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Regulatory Measures

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The Medicare Shared Savings Program: Four Tools for Better Profit Margins and High-Quality Care

Medicare patients make up the majority of health systems’ revenue; yet, organizations earn only a one percent profit while caring for this population. Despite historically low profit margins, Medicare can be lucrative for health systems, and through the Medicare Shared Savings Program, healthcare organizations can increase revenue with four tools:

  1. The ability to aggregate and analyze data.
  2. The ability to align financial incentives between payers and providers.
  3. The ability to engage patients in behavior or lifestyle modifications.
  4. The ability to garner support from clinicians and encourage them to lead the shift to VBC.
As the shift from fee-for-service to value-based care continues, health systems can leverage MSSP to deliver the highest level of care while also increasing profit margins.

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2021 Changes to the Quality Payment Program: Must-Know Guidelines for ACOs

In 2021, CMS proposes the following four key changes to the Quality Payment Program (QPP) that will impact quality measurement for ACOs and ACO participants:

  1. The discontinuation of the CMS Web Interface.
  2. The introduction of the alternative payment model (APM) Performance Pathway (APP).
  3. The discontinuation of the APM scoring card.
  4. The addition of the APM entity as a submitter type for MIPS.
Each change will create new challenges for ACOs and ACO participants. Organizations can successfully navigate these shifts by partnering with a robust quality measures solution that creates a complete picture by combining comprehensive data and measures information in performance visualizations. An inclusive quality measures solution also creates a thorough workflow by combining the monitoring and improving processes, then submitting performance to payers.

The Complete Guide to MIPS 2021: Scoring, Payment Adjustments, Measures, and Reporting Frameworks

This resource is a comprehensive guide to 2021 updates to Merit-based Incentive Payment System (MIPS) quality measures. This guide will help increase your understanding of MIPS quality measures so you can choose the best quality measures for your team. Learn about important updates to MIPS for 2021, including:

  • Four significant scoring changes for MIPS 2021.
  • How CMS weights MIPS categories differently for different MIPS reporting frameworks.
  • New MIPS scoring hierarchy.
  • And much more.

Complete Guide to the APM Performance Pathway (APP) for MIPS APM Participants and ACOs

In the 2021 Final Rule, CMS introduced a new and streamlined QPP reporting framework for both MIPS APM participants and ACOs. (Note: a MIPS APM participant is a clinician that participates in an APM but does not qualify as an advanced-APM participant, meaning the clinician is not exempt from MIPS.) The new reporting framework is the APM Performance Pathway (APP). The APP is optional for all MIPS APM participants but required for ACOs participating in the Medicare Shared Savings Program (MSSP).

Complete Guide to CMS-HCC Risk Scores—RAF Scores and Medicare Risk Adjustment

Medicare uses the CMS-HCC model to calculate risk scores that quantify and project the financial risk of each Medicare beneficiary. CMS uses risk scores created by the CMS-HCC model to adjust Medicare capitation payments to Medicare Advantage (MA) plans. With risk-adjusted payments, Medicare pays MA plans more money for patients with greater risk and less money for patients with less risk.

Medicare Advantage HEDIS and Risk Reporting: A Primer for Providers

Medicare Advantage (MA) has exploded over the last 10-15 years, with the number of beneficiaries increasing by almost 400 percent in that timeframe. Provider groups have an increasing percentage of revenue and patients in MA plans and providers are increasingly compensated based on HEDIS quality measures and risk scores through a combination of claims data and supplemental data. Submitting supplemental data can be critical to ensure providers receive credit for the quality of care they deliver and the true complexity of their patient population. Some plans have well-defined reporting programs, while others have little-publicized channels for reporting supplemental HEDIS and risk data. There are also significant bonuses that MA plans offer to providers for reporting, since the plan benefits immensely from receiving the data. In this article, you’ll learn:

  • Why is HEDIS and risk data so important to health plans?
  • What is supplemental data?
  • And how do you as a provider organization report this data efficiently to earn incentives?

The Medicare Shared Savings Program: Four Tools for Better Profit Margins and High-Quality Care

Medicare patients make up the majority of health systems’ revenue; yet, organizations earn only a one percent profit while caring for this population. Despite historically low profit margins, Medicare can be lucrative for health systems, and through the Medicare Shared Savings Program, healthcare organizations can increase revenue with four tools:

  1. The ability to aggregate and analyze data.
  2. The ability to align financial incentives between payers and providers.
  3. The ability to engage patients in behavior or lifestyle modifications.
  4. The ability to garner support from clinicians and encourage them to lead the shift to VBC.
As the shift from fee-for-service to value-based care continues, health systems can leverage MSSP to deliver the highest level of care while also increasing profit margins.

A Complete Guide to MIPS Quality Measures

This comprehensive guide includes 12 frequently asked questions about Merit-based Incentive Payment System (MIPS) quality measures. This guide will help increase your understanding of MIPS quality measures so you can choose the best quality measures for your team. Find answers to your questions, including:

  • Where can I find a list of MIPS quality measures?
  • What are specialty measure sets and how do they categorize MIPS quality measures?
  • What are submission methods for MIPS quality measures?
  • How are benchmarks used to score your performance in MIPS quality measures?
  • What is the burden of different MIPS quality measures?

The Able Health Quality Measures Solution: Why a Comprehensive Approach Matters

Able Health combines all claims and clinical data from a health system’s data sources (inside and outside of the hospital) into one location, allowing healthcare leaders to focus more on improving care and less on data management. The combination of a measures engine that calculates performance, a performance dashboard that displays measure performance, and a submission engine that submits data to payers, all powered by the Health Catalyst® Data Operating System (DOS™), enables health systems to identify areas for improvement based on one complete picture of quality performance.

Putting Patients Back at the Center of Healthcare: How CMS Measures Prioritize Patient-Centered Outcomes

Today’s healthcare encounters are too often marked by more clinician screen time than patient-clinician engagement. Increasing regulatory reporting burdens are diverting clinician attention from their true priority—the patient. To put patients back at the center of care, CMS introduced its Meaningful Measures framework in 2017. The initiative identifies the highest priorities for quality measurement and improvement, with the goal of aligning measures with CMS strategic goals, including the following:

  1. Empowering patients and clinicians to make decisions about their healthcare.
  2. Supporting innovative approaches to improve quality, safety, accessibility, and affordability.

Evolving CMS Quality Measures Move Towards More Patient-Centered Care, Less Burden for Clinicians

With today’s comprehensive Meaningful Measures initiative, CMS has refocused healthcare quality measures on improving patient needs and experiences, reducing regulatory burden on clinicians, and removing barriers to value-based payment. The evolved quality measures center on patient, clinician, and health system needs and strategic goals to truly impact improving care and lowering costs. Meaningful Measures, according to CMS, must meet seven criteria:

  1. Are patient-centered and meaningful to patients, clinicians, and providers.
  2. Address high-impact measure areas that safeguard public health.
  3. Are outcome-based where possible.
  4. Minimize the level of burden for providers.
  5. Create significant opportunity for improvement.
  6. Address measure needs for population-based payment through alternative payment models.
  7. Align across programs.

Complete Guide to MIPS Value Pathways (MVPs)

In the 2020 Final Rule, CMS confirmed MIPS Value Pathways (MVPs) as the “future state” of MIPS. MVPs would significantly change the way clinicians participate in MIPS starting in MIPS 2021. This guide explains that transformation. This guide answers these questions:

  • What are MIPS Value Pathways?
  • Will CMS make MIPS Value Pathways mandatory or optional?
  • When will CMS implement MIPS Value Pathways?
  • Why is CMS moving to MIPS Value Pathways?
  • How would MIPS change with MIPS Value Pathways?

A Complete Guide to MIPS Scoring

A final MIPS score is one simple number. However, many measurements make up that number. This guide explains MIPS scores, MIPS scoring in each performance category, and MIPS scoring in each measure.

Engaging Health System Boards of Trustees in Quality and Safety: Six Must-Know Guidelines

The quality and patient safety movement of the early 21st century called for greater board of trustee involvement in improvement. However, too many health systems still don’t have the resources in place to effectively engage their boards around quality and safety measures. Six guidelines describe how organizations can better leverage data to inform their boards:

  1. Emphasize quality and patient safety goals.
  2. Leverage National Quality Forum-endorsed measures.
  3. Use benchmarking and risk adjustment to select targets.
  4. Access data beyond the EHR.
  5. Provide data and information for multiple organizational levels.
  6. Develop a board-specific measurement and presentation strategy.

Exceptions to Information Blocking Defined in Proposed Rule: Here’s What You Need to Know

Information blocking practices inhibit care coordination, interoperability, and healthcare’s forward progress.  The ONC’s proposed rule ushers in the next phase of the Cures Act by defining information blocking practices and allowed exceptions. To make the final rule as strong as possible, exceptions should be narrowly defined. In proposed form these include the following:

  1. Preventing Harm.
  2. Promoting the Privacy of EHI.
  3. Promoting the Security of EHI.
  4. Recovering Costs Reasonably Incurred.
  5. Responding to Request that are Infeasible.
  6. Licensing of Interoperability Elements on Reasonable and Non-discriminatory Terms.
  7. Maintaining and Improving Health IT Performance.
This article covers each of these exceptions and discusses what to watch for in the final version of the rule.

How Healthcare Text Analytics and Machine Learning Work Together to Improve Patient Outcomes

Healthcare organizations that leverage both text analytics and machine learning are better positioned to improve patient outcomes. Used in tandem, text analytics and machine learning can significantly improve the accuracy of risk scores, used widely in healthcare to help clinicians identify patients at high risk for certain conditions and, therefore, intervene. Health systems can run machine learning models with input from text analytics to provide tailored risk predictions on both unstructured and structured data. The result? More accurate risk scores and the ability to identify every patient’s level of risk in time to inform decisions about their care.

Value-Based Purchasing: Four Need-to-Know Domains for 2018

Health systems that meet the 2018 Hospital Value-Based Purchasing Program measures stand to benefit from CMS’s $1.9 billion incentive pool. Under the 2018 regulations, CMS continues to emphasize quality. To reduce the risk of penalty and vie for bonuses, it’s increasingly critical that organizations leverage data to build skills and processes that meet more demanding reimbursement measures. To thrive under value-based payment, healthcare systems must understand CMS’s four quality domains, and their associated measures, for 2018:

  1. Clinical Care
  2. Patient- and Caregiver-Centered Experience of Care/Care Coordination
  3. Efficiency and Cost Reduction
  4. Safety