Concierge medicine, also known as boutique or private medicine, has grown beyond just a trend. Paid entirely by patients rather than health insurance companies, “concierge” physicians offer more personalized healthcare to smaller patient bases.

Although once thought to be an insignificant niche in healthcare delivery, more and more consumers are seeking out this model. Ten years ago, there were only a few hundred of these practices in the country, according to an article published in Tennessee Medicine in 2006.. Today, the number of concierge and direct-pay physicians it is estimated at more than 12,000.

As stifling healthcare regulations continue to overwhelm physicians, many feel as though they’ve done everything humanly possible to continue delivering quality healthcare under their current model of care. To compensate, physicians and their staff must either spend less time with each patient or devote more of their day to patient visits – by coming in earlier, staying later, or shortening their lunch breaks.

Despite the extra effort, practice revenues are stagnant at best. As reimbursements shrink and quality assurance demands from government and private insurers increase, physicians and staff – who are already overextended – are feeling the pressure. Smaller practices with limited resources to meet the requirements healthcare reform are turning to the concierge medicine model as a way out of the modern medicine labyrinth.

The Return of Personalized Care

As trends converge and the landscape of healthcare morphs, savvy physicians are developing models to meet the needs of their patients, deliver care as they see fit for each patient, and create a more palatable lifestyle for themselves. Physicians who set out to design a concierge practice have creative license to design a framework that best suits their professional and personal goals and take into account the needs of their patient base and market demographics.

The imbalance between supply and demand also helps make the case for concierge medicine. A 2016 study conducted for the AAMC by IHS Inc. predicts that the United States will face a shortage of between 61,700-94,700 physicians by the year 2025. Combine that with physician shortages with the aging population in the U.S. and the writing on the wall becomes quite clear; demand for timely access to quality healthcare will soon be greater than ever.

As this reality filters to the consumer through the media and personal experience, patients interested in the peace of mind that comes with flexible scheduling, immediate access to a physician, and more personalized attention may drive an increased demand for concierge physicians. Baby boomers (those born during the demographic boom between 1946 and 1964) are projected to have enough disposable income to take advantage of this more tailored delivery of healthcare. Boomers will be the wealthiest group of elderly in history, USA Today has reported, and although they make up only 20 percent of the population, baby boomers will control 40 percent of the nation’s disposable income.

How Concierge Medicine Works

In the classic concierge medical practice, a physician accepts a monthly or annual fee in exchange for granting patients special access. Services may include priority appointments (same day, in some cases), 24/7 access via email and cell phone, house calls, ample time with the physician during visits, and escort service to hospital emergency room visits. Depending on the services they deliver, concierge physicians charge up to $10,000 a year, with most charging $1,500 to $2,000, according to The New York Times.

Some high-end concierge practices are all-inclusive, while others charge a modest annual fee, with additional fees required for services and tests as they are rendered. It is common for a concierge physician to set a price schedule that offers several tiered options. For example, one option might include ample visits per year, along with various tests and maybe even a couple of visits for out-of-town guests (should the need arise). A different option, with a lower annual fee, might offer two visits per year, one round of standard bloodwork with additional visits, and tests available at pricing spelled out in the patient contract. The variations are endless, and it is up to the physician to decide the structure based on the needs of the patient base and vision for the concierge practice. A very clear and concise contractual relationship is vital.

In the classic model, the physician does not accept any form of health insurance. In addition to the physician having the freedom to deliver the level of care he or she sees fit, the primary advantage of a classic concierge practice is reduced administrative costs, made possible by cutting out third-party payors. Patients participating in a concierge arrangement generally also have a high-deductible medical insurance plan to cover catastrophic events or other medical services that the concierge practice cannot provide.

Hybrid Practices Are an Option

The “hybrid” concierge practice is an alternative that is also becoming more popular. In this model, the physician accepts a limited number of patients from his or her current practice who choose to join the concierge option. Patients who do not want to participate in the concierge model continue to see their physician as they always have. The concierge patients get a direct line of communication with the physician. In these practices, doctors and staff juggle the task of managing two levels of patients, and still retain a large patient base.

This option provides a way for physicians to dip their toe in the water, providing the personalized care and attention that concierge patients desire while not abandoning the patients that otherwise can’t or won’t transition over from traditional practice. One challenge with this model is developing a schedule that will accommodate the needs of the concierge patient, specifically same-day or immediate appointments, and the normally scheduled patients from the traditional practice.

Practicing concierge medicine is not for every physician. Physicians must be willing to be available to patients 24/7. And each physician must do it for the right reasons. Converting to a concierge practice purely to rebel against a healthcare delivery model that is no longer tolerable is probably not the best motive.

How to Get Started

After the decision has been made, converting to a concierge practice requires considerable planning and execution, because there are countless ways a practice can be structured. Even those simply pondering the possibilities of concierge medicine will find the following tips helpful:

  1. Survey your current patients. It is imperative to look carefully at your patient base, get to know the demographics, run statistics on the average number of visits per year, and even break down the numbers based on age ranges. This will help determine a fee schedule that is fair to both you and your overall patient base.
  2. Make a timetable. There are many steps involved in a practice conversion. A timetable will help identify each step and determine and maintain a realistic target conversion date.
  3. Address legal issues. It is paramount that a competent healthcare attorney be identified and retained. Although there are several online resources for attorneys (such as lawyers.com and findlaw.com), it is crucial to ask if the firm has experience structuring a retainer-style medical practice.
  4. Notify third-party payors. In some cases, insurance companies will not contract with physicians that charge a retainer. Others are perfectly fine with reimbursing physicians for covered services, with the understanding that they will not reimburse the patient’s retainer. It is best to identify these issues early in the process.
  5. Determine the pricing model. Will the practice be a classic concierge model, or a hybrid practice that continues to accept and file insurance claims for some patients? The existing patient base will tell a great deal about what type of model should be leveraged and how many pricing options should be offered.
  6. Create marketing materials. The tone and message of the marketing materials will depend somewhat on whether the practice will target the existing patient base or solicit new patients.
  7. Communicate the transition to the existing patient base. Keep in mind that patients may not be familiar with concierge medicine. Carefully explain why the practice is making the transition, what this means to the patient, and what they need to do next. Offer assistance finding a new provider to those who elect not to participate. Most concierge physicians set a limit to the number of patients they will accept, and retain patients on a first-come, first-serve basis.
  8. Schedule follow-up meetings. Some patients may require a detailed explanation. A great way to deliver this is to invite patients to a presentation about the transition at the practice or another convenient location. Offer individual meetings, as required.
  9. Hire a consultant. Running a practice while converting to another model can be arduous. A consultant can guide you through many of the steps involved and can pay attention to important details that may otherwise be overlooked.

The impact of healthcare reform on the aging baby boomer population remains to be seen. The growing number of concierge practices is testimony, however, that such medicine will continue to find a place in the U.S. healthcare market.

About the Authors

Doug Graham is a senior management consultant with DoctorsManagement, LLC, and specializes in concierge medicine conversions.

Karen Petrillo is the director of marketing with DoctorsManagement, LLC.

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The Centers for Medicare and Medicaid (CMS) released the 2017 OPPS Rule on July 6, 2016 and accepted comments up until Tuesday, September 6, 2016.  Now CMS has the task of reading and responding to all of the comments received in the final rule that is expected out sometime in November.

Below is the CMS News Release from July 6th, 2016:  

Hospital Value-Based Purchasing (VBP) Program

The Hospital VBP Program, funded by a 2 percent reduction from participating hospitals’ base operating diagnosis-related group (DRG) payments each year, requires CMS to redistribute a portion of the Medicare payments to hospitals for inpatient services based on performance.  In this CY 2017 OPPS/ASC proposed rule, CMS is proposing to remove the Pain Management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for purposes of the Hospital VBP Program, beginning with the FY 2018 program year.  Other Hospital VBP Program requirements will be set forth in an upcoming FY 2017 IPPS/LTCH PPS final rule to be issued on or around August 1, 2016.

CMS has received feedback that some stakeholders are concerned about the pain management dimension questions being used in the Hospital VBP Program, believing that the linkage of these particular questions to the Hospital VBP Program payment incentives creates pressure on hospital staff to prescribe more opioids in order to achieve higher scores on this dimension.  The pain management dimension questions do not specify any particular type of pain control method.  In addition, appropriate pain management includes communication with patients about pain-related issues, setting expectations about pain, shared decision-making, and proper prescription practices.  Although CMS is not aware of any scientific studies that support an association between scores on the pain management dimension questions and opioid prescribing practices, we are proposing to remove the pain management dimension of the HCAHPS survey for purposes of the Hospital VBP Program in an abundance of caution. We are also developing and field testing alternative questions related to provider communications and pain in order to remove any potential ambiguity in the HCAHPS survey.

While CMS is developing alternative pain management questions, HCAHPS survey data on all dimensions of care, including pain management, will continue to be publicly reported under the Hospital Inpatient Quality Reporting (IQR) Program in recognition that pain control is an important aspect to delivering quality care.  We believe this approach would appropriately balance concerns that clinicians could face financial pressure to prescribe opioids without compromising the only source of nationally comparable data on pain management and pain management disparities.

Hospital Outpatient Quality Reporting (OQR) Program: Proposed Changes for CY 2018, 2019, and 2020 Payment Determinations and Subsequent Years

The Hospital OQR Program is a pay for quality data reporting program for outpatient hospital services. The Hospital OQR Program requires hospital outpatient facilities to meet administrative, data collection, and submission, validation, and reporting requirements, or receive a reduction of 2.0 percentage points in their annual payment update for failure to meet these requirements.

In the CY 2017 OPPS/ASC Proposed Rule, CMS is proposing to add a total of seven measures to the Hospital OQR Program for the CY 2020 payment determination and subsequent years: Two claims-based measures, and five Outpatient and Ambulatory Surgery Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey-based measures. The seven measures are:

  • OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy, which assesses the care provided to cancer patients and encourages quality improvement efforts to reduce the number of unplanned inpatient admissions and emergency department (ED) visits among cancer patients receiving chemotherapy in a hospital outpatient setting.
  • OP-36: Hospital Visits after Hospital Outpatient Surgery (NQF #2687), which assesses variations in patient outcomes following surgery at a hospital outpatient department (HOPD). 
  • OP-37(a-e):  Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients’ access to care, interactions with facility staff, and overall experience at the facility.

CMS is seeking public comment on a future electronic clinical quality measure concept for the Hospital OQR Program that addresses concerns associated with overlapping or concurrent prescribing of opioids or opioids and benzodiazepines. This measure concept is designed to reduce preventable deaths as well as reduce costs associated with the treatment of opioid-related ED use by encouraging providers to identify patients at high risk for overdose due to respiratory depression or other adverse drug events.

We note that CMS is not proposing any changes to the CY 2018 and CY 2019 Hospital OQR Program measure sets, which include 26 measures—25 required and one voluntary.

Additionally, beginning with the CY 2018 payment determination, CMS is proposing to publicly display data on the Hospital Compare Web site, or other CMS Web site, as soon as possible after measure data have been submitted to CMS.  In addition, the agency is proposing that hospitals will generally have approximately 30 days to preview their data.  CMS is also proposing to announce the timeframes for the preview period on a CMS Web site and/or on its applicable listservs.  Furthermore, beginning with the CY 2019 payment determination, CMS proposes to update the Extraordinary Circumstances Exemptions (ECE) policy by changing the ECE request deadline from 45 days from the date that the extraordinary circumstance occurred to 90 days from the date that the extraordinary circumstance occurred.

Ambulatory Surgical Center Quality Reporting (ASCQR) Program 

The ASCQR Program is a pay-for-reporting program that requires ambulatory surgical centers (ASCs) to meet administrative, data collection, and reporting requirements, or receive a reduction of 2.0 percentage points in their annual payment update for failure to meet the requirements.

In the CY 2017 OPPS/ASC proposed rule, CMS is proposing to add seven measures to the ASCQR program measure set for the CY 2020 payment determination and subsequent years.  The seven measures are:

  • ASC-13: Normothermia Outcome, which assesses the percentage of patients having surgical procedures under general or neuraxial anesthesia of 60 minutes or more in duration who are normothermic within 15 minutes of arrival in the post-anesthesia care unit (PACU).
  • ASC-14: Unplanned Anterior Vitrectomy, which assesses the percentage of cataract surgery patients who have an unplanned anterior vitrectomy (removal of the vitreous present in the anterior chamber of the eye).
  • ASC-15(a-e): Five proposed measures that are collected using the Outpatient and Ambulatory Surgical Center Consumer Assessment of Healthcare Providers and Systems (OAS CAHPS) survey, a patient experience of care survey which assesses patients’ access to care, interactions with facility staff, and overall experience at the facility.

CMS is seeking public comment on a quality measure for future consideration in the ASCQR Program that addresses Toxic Anterior Segment Syndrome (TASS), a complication of anterior segment eye surgery.  This measure assesses the number of ophthalmic anterior segment surgery patients diagnosed with TASS within two days of surgery.

We note that CMS is not proposing any changes to the CY 2018 and CY 2019 ASCQR Program measure sets, which include 12 measures—11 required and one voluntary.

Additionally, beginning with the CY 2018 payment determination, CMS is proposing to publicly display data on the Hospital Compare Web site, or other CMS Web site, as soon as possible after measure data have been submitted to CMS.  In addition, the agency is proposing that hospitals will generally have approximately 30 days to preview their data.  CMS is also proposing to announce the timeframes for the preview period on a CMS Web site and/or on its applicable listservs.  CMS is further proposing, beginning with the CY 2019 payment determination, to update the Extraordinary Circumstances Exemptions (ECE) policy by extending the ECE request deadline from within 45 days of the date that the extraordinary circumstance occurred to within 90 days of the date that the extraordinary circumstance occurred.  CMS is also proposing to implement a May 15 submission deadline for all data submitted via a CMS Web-based tool in the ASCQR Program beginning with the CY 2019 payment determination.

The proposed rule will appear in the July 14, 2016, Federal Register and can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.

VBPmonitor will be covering more on this once the final rule is released.

About the Author

Kim Charland is the editor of VBPmonitor and the senior vice president of clinical innovation with Panacea Healthcare Solutions. Kim has 30 years of experience in health information and reimbursement management for hospitals and physician offices. Kim’s primary role with Panacea is publisher of VBPmonitor.com, which is the company’s newest online monitor and is focused on value-based purchasing and quality. She is also co-host of ICD10monitor.com’s Internet news broadcast Talk-Ten-Tuesdays. In addition, she assists with product development for Panacea’s consulting and software divisions, as well as the MedLearn publishing division. Kim is also recognized as a national speaker who has spoken for numerous organizations.

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The two-midnight rule for observation status went into effect two years ago, along with great confusion. On Jan. 1, the Outpatient Prospective Payment System (OPPS) final rule for the 2016 fiscal year went into effect, meaning that shorter stays could qualify for inpatient reimbursement based on physician judgment, not just time. Unfortunately, this has only created greater confusion, and a national rise in observation status usage.

Results

  • Providers, confused about the criteria, often err on the side of observation status for patients
  • Observation patients are not being managed differently from inpatients, with timely assessment and interventions necessary being applied for both
  • Patients receiving observation services are responsible for up to 20 percent of their bill if they don’t have secondary insurance, and the time they spend in the facility does not count toward the minimum three-day inpatient stay mandated by the Centers for Medicare & Medicaid Services (CMS) for skilled nursing facility (SNF) care
  • Higher observation rates yield significant financial impacts for hospitals

Essential Drivers for Improvement

  • Standardization of the hospitalist care:
    • Consistent, committed staffing – locums staffing is a key issue driving inappropriate observation status use
    • Quality
    • Improved timely care management for observation patients
  • Clinical documentation
  • Effective observation determination
  • Leadership and performance of each hospitalist group
  • Improved coordination between the ED and hospitalist services in admission and observation care management
  • Improved case management systems, staffing, and oversight
  • Enhanced CDI program performance supporting improved physician documentation
  • Structured systems for observation care placement and management
  • Key dashboards and metrics for managing inpatient and observation care
  • Availability of weekend diagnostic testing and specialty support

Determining the appropriate patient status initially, managing patients effectively, and avoiding conversions represent significant quality and financial opportunities for patients, providers, and facilities.

About the Author

Debbie Linnes is a partner and chief operating officer for DCCS. She has a broad background of service as a CEO, COO, and operations leader in accredited (CHW, SCLHS, CHI) and freestanding health systems across the country. She brings experience in moving organizations forward to consulting and interim senior leadership and operating positions and has a strong strategic and clinical background with outstanding physician relations skills. She rejuvenates underperforming organizations and programs, raising performance and profitability, and develops leadership and workplace cultures that lead to high levels of performance and employee satisfaction.

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 The PQRS feedback release may not be the most wonderful time of year anymore, but providers’ anticipation is at an all-time high. Accepting rewards for voluntary exceptional performance is no longer an option. Rather, failure to have reported for the 2015 performance year leaves providers susceptible to the application of a 2-percent downward payment adjustment for 2017.

Additionally, this comes along with the new implementation of a direct impact associated with value-based modifier (VBM) outcomes. Providers’ participation and collection of reported quality healthcare performance submissions have been evaluated by the Centers for Medicare & Medicaid Services (CMS), and its determined outcomes will be made available along with the announcement of the PQRS feedback reports for the 2015 reporting year.

While providers wait hopefully and patiently for their results, can they help but wonder: is CMS in the spirit of giving?

PQRS Negative Payment Adjustment Summary

From a financial perspective, the best gifts of successful participation in the PQRS program are not only the avoidance of the negative payment penalty, but ultimately granted enrollment into the quality tiering portion of the VBM program. Practices will be obliged to learn that this results in the avoidance of an automatic VBM penalty entirely.

In order to maximize providers’ Medicare reimbursement, this two-pronged system must first and foremost include successful participation in the PQRS program. This in itself will avoid the automatic negative 2-percent adjustment in the basic Medicare Part B fee schedule. Practices must secondly ensure achieving above-average performance in their PQRS measure submissions, which will be reflected in the quality portion of their VBM score.

Together these feats likely will be expected to result in the acquisition of a higher Medicare reimbursement rate, up to four times the budget-neutral adjustment factor (AF) for high-quality/low-cost PQRS reporting.

Figure 1 represents how these solo and additive payment adjustments are applied to all providers and group practices that are not successful in reporting under PQRS. Providers that fail to do so should expect penalties that may exceed the negligible threshold – as much as 6 percent of their Medicare revenue – whereby those that met the criteria for satisfactory reporting have the ability to gain those incentive funds.

 

Of note, each provider’s performance is evaluated and penalties are applied in isolation if reporting individually under the PQRS program. If electing to report as a group, all providers that bill under the same tax identification number (TIN) would be subject to penalties if not successfully reporting at the TIN level.

PQRS Feedback Report Overview

The PQRS program can bring forward eager, yet occasionally anxious, anticipation of outcomes each year. CMS will generate a distinct report for each individual TIN/NPI combination or group practice for both scenarios when individual eligible professionals (EP) or group practices submit PQRS quality data through one of the approved reporting mechanisms – or when EPs submit Medicare Physician Fee Schedule (MPFS) claims that included denominator-eligible instances but did not submit PQRS quality data. Beyond traditional report features, CMS has highlighted the implementation of stakeholder feedback considerations. Likewise, PQRS participants will be able to recognize updates to be incorporated in their 2015 PQRS feedback reports.

At the highest level, the reports will deliver information about whether individual EPs or GPRO participants have satisfactorily reported. The feedback reports will feature a detailed level of both reporting and clinical performance rates across three different levels, including provider, reporting mechanism, and measures. Mechanism data and measure performance detail will be provided for GPRO registry and GPRO electronic health record (EHR) submissions specifically, but the measure performance detail data for GPRO Web interface submissions will be included in the 2015 Quality and Resource Use Reports (QRURs).

The reporting outcome ultimately will determine the final payment adjustment assessment status, through which financial information about the incentive earned or penalties incurred will be reflected at the individual level for all NPIs that submitted information under a certain TIN. In addition, the reporting rate and available supporting data elements will be conveyed for the measure applicability validation (MAV) process, which will include MAV eligibility notes and other satisfactorily reported criteria addendum notes. Reports at the TIN level will include summary information, success rates, and the associated financial effects as a result of calculated performance on physician quality reporting. Although CMS has not established an official feedback report distribution date, with heightened anticipation, practices can generally look for their release in early fall of 2016.

Gaining Access to the Feedback Reports

In looking ahead, to avoid delay, CMS has strongly encouraged that both new and existing PQRS participants request or access their Enterprise Identity Management System (EIDM) accounts today to ensure that they have the proper tools necessary to obtain their PQRS feedback reports. Anyone to register to create an EIDM account, but CMS limits the scope of the account owner as the only one permissible to make an initial request or gain access to the account. An initial request will require the distribution of some personal information (email, phone, etc.), along with the submission of a role request in order to associate applicants with an individual or organization.

The physician quality and value programs’ domain role options available will be dependent upon the “group” selection, the options for which consist of Physician Quality Reporting System (PQRS) provider, physician value (PV) provider, or provider approver. Figure 2 represents the domain role options available under the associated groups. Participants should be aware that the appropriate role selections vary for each TIN and each set of grant distinct access privileges. Participants can access and complete the EIDM requirements through the CMS Enterprise Portal, available via the provided link, https://portal.cms.gov. It is strongly encouraged to review the Physician and Other Health Care Professionals Quality Reporting Portal to assist in ensuring that role request(s), access privileges, and organization affiliations are aligned accordingly. Further reference information on 2015 PQRS feedback report details and how to request them can be found through the How to Obtain a Quality Resource and Usage Report (QRUR) web page.

PQRS Informal Review

Provider and practice PQRS submissions have been evaluated, and the determined outcomes can make all the difference when it comes to provider livelihood. CMS offers an opportunity to have the list checked twice for those participants that believe their future payment adjustment has been inadvertently jeopardized through the analysis of reporting. In such instances, individual EPs, comprehensive primary care (CPC) practice sites, PQRS group practices, or accountable care organizations (ACOs) may request that CMS audit their payment adjustment determination through an informal review process. An official request will mandate an investigation as to whether the outcome was appropriate.

Providers and/or practices that believe that a negative payment adjustment was applied in error should follow the briefly outlined steps to submit an informal review request. The first step requires knowledge that the review has been completed at the TIN/NPI level, meaning that individual EPs or support staff must file a separate request for each TIN/NPI in question regarding the submitted 2015 PQRS data. The group practice reporting level, via PQRS, GPRO, or ACO, will require a request for the PQRS group practice TIN or each individual ACO participant TIN under which 2015 PQRS data was submitted.

The second step is to determine where to file the request. When available, participants are instructed to visit the Quality Reporting Communication Support Page (CSP), where they should proceed to navigate in selecting “Communication Support Page” below “Related Links,” and within the drop-down menu, select “Informal Review Request” and choose the appropriate option.

All informal review requests for 2015 reporting results require electronic submission through this page. Participants can look for the announcement of the CSP roughly around the fall of 2016, available through any related CMS listservs.

Step three is to ensure that submissions are correct and complete in order for the reconsideration request to be deemed valid. CMS will reverse the negative payment application if it determines that satisfactory reporting was achieved. Figure 3 simply aligns the key steps to take in the informal request submission. The informal review process is aimed to be completed prior to the start of the payment adjustment period, but participants should note that the request is not an immediate reversal, and it may take several weeks for the reprocessing of claims. Of the utmost importance is recognizing that the informal review determination issued will be a final decision, and there will not be any further review.

Monitoring PQRS Performance

The PQRS program continues to challenge providers to remain in strict compliance with various regulations through its evolutionary complexities in both rules and processes. Preparing to ensure that the various reporting requirements and performance criteria are met is only the beginning to successful participation.

Consequently, avoiding a PQRS payment penalty provides advancement into the quality tiering portion of the Value- Based Payment Modifier program, which in turn also avoids an automatic VBM penalty. The penalty for failure to report encompasses the entire practice, meaning under PQRS, it is applied to the individual physicians’ reimbursement, while under the VBM program, the downward or upward payment adjustment is applied at the group reporting level.  Therefore, it is imperative for participants to understand the importance of incorporating ongoing performance monitoring to ensure practice-wide compliance. Participants can support performance outcomes by considering the utilization of reporting mechanisms that provide essential tools for monitoring and predicting practices’ outcomes across the course of the performance year. Participants cannot be discouraged by the varying, multifaceted opportunities accessible for PQRS and VBM participation, because the cost of defeat will be far more significant for any practice billing under Medicare Part B.

Paying close attention to your practice is the key to achieving maximum upward payment adjustments and reflecting the true meaning of quality health outcomes.

About the Authors

Gloria Johnston is an accomplished healthcare executive with extensive experience leading people, improving and expanding healthcare operations, and providing consultative services to healthcare systems. Gloria has held leadership positions at several prestigious academic medical centers. She holds MBA, BSN, and AS degrees and is a credentialed health information professional. 

Stephanie Doran is a health information management (HIM) consultant and project manager for HealthAdvanta, a health information and technology company. She is a graduate of Temple University, where she earned a bachelor’s degree in health information management and was honored with the Health Information Management Professional Excellence Award for her distinguished development and achievement.

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The Centers for Medicare and Medicaid released the following today:

September 8, 2016
By Andy Slavitt, Acting Administrator of CMS

“Plans for the Quality Payment Program in 2017: Pick Your Pace"

As the baby boom generation ages, 10,000 people enter the Medicare program each day. Facing that demand, it is essential that Medicare continues to support physicians in delivering high-quality patient care. This includes increasing its focus on patient outcomes and reducing the obstacles that make it harder for physicians to practice good care.

The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) offers the opportunity to advance these goals and put Medicare on surer footing. Among other policies, it repeals the Sustainable Growth Rate formula and its annual payment cliffs, streamlines the existing patchwork of Medicare reporting programs, and provides opportunities for physicians and other clinicians to earn more by focusing on quality patient care. We are referring to these provisions of MACRA collectively as the Quality Payment Program.

We received feedback on http://www.hhs.gov/about/news/2016/04/27/administration-takes-first-step-implement-legislation-modernizing-how-medicare-pays-physicians.html">our April proposal for implementing the Quality Payment Program, both in writing and as we talked to thousands of physicians and other clinicians across the country. Universally, the clinician community wants a system that begins and ends with what's right for the patient. We heard from physicians and other clinicians on how technology can help with patient care and how excessive reporting can distract from patient care; how new programs like medical homes can be encouraged; and the unique issues facing small and rural non-hospital-based physicians. We will address these areas and the many other comments we received when we release the final rule by November 1, 2016.

But, with the Quality Payment Program set to begin on January 1, 2017, we wanted to share our plans for the timing of reporting for the first year of the program. In recognition of the wide diversity of physician practices, we intend for the Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017. During 2017, eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019. These options and other supporting details will be described fully in the final rule.

First Option: Test the Quality Payment Program.

With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

Second Option: Participate for part of the calendar year.

You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment. For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.

Third Option: Participate for the full calendar year.

For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on January 1, 2017. For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. We've seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.

Fourth Option: Participate in an Advanced Alternative Payment Model in 2017.

Instead of reporting quality data and other information, the law allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.

However, you choose to participate in 2017, we will have resources available to assist you and walk you through what needs to be done. And however you choose to participate, your feedback will be invaluable to building this program for the long term to achieve outcomes that matter to your patients.

We appreciate the sincere and constructive participation in the feedback process to date and look forward to advancing step-by-step in that same spirit. We look forward to releasing the final details about the program this fall. Most importantly, we look forward to further engagement with physicians and other clinicians toward our shared goal of the highest quality of care and best outcomes for patients.

VBPmonitor will cover more on this once the final rule is released.

Reference

CMS BLOG

About the Author

Kim Charland is the editor of VBPmonitor and the senior vice president of clinical innovation with Panacea Healthcare Solutions. Kim has 30 years of experience in health information and reimbursement management for hospitals and physician offices. Kim’s primary role with Panacea is publisher of VBPmonitor.com, which is the company’s newest online monitor and is focused on value-based purchasing and quality. She is also co-host of ICD10monitor.com’s Internet news broadcast Talk-Ten-Tuesdays. In addition, she assists with product development for Panacea’s consulting and software divisions, as well as the MedLearn publishing division. Kim is also recognized as a national speaker who has spoken for numerous organizations.

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