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CMS Announced Opening the BPCI Advanced Application for 2020 Participation
CMS will open the application process in mid-April to participate in Model Year 3 that begins on 1/1/2020. (Model Year 1 was 10/1/18-12/31/18 and Model Year 2 is this year, 1/1/19-12/31/19 and reflects the first and only BPCI Advanced Cohort to date.) At this time, CMS does not intend to have additional enrollment periods for Model Year 4 (2021) or Model Year 5 (2022). BPCI Advanced (BPCI-A) currently consists of 32 bundled clinical episodes (29 inpatient and 3 outpatient). CMS is finalizing the selection of new clinical episodes for Model Year 3, which will include outpatient Total Knee Arthroplasty (TKA). The application process will be very similar to the last round so Navvis has access to the CMS systems and is experienced in the application process. CMS defines an episode of care (episode) as the set of services provided to treat a clinical condition or procedure. BPCI-A is a value-based bundle payment that is a single payment for treating a patient with a specific condition (DRG) across a 90-day period of care. It is a single retrospective bundled payment model that combines payments to the physician, hospital and other healthcare provider services. Participants can get an additional payment if all the costs for an episode of care are less than a benchmark price (historical cost that makes up the expected cost), discounted by 3%. If they exceed the benchmark, the providers would have to repay up to 20% of the excessive costs to Medicare.
Takeaway: BPCI-A began on October 1, 2018 and March 1stwas the six-month deadline to withdraw some or all of an Episode Initiator or Clinical Episodes from the program without financial risk or penalty of repaying downside losses. CMS reported that 16% of the participants dropped from the program before the March deadline and 1,086 participants remain in the program. Taking into account the short notice of application and limited program details last year, it explains why some of the participants withdrew before incurring downside risk but overall shows early signs of a successful demonstration program.
UPS Eyes In-Home Health Services with U.S. Vaccine Project
Reuters reported that the world’s largest package delivery firm is preparing to test a U.S. service that dispatches nurses to vaccinate adults in their homes as the company and its healthcare clients work to fend off cost pressures and competitive threats from Amazon.com. UPS did not disclose which vaccines it would be using in the project, but drug and vaccine maker Merck & Co told Reuters it is looking at partnering with the company for the initiative. The project, previously unreported, shows how UPS is targeting a larger slice of the $85 billion outsourced healthcare logistics market. Deutsche Post’s DHL Group dominates the market, which is expected to grow to $105 billion by 2021. “Over-the-threshold services is where the world is headed,” said Chris Cassidy who oversee global healthcare logistics strategy. Workers in UPS’ 1.7 million-square-foot healthcare complex at Worldport will package and ship the vaccine to one of the more 4,700 franchised U.S. UPS stores. A home health nurse contracted by UPS’ clinical trial logistics unit known as Marken will collect the insulated package, transport it the “last mile” to the patient’s home and administer the vaccine, which will target a viral illness in adults. The aim of the test is to “see if we can connect all these dots,” said Wes Wheeler, chief executive at Marken, which was purchased by UPS in 2016 and is overseeing the vaccine project. Experts said the UPS project could also save money by having contract home nurses, rather than higher paid doctors, administer the vaccine. But the test, a first for a large U.S. shipper, is not a guaranteed slam dunk for UPS: Marken’s CEO said it must figure out how to get medical insurers to pay for the new service.
Takeaway: It is an interesting concept and partnership since UPS has the home delivery infrastructure and a clinical supply delivery subsidiary, Marken, and Merck has a large portfolio of vaccines for viral illnesses ranging from shingles and hepatitis B to the flu. UPS is testing if it can connect the home-based care delivery system and if it can, it will have a contracted network of providers and can expand upon its home based healthcare services. It is an interesting approach and one worth watching as UPS competes against Amazon in healthcare.
CMS Releases 2017 Quality Payment Program Experience Report
The Report, with Appendix, provides a comprehensive overview of the clinician reporting experience during the first year of the Quality Payment Program (QPP). Data within the report show significant participation and performance in both the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) tracks for the 2017 performance year. Key 2017 findings include: of the 1,057,824 clinicians eligible for MIPS, 1,006,319 (95 percent) participated in MIPS and avoided a negative payment adjustment. Most eligible clinicians (93 percent) who participated in MIPS earned a positive payment adjustment and 2 percent earned a neutral adjustment. Of the eligible clinicians who participated in MIPS, 54 percent did so as groups, 12 percent as individuals, and 34 percent through MIPS APMs. MIPS eligible clinicians who were in small or rural practices had participation rates of 81 and 94 percent, respectively. A total of 99,076 clinicians were Advanced APM Qualifying Participants (QPs) and an additional 52 were Partial QPs. The report shares the amount of data clinicians chose to submit, the ways they submitted data, and the most commonly reported quality measures and the types of reporting.
Takeaway: CMS invested time and resources to help providers prepare for the transition into the quality payment program (QPP) where they need to manually report through MIPS or participate in an APMs. While the results show that only 0.09% of providers participated in an Advanced APM, which qualifies eligible providers for the 5% FFS bonus, there were far fewer advanced APM models in 2017 to participate in than there are today. CMS continues to enhance the QPP reporting and has signaled it is continuing to look at streamlining the reporting method and requirements based upon MedPAC report and other findings.
Death By 1,000 Clicks: Where Electronic Health Records Went Wrong
The U.S. government claimed that turning American medical charts into electronic records would make health care better, safer, and cheaper. Ten years and $36 billion later, the system is an unholy mess. Inside a digital revolution that took a bad turn. Kaiser researched what went wrong, including multiple lawsuits where patients sued electronic health record (EHR) companies and published an in depth article with five key takeaways. (1) Patient harm: Electronic health records have created a host of risks to patient safety. Alarming reports of deaths, serious injuries and near misses — thousands of them — tied to software glitches, user errors or other system flaws have piled up for years in government and private repositories. Yet no central database exists to compile and study these incidents to improve safety. (2) Signs of fraud: Federal officials say the software can be misused to overcharge, a practice known as “upcoding.” Some doctors and health systems are alleged to have overstated their use of the new technology, a potentially enormous fraud against Medicare and Medicaid likely to take years to unravel. Two software makers have paid a total of more than $200 million to settle fraud allegations. (3) Gaps in interoperability: Proponents of electronic health records expected a seamless system so patients could share computerized medical histories in a flash with doctors and hospitals anywhere in the country. That has yet to materialize, largely because officials allowed hundreds of competing firms to sell medical records software unable to exchange information. (4) Doctor burnout: Many doctors say they spend half their day or more clicking pulldown menus and typing rather than interacting with patients. An emergency room doctor can be saddled with making up to 4,000 mouse clicks per shift. This has fueled concerns about doctor burnout, which in January the Harvard T.H. Chan School of Public Health and Massachusetts Medical Society called a “public health crisis.” (5) Web of secrets: Entrenched policies continue to keep software failures out of public view. Vendors of electronic health records have imposed contractual “gag clauses” that discourage buyers from speaking out about safety issues and disastrous software installations — and some hospitals fight to withhold records from injured patients or their families.
Takeaway: This is an example of where consequences are not visible at the time policy is formed which is the story of Meaningful Use. Today, doctors spend an average of 5.9 hours (out of an 11.4-hour workday) on EHRs, compared with 5.1 hours spent with patients, according to a 2017 study in the Annals of Family Medicine. Policy makers never intended to create a burdensome model where providers would spend more time clicking in an EHR than spending time with patients and no one expected the EHR industry to attempt to make patient data proprietary through incompatible records, secrecy clauses where providers and systems couldn’t report system errors that risked lives. The problem is that some EHR vendors have such overwhelming market power that they insert gag clauses into their contracts with hospitals, ostensibly to protect their intellectual property. In effect, these vendors have prohibited the free exchange of information—including discussion of safety-related issues.
CMS Issues New Guidance on State Implementation of Home and Community Based Services Regulation
On Friday, CMS issued a letter and updated guidance to State Medicaid Directors on implementation of the 2014 Home and Community Based Services (HCBS) regulation. The HCBS regulation impacts older adults and individuals with disabilities eligible for Medicaid HCBS (including intellectual, developmental and physical disabilities, as well as behavioral health conditions). The regulation and related guidance sought to define the characteristics of settings that were community-based vs those of an institution. The 2014 regulation also required states to develop a transition plan to ensure that all settings receiving certain Medicaid funding met federal HCBS standards. In response to concerns raised by states and other stakeholders about this process, CMS granted a three-year extension of that transition period in 2017, extending the date by which states must demonstrate compliance from March 2019 to March 2022. Stakeholders expressed the guidelines were too prescriptive. “Even well-intentioned policies from Washington often lack the flexibility needed to work for every state, community, setting, or family,” said CMS Administrator Seema Verma. “We believe our revised guidance strikes the appropriate balance to protect individual choice while maintaining the integrity of home and community-based funding.” Some examples of the changes incorporated into this updated guidance include streamlining and better defining settings that isolate HCBS beneficiaries, more flexibility for the states and less CMS review and sampling, broader HCBS setting, Another focus of the guidance communicated from the State Medicaid Director letter and FAQs include clarification on community activities and community support. To encourage families and friends to participate regularly in activities with the beneficiary onsite as well as in the broader community; and/or decentralize staff structures to promote greater flexibility and encourage staffing focused on individuals’ access to and participation in the broader community rather than centralized insular staff models focused around a specific facility/site. Expanding strategies for increasing beneficiary access to transportation, including through existing public transportation, friends/family, and volunteer organizations, to activities in the broader community. This could include providing transportation in a way that promotes ease of access and optimizes individuals’ ability to select their own options and make decisions about their services and supports.
Takeaway: The Trump administration is continuing its focus on deregulation and shifting more power from Federal agency to the states while continuing to focus on supporting beneficiaries age in place in the community and integrating more community-based services. CMS will take a more limited federal oversight role for private homes by clarifying that private residences where individuals received Medicaid funded services are assumed to comply with the regulatory criteria; and that settings in which Medicaid HCBS are not received do not need to comply with the criteria of a home and community-based setting at all.
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