as well as CoChairman of the Accountable Care Community of Practice. He is also host
of the weekly syndicated radio show “This Just In.”
As a partner with iHealth, Justin assists healthcare providers with
optimizing their revenue sources as well as navigating from traditional
fee-for-service (FFS) models into evolving value-based payment & care
delivery models.
Justin has formally addressed and/or testified before Congress as well as
the last two Presidential Administrations on more than twenty occasions
since 2005 with statements relating to alternative payment & care
delivery models, MACRA, value-based medicine, accountable care,
interoperability, EHR meaningful use, consumerism and much more.
Barnes is a regular public speaker on these issues and has appeared in
more than 1,200 journals, magazines and broadcast media outlets.
The Changing Landscape in Healthcare
Physician practices & hospitals expanding services & strategies
◦ Expanding services, programs, partnerships and “consumer” access to care
◦ Exploration or management of risk-based contracts
◦ Physician practice strategies to stay independent as well as the pendulum “effect”
The Changing Landscape in Healthcare
Focus on optimization, efficiencies & economies of scale
◦ Look across organization and community for new revenue and higher
profitability of current services
- Optimize “revenue cycle”, new services & care delivery opportunities as well as new specialtyspecific program options
◦ Organizations of all sizes are working to make conducting business with their
organization easier
- Align processes, services and innovation to ensure that patients can easily access scheduling,
appointments and, certainly, payments
Optimize your Revenue Cycle Today
Optimize documentation to mitigate issues and reduce risk
◦ Audit provider workflow
◦ Comprehensive documentation and notation (under-documenting; get paid for what you did)
◦ Assessments, questionnaires, evals, services, tests & screening – All counts towards points in MIPS…
◦ Random chart audits – 10 per provider; monthly or bi-monthly
Regular review of coding by expert billers
◦ Look for missing charges (consultation, no notes, wrong provider noted), down-coding, up-coding, wrong
ICD-10 codes, missing modifiers, etc… – All prevent rejections, denials & audits…
Keep the future in mind
◦ Optimize coding & EHR for PQRS, MIPS, APM & other Quality Reporting Initiatives
Manage Credentialing – Monitor par & non-par care providers
Optimize Collections with eligibility verification, prior authorizations, etc…
Manage fee schedules
Efficiencies & Economy of Scale
Understand & manage your cost structure
Streamline operations and increase throughput
Cost of operations increased 50%+ over past 10 years – Must mitigate
Understand current staffing model
Automation & co-source options to improve economies of scale
◦ Reduce cost per case
◦ Leverage innovation internally & externally
◦ Implement clinical, financial & administrative best practices
KPIs to Manage for Your Practice
Set and manage specialty-specific KPIs
Revenue optimization – $$$ & cash flow:
◦
Denial root causes & appeal success rate – Be tenacious in appeals!
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◦
◦
33% of providers don’t use analytics to identify root cause
Underpayment reviews – Payor analysis every 6 months
Incomplete & missing charges
Efficiencies & throughput:
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◦
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Patient wait times
Cancellations & no-shows
Coding turnaround time
Operational cost & cost per case:
◦
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Understand the “true” cost of a claim within your practice
Comprehensive internal audit of the practice’s costs
Value-based Initiatives & Incentives
MACRA, MIPS & APMs…
MACRA & MIPS: Healthcare Reform/Transformation
◦ Medicare Access & CHIP Reauth Act (MACRA) of 2015. Phase-in an alternative payment model that
leverages outcomes & quality-based payments with a reduced fee-for-service reimbursement.
Proposed Rule Published on 4/27. Final Rule released Oct.14 with 60-day comment period.
• Eligible physicians and clinicians will be given 4 options to comply with new payment schemes
• Option 1: Allows providers to report any 1 measure for 90-day period to avoid a negative payment adjustment
• Option 2: Allows providers to submit data for a reduced number of days - this means their first performance
period could begin later than 1/1/17
• Option 3: Practices that are ready to go on 1/1/17 for the full 365 day quality reporting period in 2017
• Option 4: Participate in an advanced alternative payment model such as a Medicare Shared Savings ACO Track 2+
Medicare Access & CHIP Reauthorization Act
(MACRA) incentives
Advanced APM
Non-Advanced
APM
MIPS Only
MIPS Payment
Adjustment:
±4% - Year 1
±5% - Year 2
±7% - Year 3
±9% - Year 4+
MIPS payment
adjustment + APM
specific rewards
5% Medicare Part B
incentive payment
+ APM specific
rewards
MIPS performance categories
A single MIPS composite performance score will factor in performance in four weighted categories on a scale of 0-100
Quality
• Replaces PQRS.
• Accounts for
60% of total
performance
score in year
one.
Resource
Use/Cost
• Begins in
performance
year 2018.
• Replaces valuebased modifier.
Improvement
Activities (IA)
• Accounts for
15% of total
performance
score in year
one.
Advancing Care
Information (ACI)
• Replaces
Medicare MU.
• Accounts for
25% of total
performance
score in year
one.
MIPS performance categories
A single MIPS composite performance score will factor in performance in four weighted categories on a scale of 0-100.
Quality
Improvement
Activities
Advancing Care
Information (ACI)
60%
15%
25%
Select :
• 6 quality measures including:
• 1 outcome measure
• Groups using web interface: report
15 quality measures for a full year
Select :
• 4 improvement activities
• Groups with less than 15
participants or those in a
rural/health professional shortage
area: 2 activities
•
•
ECs report on up to 9 measures of
patient engagement and
information exchange.
You may not need to submit ACI if
these measures do not apply to you
Key MIPS/ QPP Final Rule takeaways…
Pick your pace
Highly flexible - You choose what objectives & measures
best fit your practice, specialty & workflow
It’s not all or nothing - Partial credit & bonuses available to
easily avoid penalties and to also increase payments
Radiology
Expected Revenue & Adjustments
•
•
•
•
Total Industry – 50,770 clinicians included
Positive payment adjustment 68.4%%, $131 Million
Negative payment adjustment 31.6%, $12 Million
Average for 10 Physician Radiology Practice
• +/-$50,195 in 1st Year
Radiology Specialty Measures
Number of Specialty Measures Included in Final Rule – 22
• 15 Process Measures for Effective Clinical Care
• 4 Structure Measures for Care Coordination
• 3 Outcome Measures for Patient Safety
Specialty Examples
NQF/Quality/CMS
Priority
Rate of Postoperative Stroke or Death in Asymptomatic Patients Undergoing Carotid Artery Stenting
(CAS)
1543/345/NA
High Priority
Radiation Consideration for Adult CT: Utilization of Dose Lowering Techniques
NA/436/NA
High Priority
Radiology: Exposure Dose or Time Reported for Procedures Using Fluoroscopy
NA/145/NA
High Priority
Radiology: Reminder System for Screening Mammograms
509/225/NA
High Priority
Measure ID’s Categories: Existing Core Measures, Core Measures with substantive changes, new proposed measures, high priority measures, and high priority measures appropriate use measures
Radiology – Cumulative Penalties
•
For years 2019-22+, based on EC performance, physicians and practitioners can receive cumulative negative or positive
payment adjustments.
Internal Medicine
Expected Revenue & Adjustments
•
•
•
•
Total Industry – 119,001 clinicians included
Positive payment adjustment 70.6%, $120 Million
Negative payment adjustment 29.4%, $22 Million
Average for 10 Physician IM Practice
• +/-$37,326 in 1st Year
Internal Medicine– Cumulative Penalties
•
For years 2019-22+, based on EC performance, physicians and practitioners can receive cumulative negative or positive payment
adjustments.
Family Practice
Expected Revenue and Adjustments
•
•
•
•
Total Industry – 114,574 clinicians included
Positive payment adjustment 64.5%, $84 Million
Negative payment adjustment 35.5%, $16 Million
Average for 10 Physician FP Practice
• +/-$23,750 in 1st Year
Orthopedics
Expected Revenue and Adjustments
•
•
•
•
Total Industry – 25,998 clinicians included
Positive payment adjustment 77.4%, $174 Million
Negative payment adjustment 22.6%, $17 Million
Average for 10 Physician Ortho Practice
• +/-$57,671 in 1st Year
Cardiology
Expected Revenue & Adjustments
•
•
•
•
Total Industry – 36,128 clinicians included
Positive payment adjustment 73.3%, $224 Million
Negative payment adjustment 26.7%, $25 Million
Average for 10 Physician Cardiology Practice
• +/-$87,203 in 1st Year
Cardiology Specialty Measures
Number of Specialty Measures Included in Final Rule – 20
• 16 Process Measures for Effective Clinical Care
• 3 Efficiency Measures for Cost Reduction
• 1 Outcome Measures for Patient Safety
Specialty Examples
NQF/Quality/CMS
Priority
Heart Failure (HF): Angiotensin – Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker
(ARB) Therapy for Left Ventricular Systolic Dysfunction
0081/005/135v4
Core Measure
Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)
0083/008/144v5
Core Measure
w/changes
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Preoperative Evaluation in Low-Risk
Surgery Patients
NA/322/NA
High Priority
Cardiac Stress Imaging Not Meeting Appropriate Use Criteria: Routine Testing After Percutaneous
Coronary Intervention (PCI)
NA/323/NA
High Priority
Measure ID’s Categories: Existing Core Measures, Core Measures with substantive changes, new proposed measures, high priority measures, and high priority measures appropriate use measures
Ophthalmology
Expected Revenue & Adjustments
•
•
•
•
Total Industry – 21,691 clinicians included
Positive payment adjustment 78.9%, $465 Million
Negative payment adjustment 21.1%, $24 Million
Average for 10 Physician Ophthalmology Practice
• +/-$141,949 in 1st Year
OB/GYN
Expected Medicare Revenue and Adjustments
•
•
•
•
•
Total Industry – 36,758 clinicians included
Positive payment adjustment 51.1%, $28 Million
Negative payment adjustment 48.9%, $8 Million
Average for 10 Physician OB/GYN Practice
• +/-$12,000 in 1st Year
Sample State-based Incentive Programs
NEW YORK
GEORGIA
Aetna PCMH Program
GA PCMH University
◦ Recognized providers will receive a
quarterly Coordination of Care payment for
each (non-Medicare) Aetna member
◦ Outcomes show earnings of $300,000 in
incentive payments in one year for
achieving targets
◦ Increase in primary care visits and revenue
Oncology Care Model (OCM)
◦ Monthly Enhanced Oncology Service
Payment of $160 per-beneficiary for
delivery of OCM services +
◦ Performance-based Payment for OCM
Episodes
Sample State-based Incentive Programs
KENTUCKY
Enhanced Personal Health Care
Program
◦ General increase to the regular fees paid to
physician practices for specific services
Comprehensive Primary Care Initiative
(CPCI)
◦ Independence Primary Care
◦ AAPM model (per proposed Rule)
FLORIDA
Blue Cross Blue Shield Value-Based
Care Program
◦ Awards are paid as a fee schedule multiplier to
applicable primary care codes for the program year
and range from adding up to 16% to the groups
contracted fee schedule
◦ In addition, a medical home initial assessment fee will
be paid annually for the management of patients with
chronic diseases such as diabetes, chronic obstructive
pulmonary disease (COPD), coronary artery disease
(CAD), asthma, congestive heart failure (CHF)
◦ PCMH physicians will also receive the management fee
for well visits of children newborn to age seven.
What It Will Take to Succeed Financially
Close attention to the bottom line
◦ Providers can’t afford to relinquish any of the money they’ve earned
◦ Optimize operational efficiency as well as clinical and financial health
◦ Close attention to the “nuts and bolts”
◦ Eligibility verification
◦ Authorization management
◦ Optimized coding
◦ Claim creation, scrubbing and submission
◦ Denial management with root cause review, mitigation and resubmission
◦ Close analysis of payor contracts and variance rates
◦ Key performance indicator (KPI) monitoring
What It Will Take to Succeed Clinically
Population health and care coordination – the heart of new payment models
◦ Need to integrate data from clinical and financial sources
◦ Customize EHR and “dashboards” to capture, monitor and report on all key measures and factors
◦ Monthly “scorecard” review for clinical and financial key performance metrics.
◦ Addresses those most in need and who are the greatest financial burdens
◦ Coordination across the care continuum to optimize outcomes
◦ Opportunities for patient engagement, education and empowerment
I Believe…
“I personally believe that all care providers that
intentionally and deliberately engage with new
payment & care delivery models, and create the right
partnerships, will have more opportunity in the future
than they have today.”
Questions or Comments?
Justin T. Barnes
[email protected]
@HITAdvisor
Thank you!