Navvis Right Now: Issue 21 – April 26, 2019

April 26, 2019

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Primary Care Transformation

On Monday, CMS announced through its Innovation Center the Value-Based Transformation in Primary Care. The Primary Cares Initiative is comprised of five voluntary payment models under two paths: Primary Care First and Direct Contracting.  These models move primary care providers to the center of the healthcare universe in playing the key role for helping to reduce healthcare costs, the importance of coordinating care and attaching financial responsibility for outcomes. HHS Secretary Alex Azar says the new primary care experiment will “move toward a system where providers are paid for outcomes rather than procedures and free up doctors to focus on the patients in front of them rather than the paperwork …” “CMS Administrator Seema Verma said, “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost while allowing clinicians to focus on what they do best: treating patients.” The Primary Care First model is the next evolution of the Comprehensive Primary Care Plus (CPC+) model that is available to individual primary care practices and tests paying practices through a simplified total monthly payment plus flat fees, which allows clinicians to focus on caring for patients rather than tracking their revenue cycle. Direct Contracting is the next evolution of NextGen ACOs where participants receive a fixed monthly payment that can range from a portion of anticipated primary care costs to the total cost of care. These are brand new payment models represent sweeping changes which build on existing models including CPC+, ACOs, Next Gen ACOs, and Medicare Advantage and private sector risk-sharing arrangements.  (See attached for a summary of the model and model comparison.)

Takeaway:  These new models provide partial primary care capitation payments to full capitation rates enabling primary care practices to contract directly with CMS for smaller patient populations under the Primary Care First (PCF) model and ACOs, Medicaid Managed Care Organizations (MCOs) and Medicare Advantage Organizations to contract directly with CMS to participate in the Direct Contracting (DC) models. CMS is forecasting that 11 million Medicare Fee for Service beneficiaries (over 25%) will potentially be included (5 million in the DC payment option and 6.4 million in PCF payment model options) and new coordinated care opportunities for 11-12 million beneficiaries dually eligible for Medicaid managed care and Medicare FFS. CMS is seeking feedback on the Direct Contracting geographic model which enables a group to take responsibility for an entire geographic population. These new coordinated care models offer higher rewards that come with higher risk that I suspect will significantly change the Medicare FFS landscape. The question now is which is the best model for managing a population based upon the organization, population and local healthcare ecosystem and which models fit together best under the new options? These are the questions that we will be asking and exploring internally over the next few weeks to form Navis’s point of view as CMS opens the notice of intent to apply timelines, which is the first phase of the application process.

‘Meet PillPack’: Amazon Rolls Out Rx Delivery Direct Marketing

“Meet PillPack, a new member of the Amazon family,” the email reads. “Our service and shipping are free — you pay only for your medication.” On Tuesday, Amazon begun marketing PillPack’s at-home prescription drug deliveryto Amazon Prime members via email about the monthly medication and created a webpage about the service. Amazon is promoting monthly medication delivery service, touting zero shipping costs and increased convenience. The marketing effort so far targets chronic conditions. The medications highlighted on the PillPack packaging include high blood pressure drugs amlodipine and lisinopril and diabetes drugs glipizide and metformin. PillPack is licensed to ship prescriptions to all states except Hawaii and can fill schedule III, IV and V medications. As previously discussed, PillPak is designedto serve people who manage multiple medications. Each month, customers receive a personalized roll of pre-sorted medications, along with a convenient dispenser for the perforated pill packs that prevent taking the wrong dose out of order. (PillPack also provides medications that cannot be placed into packets, like liquids and inhalers.) Each shipment includes a medication label that has a picture of each pill and notes on how it should be taken.

Takeaway: With Amazon’s 100 million-plus Amazon Prime members, this is a direct competitive threat to retail pharmacies such as CVS, Walgreens, Walmart and mail order Express Scripts. Only 16 months ago, the industry detected the first signal that Amazon was looking to enter the healthcare space disrupting the industry and becoming a serious competitive threat. Since January 2018, Amazon joined with JPMorgan and Berkshire-Hathaway to form Haven, it sells six HIPAA-eligible AI and machine learning Amazon Web Services offerings, has a patent that would allow its smart speaker Alexa to tell when users are sick from their voice patterns, offers pattern-recognition software that combs through medical records, and has begun selling its own exclusive line of OTC health products direct to consumers. For a timeline of Amazon’s moves into healthcare, you can see the 2018 timeline here.

Humana Announces Virtual Primary-Care Plan

Humana and telehealth company Doctor on Demand will launch a new health plan design allowing employers and employees to receive primary care predominantly through virtual visits. The plan, called On Hand, allows Humana members to avoid the doctor’s office and access primary-care services virtually from one Doctor on Demand physician, with access to urgent care, preventive care and behavioral health services. When needed, patients would receive referrals to specialists in Humana’s network for in-person doctor visits. “Through virtual care delivery, On Hand gives employers the opportunity to affordably offer healthcare benefits to employees without sacrificing comprehensive, quality care,” Chris Hunter, president of Humana’s group. The plan’s average monthly premiums would be nearly half those of the company’s most popular purchased plan and members can still use their own PCPs. Members would have no copayments for virtual care visits and a $5 copayment for common lab tests and prescriptions. They would also receive a medical device kit with a digital blood pressure cuff, thermometer and log. Humana will pilot the plan to small businesses in Florida and Texas as a self-funded product starting in June.

Takeaway: Humana has invested heavily in care at home and the home healthcare segment and the virtual visits is a natural extension. Humana is providing both affordability and convenience in their new plan design and is following the model that Oscar Healthbuilt along with others. Humana is meeting consumer demand for access along with the convenience of when and where they want to seek care at a time when the regulations are evolving supporting and reimbursing providers for televisits.

Emergency Rooms Get a Makeover for the Elderly

Visits to emergency rooms by people over age 65 rose by more than 27% from 2005 to 2015, according to the Centers for Disease Control and Prevention. “There’s a growing awareness that the traditional design of emergency-department care isn’t well suited to frail, older adults,” says Kevin J. Biese, an emergency-medicine physician who heads the new Geriatric ED Accreditation Board of the American College of Emergency Physicians, or ACEP. Emergency care was designed for things like heart attacks and gunshot wounds, but seniors tend to present with complications from conditions like diabetes and heart failure, and injuries from falls. While any ER can treat heart issues and broken bones, geriatric ERs also look at the context of the emergency. In the case of a fall, for example, the staff typically will investigate its cause, such as a medication side effect or sign of a medical condition, check a patient’s balance and even assess their home for fall risks. A key goal of geriatric ERs is to save the patients from being admitted to the hospital, where they face a greater risk for hospital-acquired infections, delirium and falls. Even short hospitalizations can have detrimental long-term effects. “Older patients tend to not bounce back as well if they’re admitted to the hospital the way a younger person would have,” says Denise Nassasi, director of the geriatric emergency department at Mount Sinai. “They will often lose one of their activities of daily living, perhaps irreversibly.” To prevent a potential downward spiral, staff of a geriatric ER might instruct a social worker to assess a patient’s home for problems like rugs that can cause falls. Doctors might prescribe a visiting-nurse service so a patient can receive IV antibiotics at home, or a stint in a rehabilitation facility. So far, more than 50 geriatric emergency departments have earned the Geriatric Emergency Department Accreditation, or GEDA, and more than 100 are in the process of getting accredited nationwide, according to ACEP’s Dr. Biese. (See WSJ hereor attached.)

Takeaway: More geriatric ERs are expected as the retirement-age population continues to increase along with the rise of value-based risk contracts where there is an emphasis on reducing unnecessaryhospital admissions. Many of the structural elements of these new ERs are meant for safety and to provide a soothing environment for patients and their families. They are designed for treatment and release in a few hours. Geriatric ERs typically rely on a multidisciplinary team with advanced training such as nurses trained in geriatric care who can screen patients for issues such as cognitive impairment, depression, elder abuse and fall risk. Care teams or resources may include case managers, social workers, pharmacists, nutritionists, physical therapists and, in some cases, palliative-care specialists. Data show that such practices can help older people avoid unnecessary hospital admissions by as much as 16%, according to a 2018 study in the Journal of the American Geriatric Society.  Existing ERs can also be redesigned and accredited by following certain processes and policies.

HHS to Cap HIPAA Fines Based on ‘Culpability’

HHS updated the maximum it will penalize providers, health plans and their business associates in the wake of HIPAA violations, in some cases dropping the upper limit by more than $1 million. The new system sets annual limits for these fines based on the organization’s “level of culpability” associated with the HIPAA violation, according to the department’s notice of enforcement discretion released late Friday. That means organizations that have taken measures to meet HIPAA’s requirements will face a much smaller maximum penalty than those who are found neglectful. The Health Information Technology for Economic and Clinical Health Act, better known as the HITECH Act, outlines minimum and maximum civil money penalties for HIPAA enforcement based on four tiers, which consider whether the organization in question was aware of the violation and whether it had taken steps to abide by HIPAA’s rules. The tiers escalate in severity, from an organization that is unaware of the violation to one that demonstrated “willful neglect” in not correcting violations. The possible penalties for each tier range from Tier 1 $100-$50,00 per violation, capped at $25,000 per year the issue persisted through Tier 4: $50,000 per violation, capped at $1.5 million per year the issue persisted the updated annual caps are interim figures pending further rulemaking, according to the notice.

Takeaway: This proposed rule is important because HHS is looking at not only the breach but also the underlying responsibility of the breach to see if the health organization was at fault due to poor controls, processes or policies. Under HIPAA, organizations are required to report breaches that impact 500 or more individuals to federal regulators and affected individuals within 60 days. HIPAA breaches are serious and costly. One studyreports that healthcare had the highest average cost per stolen record at $363 compared to an average $154 for other sectors and the cost of remediation can be far more than the fine. Health systems like Advocate Health Care Network received a $5.55 million penalty and Memorial Healthcare System, $5.5 million.


Disclaimer: This blog includes content gathered from other published sources, not authored by Navvis, and is presented as information only. As with any news story, this information may have changed since its publication date. Commentary included with the information is the opinion of its authors, and is not indented to provide legal or regulatory advice or guidance to the reader. Navvis does not represent the accuracy of or assume liability for the content presented herein.