PulseThe

ofFall 2016

Disruptive change continues to permeate the healthcare marketplace. MACRA, MIPS, APMs, CPC+, MiSIM, OSC PPO product, changes to the Medicare Advantage model and significant changes in the BCBSM Physician Group Incentive Program (PGIP) are just some of the disruptive changes that will impact physician reimbursement for years to come. The pressures being applied to our physicians and TPA staff due to the volatility these changes are having on the zero sum game of capturing health care dollars is tremendous. The pressure to reduce cost is being applied to the payers, both private and governmental, by employers and taxpayers (patients) is greater than ever and will continue to escalate. Even though the changes are disruptive, TPA physician leaders and I view them as opportunities to maximize physician reimbursement and improve the care provided to patients.

The current U.S. real median household income is $57,775 and the current real median per capita income is $29,979.* The average worker now pays an average of $1,318 out of pocket before health insurance coverage begins and that number does not include the worker’s contribution to the premium. Increasing patient deductibles and new patient incentives will leverage patients to believe the physician has an ethical responsibility to direct them to the lowest cost providers. Future physician cost reduction incentives will stimulate physicians to direct patients to the lowest cost providers.

The BCBSM PGIP is shifting more attention to stimulating physicians and physician organizations to facilitate absolute cost reduction. After 2017, the MIPS component of MACRA will integrate a cost reduction component into the model. MIPS can either favorably or negatively impact a physician’s Medicare reimbursement by ±4% in 2019 (2017 is the measurement period) and it will incrementally escalate to ±9% in 2022 (2020 is the measurement period).

TPA leadership’s initial reaction to changes in the healthcare marketplace is typically the same reaction as our physicians: I can’t believe we have to pivot our business model again for another program. Then we settle ourselves to learn the details and rules of the programs to develop strategies to work with our physicians to employ the correct tactics to help them capture additional reimbursement and be successful in these programs.

I am proud to state that the Patient Centered Medical Home (PCMH) Neighborhood/Organized System of Care (OSC) work that The Physician Alliance has been doing with our physician practices over the past five years has positioned our physicians well for these new programs. Keep in mind that TPA borrowed $400,000 in 2012 to get the organization established. Our PCMH-N/OSC work has turned a $400,000 loan into more than $70 million in incentives paid directly to our physicians. For 2016, 355 (89%) of our PCPs in PGIP are designated PCMH (making them eligible for 20% - 40% BCBSM VBR incentives) and 809 (82%) of our specialists in PGIP are getting 5% or 10% BCBSM VBR incentives. Not only has the work we have been doing with our physicians been successful in PGIP, but it also has positioned our physicians well for MACRA, CPC+, MiSIM, the OSC PPO Product, changes to Medicare Advantage and future changes to PGIP.

2017 Game Changers: Are You Prepared? “Learn the rules of the game…then play better than anyone else” — Albert Einstein

continued on page 2

President’s MESSAGE

2

TeamNumber of Practices

Gaps Sent Out Gaps Found

Entered into Health eBlue

Percent False Gaps

East 20 1598 539 217 33.70%

West 18 2027 446 391 22.00%

Mid 21 1691 148 103 8.75%

Total 59 5316 1133 711 21.30%

Jan-Aug 2016 Phases 1 & 2

Project Harmony Progress

continued on page 7

When The Physician Alliance launched Project Harmony in 2015, the goal was to address physicians’ concerns that their reported quality performance is not always a true reflection of the quality of care performed by the practice. Project Harmony was designed to focus on improving data integrity so physicians can receive appropriate credit for the care that they deliver to patients and pay for performance revenue.

Project Harmony seeks to improve the Healthcare Effectiveness Data and Information Set (HEDIS) results using the Blue Cross Blue Shield of Michigan Physician Group Incentive Program all payer, all patient philosophy and by leveraging TPA’s disease registry and population health platform. The pilot initially engaged 12 practices focused on improving gaps for three preventative measures. As of August 2016, 59 practices are now participating in Project Harmony covering eight measures. More than 5,300 gaps were sent to practices, with 1,133 gaps found in the practices’ EMR.

One of the common findings of Project Harmony is “the discrepancies between a practice’s EMR, TPA’s disease

registry and the provider’s data reports,” said Ashley Shreve, senior program improvement facilitator at The Physician Alliance. Most of the offices discovered that what is perceived as a gap by a payer is often found within the EMR. Shreve said that the (Project Harmony) teams are working with practice staff to create processes for ongoing HEDIS improvement.

In 2016, The Physician Alliance restructured some staff to create a team-based model that includes practice resource team members and an assigned TPA IT staff person to support population health quality improvement. Teams were split into three regions to provide better personalized support to various practices. Each regional team works closely with assigned practices and each other to identify gaps, share best practices and assist with understanding PCMH, PCMH-N and quality improvement opportunities. Working with practices to improve HEDIS results, the IT staff person looks for discrepancies in health plans assigning patients to practices, challenges in missing EMR data, and coding errors.

The 2,238 pages of the final rules of MACRA, MIPS and APMs were released on October 14, 2016. Other programs are still in the developmental phase. I want to assure all of our 2,246 physician members that our leadership team and I have our fingers on the pulse of these programs and are not only gaining expertise in their administration, but are also influencing their development with payers. Our leadership team and I will be traveling to Washington, D.C. to meet with national leaders, including the acting administrator of CMS, to cement our understanding of the final rules for MACRA, MIPS, and APMs. We are also in the process of developing comprehensive education sessions for our physicians to help simplify the changes, and exploring the development of a complete line of services that will assist and support our physicians through the myriad of complex rules. The services are being designed to help physicians capture the maximum reimbursement and incentive dollars available while simultaneously assuring the practice is positioned for the future.

I am confident that TPA will continue to be as successful in the future with these new programs as we have been in the past with PGIP, PCMH-N and OSC. Please make sure that you and your office manager are keeping an eye out for TPA’s biweekly The Pulse e-newsletters and updates to our website that will outline upcoming training events and physician services opportunities.

In good health,

Michael R. MaddenPresident & CEO

Q u a l i t y p r o g r a m | closes gaps

*U.S. Census Bureau

3

Change continues to greet the healthcare industry on an almost daily basis. The newest change comes from the Centers for Medicare and Medicaid Services (CMS) as they shift to value based delivery and payment models through the creation of the Medicare Access and CHIP Reauthorization Act, or MACRA. This new program makes significant changes to how CMS pays those who provide care to Medicare beneficiaries.

These changes create the Quality Payment Program (QPP) that ends the Sustainable Growth Rate (SGR) formula for determining Medicare payments. It also creates a new payment framework to reward providers for giving better care to patients by combining several quality reporting systems into one new system.

MACRA has two paths that link quality to payments:

Merit-Based Incentive Payment System (MIPS) bases payment on four categories:

1. Quality (60%)

2. Advancing care information (15%)

3. Clinical practice improvement activities (25%)

4. Resource use (not applicable in 2017)

MIPS composite weighted performance scores will utilize the above four categories. MIPS consolidates elements from Meaningful Use (MU), Physician Quality Reporting System (PQRS) and Value-based Payment Modifier (VBPM) into one program. MIPS measures overall care delivery by clinicians. Scores will be used to compute positive, negative or a neutral adjustment to Medicare Part B payments.

Advanced Alternative Payment Models (APMs) are new approaches for paying for medical care in which providers take responsibility for quality and cost and are paid to support high value care. Recognized APMs are:

• Medicare shared savings program ACO

• Health care quality demonstration program

• CMS innovation center models

• Demonstration required by federal law

APMs require participants to use certified EHR technology. Implementation is meant to streamline value and quality

based payments for physicians and reward participation in advanced APMs through incentives for high quality and efficient care. MACRA does not change APM functioning, it adds extra incentives in APM participation.

“Physicians need to place MACRA on their radar screen,” said Dr. Karen Swanson, chief medical officer at The Physician Alliance and a primary care physician, “because it is a complex law that begins January 2017 and will determine how providers are paid by CMS for many years to come.”

If physicians decline to report quality and cost data, penalties will be imposed in 2019. Physicians will need to quickly educate themselves and utilize resources created by medical societies such as the American College of Physicians and American Academy of Family Physicians, and organizations such as The Physician Alliance.

Medicare Part B clinicians will be in MIPS or an Advanced APM or both, as Medicare providers must participate in one of these paths unless exempt, to receive a payment adjustment.The exemptions from payment adjustments under MIPS are:

• 1st year as a Medicare provider

• Below the low Medicare volume threshold

• Have less than or equal to $30,000 in Medicare billing charges

• Have less than or equal to 100 Medicare patients

• Significant participant in an advanced alternative payment model

The move from fee for service payments to value based purchasing with quality and cost transparency are key changes in the way clinicians will be paid by Medicare. MACRA streamlines several quality reporting programs into MIPS, with incentive payments for participation in APMs. Changes are driven by the focus on quality of care given, not quantity of care along with enhanced care coordination and improved patient-centered outcomes.

For more information on MACRA go to cms.gov.Make sure you receive TPA’s e-newsletter and updates to stay informed of new announcements and education opportunities. Email heather.hall@thephysicianalliance.org to sign up for the e-newsletter. <

CMS launches new payment system

4

Consider these facts: Every 19 minutes someone dies from an unintentional drug overdose. Three out of four of these deaths are caused by prescription pain killers. Seventy percent of young people who abuse prescription medications get these from family and friends.

By August 2015, all 50 states legalized electronic prescribing of controlled substances (EPCS). Some states are enacting laws to require electronic prescribing of all controlled substances. More states will begin requiring adoption of this process, including Michigan. EPCS has great potential to improve patient care quality and improve practice workflow and efficiency as it combines traditional e-prescribing with security measures that allow physicians to electronically order these tightly regulated substances.

Blue Cross Blue Shield of Michigan reports that more than 60 percent of controlled substances are electronically prescribed. There is opportunity for growth and The Physician Alliance is working with BCBSM and St. John Providence to educate and assist practices in initiating electronic prescriptions for controlled substances.

EPCS can be helpful in meeting Meaningful Use percentage targets for electronic prescribing. In stage 1, 40% of prescriptions must be submitted electronically and stage 2 requires 50% of prescriptions to be submitted electronically. Many practices find it difficult to meet the stage 2 requirement without electronically transmitting controlled substances. Adding controlled substances to a practice’s e-prescribing program can improve the inclusion of e-prescribing for non-controlled substances.

E-prescribing of controlled substances requires physicians to present a two-factor authentication to prove their identity as an approved provider. The Drug Enforcement Administration (DEA) requires two of three authentication options: something the provider knows, something the provider has, and something the provider is. Options for two-factor authentication include:

• Hard token: A cryptographic password/key is sent to a hardware device (smartphone, key fob, etc.) that the physician enters into the EMR

• Fingerprint scanner (this is the most common identifier for “something you are”)

• EMR login credentials/password

Practices should contact their EMR vendor for specific education and requirements on e-prescribing. <

Electronic prescribing of controlled substancesimproves patient safety and practice workflow

Some benefits of e-prescribing include:

• Improves office efficiency by managing all prescriptions from one electronic workflow process

• Helps prevent errors related to legibility/clarity of faxed or phone prescriptions

• Improves monitoring of controlled substance prescriptions

• Aligns with Meaningful Use criteria

• Increases patient satisfaction and compliance (patients are more likely to fill prescriptions if they are electronically sent to a pharmacy)

• Improves management of medications when there is a drug shortage or dose change

5

Transition plans in healthcare can be critical and helpful to a patient’s life. Especially if you are a young adult with little to no experience in managing your own health. The world of healthcare is confusing and complex. Most adolescents pay no attention to healthcare concerns as caregivers typically manage doctor appointments, insurance and other issues. This can lead to a patient being unprepared to manage their healthcare when suddenly they find themselves considered an adult and need to transition to the adult-centered healthcare world.

The healthcare industry recommends children transition to adult-oriented health care between the ages of 18 and 21 years. According to a 2013 current population survey by the U.S. Census Bureau, 18 million U.S. adolescents ages 18–21 moved into adulthood and needed to transition from pediatric to adult-centered health care. If an adolescent is seeing a pediatrician, the transition involves finding a new primary care physician, transferring medical records, and sharing treatment histories and insurance information. Adolescents already in a family medicine practice may stay with their physician, but may need to transfer specialty care to adult subspecialists.

Got Transition is a cooperative agreement between the Maternal and Child Health Bureau and The National Alliance to Advance Adolescent Health to develop strategies and materials to help physicians, patients and parents improve the transition from pediatric care to adult-centered care. Got Transition provides helpful, free resources, including templates, flow sheets and plan of care sample templates, that cover the six core elements of health care transition. These areas include:

1. Transition policy

2. Transition tracking and monitoring

3. Transition readiness

4. Transition planning

5. Transfer of care

6. Transfer completion

Experts agree that the best way to successfully achieve these core elements is to have a formal transition policy and plan in place. Early education on these steps for both adolescents and parents can help ensure an easier transition. Many parents/caregivers have a difficult time acknowledging the patient as an adult so involving them in the transition phase may provide an easier time for all.

Got Transition’s materials, templates and resources are available to download at www.gottransition.org. <

Preparing for change can be a challenge.

Sometimes it is out of our hands and not always

welcome. Whether in business or personal,

transitioning for change comes with thoughts

and plans to handle the change.

AGEWhen patients

6

CMO CORNER Embedded care managers

benefit patients and practicesReimbursement for care management now available

By Karen Swanson, M.D.

Many physicians are uncertain whether they really need

a care manager (CM) included in their practice team. I’m

certain many of my colleagues have asked “what is the

value and role of this position? How will I pay for this

person?” The exact role of the care manager has been

evolving as pilot programs across the country have been

“testing the water” to determine if care managers improve

patient outcomes. An embedded care manager can serve

as a central point of contact for patients to help reduce

confusion and redundancy in services.

Most physician practices have informally provided care coordination services for patients, but were not able to bill for these services. The good news is that health plans and CMS are now recognizing the value of care coordination and reimbursing for ambulatory care management services. Practices committed to the Patient Centered Medical Home program have positioned themselves to receive reimbursement for the patient centric services they have been providing.

Medicare, Blue Cross Blue Shield of Michigan, and Priority Health created codes for care management services as well as codes for physician oversight of care management plans and services. Medicare pays for telephonic care management services for patients with chronic diseases (approximately $45 per patient per month) and for advanced directive discussions (approximately $85). Medicare, as well as most other health plans, is reimbursing for transition of care encounters (discharge from a hospital, observation unit, SNF), paying up to nearly $350. CMS’s Comprehensive Primary Care Plus program (CPC+) offers significant PMPM reimbursement (up $100) for participating practices that hire a care manager and commit to a population health strategy. Priority reimburses through care management services and BCBSM’s Provider Directed Care Management program pays for several specified care management services.

The embedded CM focuses on disease management (DM/COPD/CHF/CKD etc.) and population management of patients at high risk for hospitalization. The CM is the central point of contact for patients with complex medical needs and patients with recent hospitalizations. Patients with transportation issues, financial difficulties and mental health problems are referred to appropriate community programs by the CM. The CM helps direct the practice’s care team (receptionist/medical assistant/RN) in coordinating complex transitions of care for patients with multiple complex medical needs. There is now evidence that effective CMs can help prevent unnecessary hospital admissions and readmissions as well as reduce overutilization of medical resources.

An embedded CM’s roles include:

1. Assess the patient’s medical, social and financial needs.

2. Create a care plan based on the patient’s needs and medical condition.

3. Facilitate the patient’s path through a complex healthcare web of appointments, diagnostics and services.

4. Lead care coordination after hospital/emergency room/rehabilitation/skilled nursing facility discharge

5. Advocate for the patient when addressing complex health care needs.

6. Promote quality and cost effective outcomes by outreaching to the patient population.

7. Educate patients on self-management of chronic diseases.

8. Lead the practice care team on achieving quality metric goals.

continued on page 7

7

Practices hiring a care manager should consider:

1. Define the CM’s scope of responsibilities within the practice.

2. Develop an implementation plan which includes educating the practice and patients on the role of this new healthcare provider. Clarity on how the CM integrates into the current care team is essential for success.

3. Train your care manager for coaching on self-disease management, transitions of care, billing and coding of CM services, complex patient needs etc. There are many on-line training opportunities for care managers.

4. Develop disease specific protocols with your care manager and care team.

5. Create a policy for referrals to the CM within the practice.

6. Develop a productivity goal for the CM. (Example: one wellness visit per day, four telephonic chronic care contacts per day, one complex care plan per day, two transition of care completions per day, etc.)

The evolution from a volume based to a value based reimbursement system is requiring physicians and healthcare systems to make some dramatic changes in the traditional health care delivery model. As the demand for greater value for the consumer grows, there will likely be a higher demand for care managers to coordinate the healthcare needs of more complex patients. Now is the time for primary care physicians to consider enhancing their care team with an embedded CM. <

Patient Centered Medical Home (PCMH) facts:

• In Michigan, BCBSM designated 1,638 practices as PCMH, representing 4,534 physicians

• 132 TPA primary care practices are BCBSM PCMH designated, representing 355 TPA primary care physicians

• 89% of TPA Physician Group Incentive Program (PGIP) primary care physicians are designated PCMH

• 84% of TPA PGIP practices are designated PCMH

• 93% of the BCBSM PGIP attributed lives are followed by a PCMH physician

Practices recognized for patient-centered careCongratulations to TPA’s 132 primary

care practices, representing 355 physicians, that achieved patient-

centered medical home designation by Blue Cross Blue Shield of Michigan!

Quality programs closes gaps, continued from page 2

Embedded care managers, continued from page 6

The project hasn’t been without challenges, from changing the roles of TPA staff and practice resource team members to educating practices on new processes to using a multitude of resources to identify areas of improvement. “We didn’t know what we didn’t know,” said Scott Johnson, vice president of operations at The Physician Alliance. “We’re changing the culture of how we usually look at data and do things, which subsequently changes the workflow and culture in our practices.”

While the practice resource team members and IT staff provide support to assist practices, ultimate success depends on the participation of all parties. Practice staff must be engaged and willing to commit resources to close the gaps and improve quality metrics.

“Many practices appreciate the opportunity to improve processes and work with the (Project Harmony) team,” said Johnson. One example is the Mid-Region practices who initially chose to focus on three metrics. All practices were so

engaged and ready to work with the team that improving BMI gaps was added to the goal. So far, all measures are showing improvement. According to Project Harmony data, when comparing January-June 2015 data to the same reporting period in this year, retinal eye exam gaps showed 18.4 percent improvement, adult BMI assessment 56 percent increase and colorectal cancer screening 5.6 percent increase.

TPA’s regional medical directors (RMD) also support the new team-based regions. The teams meet weekly and keep the RMDs abreast of struggles and outcomes to allow these physicians to be proactive in reaching out to practices if necessary.

TPA recently produced reports specific to practices that will pinpoint the top opportunities to improve HEDIS measures, and IT staff will help practices identify and close gaps. Future goals of Project Harmony include expanding engagement to all practices participating in Medicare Advantage, BCN and BCBSM’s PGIP. <

20952 12 Mile, Ste. 130St. Clair Shores, MI 48081

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PAIDST. JOHN HEALTH

Dennis Ramus, MD Chairperson

Daniel Megler, MD Vice Chairperson

Trpko Dimovski, MD Treasurer

William Oppat, MD Secretary

Eugene Agnone, MD

Bruce Benderoff, DO

Paul Benson, MD

Dennis Bojrab, MD

James Fox, MD

Michael Little, MD

Sidney Simonian, DO

Kevin Thompson, MD

Cherolee Trembath, MD

Michael R. Madden President & CEO

Robert Asmussen Senior Business Advisor

Heather Hall Executive Director, Corporate Communications

Scott Johnson Vice President, Operations

Michele Nichols Vice President, Administrative Services & Business Development

Carolyn Rada, RN, MSN Director, Practice Transformation

Sharon Ross, RN, MSN, NP Executive Vice President, Population Health

Oleg Savka Director, Systems and Informatics

Karen Swanson, MD Chief Medical Officer

TPA Leadership Team TPA Board of Directors

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