MIPS, MACRA, ACOs, I-SNPs, EHRs, A-APMs. Dealing with the alphabet soup of new requirements, programs, practice models, payment systems, and more are all part of post-acute and long-term care (PA/LTC) physician practices. Those that minimize the significance of these do so at their own peril; and, in this new paradigm, balancing the business and the art of medicine is a difficult juggling act. Increasingly, physicians need practice management professionals as partners who understand the business of medicine, the relationship between the practice of medicine and profitability, how to document, track, and analyze data, and how to free their practitioners to do what they do best—care for their patients.
AMDA—The Society for Post-Acute and Long-Term Care Medicine understands that practitioners can’t ignore the business end of their practices and focus on patient care in a vacuum. To help practitioners survive and even thrive in the new world of value-based medicine, quality improvement, and partnerships across settings, the Society established a Practice Management Section and is holding a cutting-edge day-long program that will explore the business and clinical leadership side of successful PA/LTC practices. The program will bring together leaders in the field, nationally-known experts, and experienced experts to discuss the issues that PA/LTC practices must tackle and master to succeed moving forward. “Relevant Topics in Practice Management: Setting Advocacy Priorities for 2018-2019” is set for Wednesday, March 21st.
We sat down with some of the program presenters to discuss the pressing issues they will be addressing and how they hope to work with practice management professionals via the Practice Management Section to ensure quality care and financial viability go hand-in-hand for physician practices.
What If MIPS Is Our Only Option?
MIPS [Merit-based Incentive Payment System] “isn’t going away,” says Ethan Bachrach, MD, Chief Medical Informatics Officer, TeamHealth. However, he notes, “There are still a lot of people who don’t understand what the requirements are and fail to do the minimum. CMS [the Centers for Medicare & Medicaid Services] is concerned about that.” As a result, the agency has extended the ramp-up period for physicians. This reprieve may be welcome news, says Dr. Bachrach, but it doesn’t mean that practice managers and their practitioners can rest. Instead, they need to focus on filling the gaps that are keeping them from fully implementing MIPS and utilizing the program so that they aren’t losing money via penalties for non-participation.
Even when practitioners are ready to dive into MIPS, they face challenges. For example, Dr. Bachrach observes, “Many practitioners are working in the facility’s system, so they have to rely on that information.” There are a few problems with this, he says. For one, many facilities have information systems that are designed for the facility’s data needs and functions, not the practitioners’ needs. Even more challenging, some facilities are still paper based. Either way, the metrics facilities are held accountable for aren’t the measures clinicians are required to track, so mining and capturing the information they need can be difficult and frustrating for practitioners. “To effectively leverage care to do well on quality measures is taxing. The data systems are designed to guide you down the path,” says Dr. Bachrach. He adds, “We need to get to a point where we can align with the facility to have shared measures that make sense on both sides so we can jointly be successful. To date, there is not a single quality program or value-based payment program that does this well.” He notes, “Until we get well defined episodes of care and can get comparative data, the best we can do is optimize performance and quality. Then we need to develop alternative payment models that make sense for the PA/LTC setting.” He observed, “There is some concern that MIPS will not be responsive enough for practitioners in this setting. Our long-term strategy should be to get them into Advance Payment Models.”
Dr. Bachrach will talk his audience through the challenges and opportunities of MIPS. It starts with buy-in; and to achieve this, he observes, “Education is key.” It is essential to work with clinicians and facilities to understand existing workflows, then work to integrate documentation and data collection into these. This work should be designed not to change the way practitioners provide patient care but enable them to document information without creating additional steps or burdens.
“Depending on how the information is captured, you should provide resources or tools to extract information, provide benchmarks, and report back to practitioners so they can track how they are doing.” This, Dr. Bachrach says, is where practice groups have the opportunity to assist clinicians. They can help ease the burden of reporting and make it part of practice.” This is a significant contribution, he stresses. “CMS says physicians will spend billions of dollars applying the revised rules. This represents an extraordinary administrative burden and investment in overhead—and that is on top of the burden of just understanding and digesting it all.” Practice managers, he says, can do some of this heavy lifting for practitioners.
It’s still too early to tell what impact MIPS will have or how the program will shake out. However, Dr. Bachrach emphasizes, MIPS is here to stay; so, the sooner medical practices get on board, the better. “Our opportunity as a clinician group in this space is that CMS really wants to improve patient care and decrease costs; and we serve a traditionally high-cost population. We have the experience and knowledge to define quality improvement and identify opportunities for cost savings. Working through our professional organizations such as the Society, we can have a powerful, effective voice. We can improve care, reduce costs, and identify where changes need to be made.”
LTC ACOs: What’s Working…or Not?
Accountable Care Organizations (ACOs) have been getting much attention; and they’ve shown promise in helping to break down siloes, promote seamless care continuums, improve quality, and reduce costs. However, for those in the PA/LTC arena, there is one problem. As Jason Feuerman, SVP, Genesis Healthcare Services, says “ACOs generally don’t want long-term care practices as part of their groups.” Why? For one, these patients—predominantly frail elders with multiple comorbidities—account for about three times the costs of other populations; and no one wants these high-cost patients in their programs.
However, Mr. Feuerman notes, no one is better equipped to reduce health care costs than the organizations and practitioners who care for the most expensive population. That is why he will be discussing LTC ACOs, those organizations that focus solely on this population. Many LTC practices make their living overseeing both short- and long-stay post-acute and nursing home patients. Through specialized ACOs, they can document and demonstrate their efficiency in caring for these patients and reducing avoidable readmission. Kerry Weiner, MD, MPH, Senior Medical Executive, Avant Healthcare Consulting, adds, “If you look at ACO performance and talk to executives, they haven’t been paying attention to the PA/LTC space. There is a huge opportunity for us to be part of the solution. ACOs actually will do better when PA/LTC is involved.”
ACOs involve taking on some financial risk, and this can be intimidating for medical practices. However, to get into these models, risk is part of the game. Dr. Weiner says, “More than ever ACOs are very dependent on risk adjustment. That is how to level the playing field.” Risk adjustment has many parts, he suggests, but “the key is how you code.” This isn’t intuitive for practitioners, he says. And this is an area where the practice management team can ensure physicians and advance practice professionals have the coding support they need.
Looking at the progress of ACOs to date, there are lessons to be learned. For instance, Dr. Weiner says, “We know that physician-run ACOs perform the best; and primary care physician-run ones perform the best of all. This demonstrates the importance of having physician involvement and leadership.”
Beyond ACOs Mr. Feuerman and Dr. Weiner will talk about all of the value-based care initiatives out there. Practice managers and practitioners need to understand the threats and challenges to long-term care with these various programs and arrangements. “It’s not just about seeing patients but ensuring that each interaction is a quality visit that supports the facility and produces the best possible outcomes.” Moving forward, Mr. Feuerman says, there will be no room for gaps in data and performance. For instance, he notes, “If you are a high hospital utilizer, you put your business and the facility at risk.” Gone are the days, he says, where there wasn’t alignment of goals and metrics between facilities and practitioners. “We have to come together. The industry has to change the way it sees itself.”
In the meantime, Mr. Feuerman suggests, practitioners need to start reading about MIPS and MACRA. They have to realize that ACO “is not a dirty word.” They need “to understand how they practice and earn income is being impacted by these forces around them. They can’t ignore them or they will be left out,” says Dr. Weiner. He urges LTC practices to get involved with ACOs in their community. He says, “It’s important to get recognition for the work you do. ACOs may see PA/LTC as a second tier, but you can get on their radar if you can show how you can influence outcomes and the bottom line.”
Advanced Bundled Payments
By now, most people have heard about bundled payments, and a few practices may actually have some experience with this payment model. Now the system is moving into advanced bundled payments, and Matt Gray, Vice President of Risk-Based Programs for TeamHealth, will discuss this model and its relevance in the PA/LTC medicine specialty.
There is good news for PA/LTC practices here. As Mr. Gray says, “We have learned that we can drive savings through bundled payments. We’ve proven this. Through trial and error, we’ve learned that it is better to go with focused, selective programs with certain themes in the market and eco-system.” Instead of programs that go superficially into many markets, greater success lies in bunded payment programs that go deeper in just a few markets. He says, “It’s better to select a handful of hospitals where you can invest heavily because you are confident that you can drive savings, operational improvements, and true clinical change.”
By targeting markets where they believe they can feasibly and financially invest, practice managers can help provide a practice’s strategic focus for entry into advanced bundled payment programs. Then they need to invest in systems—including hand-held devices and other tools—that help practitioners gather data and follow protocols without increasing the day-to-day administrative burden. The practice management team, says Mr. Gray, must align compensation with what the practitioners do clinically to drive patient quality and financial success.
To keep practitioners engaged and on-track, Mr. Gray says, it is important to provide them with the with the information they need without overwhelming them.” He offers, “Don’t overload them with multiple apps. Instead, consider dashboards or other tools that enable them to quickly access and absorb information.” He emphasizes, “The most successful programs are those that make incremental changes, so don’t try to do everything at once.” The result, he says, will be that you have physicians coming to you, asking questions and wanting to make sure they effectively captured the data for each episode of care. “When they are coming to you instead of you chasing them, you know you have arrived,” Mr. Gray says.
Mr. Gray will walk participants through the advanced bundled payment maze in a way that even beginners will feel empowered to get started. He will help them understand how to move forward when they get stuck and how to avoid pitfalls that can take them off track. He suggests, “If you are really risk-adverse, start small. Get started, learn, and decide if you want to grow and take on more risk. Let the data guide you. If you are favorable in certain markets, it is because you’ve done something right already. Learn what drove that success and you can identify best practices that you can employ in other areas.”
Victory with Vendors: Experts Discussion Recipes for Success
There is no practice model, quality improvement initiative, or value-based purchasing model where the appropriate collection, documentation, analysis, and publication of data aren’t absolutely essential. While EHRs are more user-friendly and sophisticated than ever before, there are still some issues that need to be addressed for practices to succeed in the value-based purchasing world. In a panel discussion, Richard White from Point Click Care, Denise Wassenaar, RN, MS, LHA, from Matrix Care, and Maria Arellano from American Health Tech will take on a vendor panel discussion about EHRs a “Teamwork for Success in Value-Based Purchasing Models.”
Perhaps the greatest challenge for practitioners and their practice is that they don’t always have access to facility EHRs; and even when they do, they may have to hunt for the specific information they need, and if they serve 5 different facilities, they may have to deal with 5 different EHR systems. To address these challenges, suggests Mr. White, “Remote access, mobile technology, and visibility to the resident record is key.” Another challenge, he says, is continuity. “There needs to be one source of ‘truth’ about each resident. As soon as something is updated in the EHR, practitioners should be made aware of this change or addition. Likewise, if the EHR is updated by the practitioner, the facility should be notified or the record should clearly reflect the latest up-to-date information,” he says. When a practitioner can make informed clinical decisions in concert with the facility care team and feel comfortable that everyone has the relevant information they need, says Mr. White, you get better outcomes.
Interoperability is finally becoming a reality, Mr. White suggests; however, there are still many challenges in this area, and the panel will address these challenges—and offer some possible solutions. He says, “Disparate systems in all care settings make it very challenging to maintain a continuity of care for patients. They move from the hospital to the PA/LTC facility to the home setting; and as they change settings, they change systems.” As a result, information is lost; and efforts are duplicated to recreate lost information or create new records. “This is changing,” Mr. White says, “with more cooperation between vendors, better agreement on what information is needed and when, and better coordination of care that results in better outcomes.”
Institutional Special Needs Programs: Everything You Need to Know
While everyone is talking about ACOs and bundled payments, there is another payment model that is promising–although it’s received little attention. Institutional Special Needs Plans (I-SNPs) are a type of Medicare Advantage Plan, but with membership limited to people with specific diseases or characteristics and services (benefits, provider choices, drug formularies) tailored to best meet the beneficiaries’ specific needs. There are different types of SNPs; to qualify for I-SNP participation, the patient must live in an institution such as a nursing home or require nursing care at home. SNPs are approved by Medicare and run by private companies. When a patient joins a Medicare SNP, he or she gets all Medicare hospital, medical health care services, and prescription drug coverage through that plan.
Cathy Lipton, MD, CMD, Regional Medical Director, Optum, will bring per experience with an I-SNP to the program and share her expertise. “We have the biggest I-SNP in the country, and we know how to do it,” she says. She will help both practitioners and practice management professionals visualize how they might fit into an I-SNP model and how to identify opportunities in their states. To get involved, physicians need to find I-SNP affiliated providers in their area. “Most I-SNPs get a contract and reach out to physicians to participate. Physician practices, in turn, are contracted and provide the patient care,” says Dr. Lipton.
While it takes time and effort to find and connect with I-SNPs, Dr. Lipton says, it is worth the time and energy. “The whole concept represents a shift back from the hospital setting to the nursing home setting. It empowers physicians and advance practice professionals to focus on providing patient care,” she says. Her organization’s I-SNP offers some additional benefits. For instance, the organization has a tremendous infrastructure due to its large size. Another benefit for practitioners (and practice managers) is that “we do much of the heavy lifting—the data mining—so physician groups aren’t burdened with that. We have employed advance practice practitioners to handle much of the documentation and data collection and entry.” At the same time, Dr. Lipton says, while there is risk involved, her organization—not the practitioners–assumes that risk.
There aren’t many downsides to the I-SNP, Dr. Lipton observes. However, she adds, “The larger the physician group, the more likely the program will be successful. The bigger the practice, the easier it is for us to work with them.” She stresses nonetheless that small practices still may have opportunities to join I-SNPs, particularly if they partner with others to form a larger network of practitioners and services.
The LTC practice is a natural fit for the I-SNP, Dr. Lipton suggests, as many already are focusing on concepts such as treating in place, reducing avoidable readmissions, and addressing quality improvement efforts on illnesses and conditions that most often land patients in the ER or acute care setting and adding substantial costs.
Dr. Lipton is very optimistic about the future of I-SNPs. “Medicare knows that I-SNPs are a good thing and is very supportive of these plans,” she says.
Just the Beginning
In addition to the day-long program, there will be several practice management programs throughout the Society’s Annual Conference. “We will be talking about transformational changes in the industry and the need to get payment reform front and center in people’s minds,” says Rod Baird, CEO of Geriatric Practice Management, a member of the Practice Management Section, and moderator of the day-long program. He adds, “The majority of Society members don’t think about their PA/LTC practice as being a business that has to be managed in a successful fashion. They want to practice medicine and do the right thing for their patients—that is their job, and they do it very well. But if the business end of their practice isn’t effective, things fall apart.” Mr. Baird stresses, “The practice of medicine is a calling, but it’s also a business.” The Practice Management Section program will help practice management professionals and their practitioners to support each other and successfully engage with innovative payment models moving forward.
The new Society Section promotes the concept that practice management in this space is crucial and that practice management in PA/LTC is more complex because of regulatory oversight and the high care utilization of patients in this setting. “PA/LTC practitioners are the dreamers. They are passionate about quality care, but they don’t fit into any existing bucket that CMS has. As a result, they often are misunderstood and lumped together with practitioners who serve very different populations in very different care spaces.” The Practice Management Section programs—at the conference and in the future—will provide a strong collective voice to engage regulatory officials and help them understand PA/LTC as a unique practice setting. The Section also empower practice management professionals and practitioners alike to understand the changes to health care that impact them, such as the complexities of MIPS and how to get the best results from their involvement in the program. At the same time, section programs and activities will encourage members to share information, ideas, challenges, and best practices. Ultimately, the goal is to help everyone thrive versus just survive in this evolving health care environment.