In a recent issue of the New England Journal of Medicine, a group of physicians from Harvard Medical School describe an unfortunate and instructive case [1] .  One of the system’s patients had her spleen removed after an automobile accident. I would venture to guess that just about every sophomore medical student knows that people without a spleen are more likely to have infections, especially with streptococcus pneumonia, and that those infections can lead to death or, as in this poor lady’s case, severe, permanent complications. Anyone who has had a splenectomy should be vaccinated against pneumococcus. So far so good, but the vaccine was never given in this case because the problem list in her electronic medical record was never updated to include the fact that her spleen had been removed.

When these doctors looked at the records in their practice (over 1.7 million of them), they found 7125 patients who had had their spleens removed and only 5028 (29%) had the diagnosis on their problem list. And it gets worse from there. Of the ones who had the diagnosis on their problem list, only 54% had been vaccinated; of those without the diagnosis, only 17% had been vaccinated. (Remember, the guideline is vaccination for 100 %.) And this is at one of the very best medical care delivery systems in the United States (probably in the world) and these patients all have electronic medical records. You can guess what the numbers would be like out in the real world where solo practitioners are working with paper charts.

So we have two problems. First, the list of diagnoses was incomplete. Second, there was a clear and unaddressed gap in care. How do you fix a problem like that? The first impulse would be simply to better educate the doctors. These authors conclude (and I agree with them) that “education alone is not a highly reliable intervention.” Remember, these are some of the best doctors we have and they are using some of our best clinical tools. The solution has to be in redesigning the system. And that is where Medicare Advantage plans have something really important to offer.

These authors recommend “tools such as reminders and patient-level reports about guideline compliance” as the best way to change the system. I would suggest that carefully designed and targeted member evaluations of Medicare Advantage members organized by the plans can bring together a wealth of clinical information from claims with directed face to face evaluations to yield accurate and complete diagnostic information and to identify gaps in care. If that information is collected in a proper open access data base, actionable reminders can be generated for the member, for the member’s treating physician, and for plan case management—just the sort of tool the authors recommend.

And, once again, we have an impact that cannot be replicated by fee for service Medicare.

By: Jack McCallum, CEO, CenseoHealth

Reposted with permission from the GHG Blog

[1]  Gandhi, Tejal K., Zuccotti, Gianna, and, Lee, Thomas, “Incomplete Care—On the Trail of Flaws in the System” New England Journal of Medicine, 365:486-488, August 11, 2011.

On 04/04/2011 CMS announced the final MA capitation rates and to our industry’s surprise the final rates were quite different from those projected in the initial February notice. The highlights from the final call letter are as follows:

1. 2012 MA capitation rates will increase a mere 0.4%, a staggering1.2 % less than projected 45 days ago. Health plan CFOs are already working on strategies to trim benefits and remain competitive with market competitors, this will enable plans to either reduce or eliminate the impact on their earnings.  
2. Please note that the above rate increase does not include any Risk Adjusted premium increases perceived by plans, so those of you who have been working hard will begin to reap tremendous competitive advantages in 2012.  
3. The Final Call projects a negative growth factor for MA of -0.16%. A far cry from the well-received growth projection of 0.7% given 45 days ago. This based on lower physician rates that are also announced in the Call Letter. After all it’s the providers who truly market MA products based on their overall satisfaction with plan benefits and compensation.  
4. CMS will conduct Integrity Audits on plans with members’ share of cost at or above 10% after 7/1/2011. Expect to see plans try to stay below the 10% to avoid CMS audits 
5. RADV Audit Methodology has remained unchanged.  While CMS received a tremendous response rate from the letter sent out in December 2010, it has decided not to implement method changes for the time being.  Expect the method announcements later this year.  
6. STARS – CMS will be paying Quality bonuses for plans with higher than 3 Stars in 2012; these plans will also be given competitive advantages during enrollment periods in an attempt to increase highly rated plans’ growth year round. The key here will be plans’ ability to work with providers, since a large number of the STAR measures are directly dependent on the Provider offices.   

   In short this ride of ups and downs continues; the survival skills for MA remain constant: excellence in HCC, and your plan’s ability to develop long term partnerships with providers to yield the high quality equitable healthcare delivery experience we all want for ourselves in the not too distant future!

    

   Kenneth Persaud CEO, Precision Healthcare Systems  

It is officially winter and those of us in the HCC world are officially in crunch time. This is often the season that plans and IPA’s will institute their last ditch efforts to capture and code the current year’s HCC’s. This is also often when last minute efforts can fall short of their intended reach. While HCC comprises the large part of many of our worlds, it is important to remember that it is often only a small fragment of the universe of the practicing physician. Right now in my practice, I am thinking about making sure we have enough flu shots in the office, planning on managing staff absences for the holidays, trying to get all our P4P testing letters mailed out in time for patients to schedule their mammograms and remembering to budget for an extra pay period in December! In short, if it doesn’t help me take better care of patients or make my practice run smoother, it is of minimal value to me.

Risk adjustment IS important and has clinical implications. As always , the challenge is to make sure it intercolates with the practicing physician’s priorities. Here are a few things to do:

1.Streamline your communication with physician offices

Don’t send Happy Halloween , Happy Thanksgiving, P4P and HCC letters between now and December. Prioritize the messages you want to communicate with your physicians by year’s end and make sure all departments are on the same page. Use your provider relations staff to hand deliver messages of vital importance. Consider any mailed or faxed information sent after November 15^th almost a waste of time.

2. If you are giving incentives before year’s end- remind your PCP’s NOW!

It’s almost too late for them to get seniors in the door- this is made harder also by the holidays. Remind them of submission dates, incentive pay out criteria and expected pay out dates.

3.Plan for next year.

What parts of your Risk Adjustment plan worked this year? What fell flat? Who are your priority providers to contact the earliest next year? I have seen groups wait until the second quarter of a year to plan that year’s risk management process. Start early. Ask a few key providers what they would like to see next year. Remember that Risk adjustment is dynamic. (Different providers are at different points on a learning curve- structure your interventions accordingly)

As Ken Persaud implied in a previous blog, it is the responsibility of Medicare Advantage Plans to demonstrate their value to CMS. This will occur as plans continue demonstrating the value of Risk management to their practicing physicians.

-Dr. Preedar Oreggio, Clinical Director, SIERRA SPRING FAMILY WELLNESS CENTER

In this blog, I will share the approach Precision Healthcare is taking towards integrating case management and HCC coding. I would like any and all feedback from organizations which are: contemplating, currently undertaking or have already achieved such integration. In our experience greater than 60% of the patients identified for case management are also targeted for HCC coding initiatives. Given the limited time and attention span most physicians have when it comes to these topics, Precision Healthcare is taking a patient centric, action oriented approach to accomplishing its goals in both arenas. For each patient identified for both case management and HCC coding focus, the work flow essentially consists of the following:

1. Medical record audits by the case manager & HCC coder 
2. Interventions required by the PCP for case management and HCC coding are recorded during audits. An example of case management intervention would be for the PCP to prescribe more affordable pharmacy alternatives in order to help patients overcome financial obstacles to compliance with prescribed treatment plans. An examples of HCC coding interventions would be for the PCP to review a coding Query for patient specific diagnosis, to include PCP evaluation and detailed documentation of ongoing medical management (if any) during the next visit.  
3. Case manager coordinates the subsequent patient - PCP visit 
4. Case manager attends the subsequent patient – PCP visit, with a list of the fore mentioned interventions for PCP completion, and supports PCP in their execution.

The pursued outcomes are:

•  Patient empowerment to proactively participate in their healthcare  
• Provider education of case management & HCC coding 
• Support of provider office to achieve positive outcomes for the high disease acuity and severity population 
• Medical record documentation Quality Improvement (RADV risk mitigation) 
• Accurate future risk premiums 
• Improved quality of life for patient through subsequent continued case management monitoring and evaluation 
• Improved patient satisfaction as derivative of concierge care model

To date, preliminary results are as follows:

•  High ROI : 1.7 HCCs / Query 
• Complete results will be presented at the March 2011 RISE Annual Conference 
• Physician engagement is essential, so don’t forget the Incentive! 
• Physician support staff is key to your success

I am looking forward to hearing about your experiences in integrating, particularly how to work with FFS providers and incentive structures.

Ken Persaud, Chief Executive Officer, PRECISION HEALTHCARE SYSTEMS

The pace in which we deal with change in the healthcare industry has reached warped speed.  We have never had to be as flexible and as agile as we do right now!

Not only do Medicare Advantage Plans have to adjust to the pace of an ever-changing environment, but our provider partners are greatly impacted like never before.

Change has always brought about uneasiness and uncertainty, but change has also always brought about opportunities for growth and development - OGADs - as one of my mentors called them.

Now more than ever, the healthcare industry has a great opportunity to really become an integrated system that meets the healthcare needs of our members and affords them good quality of life in their latter years. Isn't that really what risk adjustment, STAR Ratings and Healthcare reform is all about ... healthcare for some, better healthcare for others?

It is an opportunity to look at and develop programs that not only assist members in becoming more aware of, and engaged in, the decisions that are being made about their health, but also empowers members to make very informed decisions in selecting who will provide their healthcare services.

The key to being successful in anything that we do is to have a strong foundation. The foundation is the starting point or ground work of anything. In healthcare, that foundation begins with our physicians.

It is more important than ever that we ensure our providers have the tools, resources and support that they need to treat their patients effectively (positive quality outcomes) and efficiently.

When risk adjustment began, data was collected but not shared with physicians. We now not only have an opportunity but also a great need to share this information.

Physicians need their patient's medical condition history in order to make informed decisions for their patients.

Providers come in contact daily with their patients, this contact, in many instances, is what forms the patients' perception of their healthcare.

As I have a great opportunity to visit and listen to our provider partners I have heard first hand to some of their challenges. In the current environment of changing technology, increased documentation requirements and yearly coding changes, the providers' main focus is still on providing their patients the best care possible. As an industry we must support, collaborate and encourage our providers. We need to remind them that what they do is important and very much appreciated. Lets not allow that message to get lost or diluted as we continue to go through change. The fact is, without our providers, there is no health care.

In summary: A few ways to support your provider partners:

• Set up some one on one time with providers and ask them what causes them the most pain, then do something about it if possible
• Create tools that are intuitive and can be viewed at a glance or accessed easily, yet provide important patient information to be used during a face to face visit
• Ask for their feedback and suggestions on information that is most important to them
• Bring them along as you implement an EMR system and consider their ideas
• Establish relationships with their office staff
• Attend Physician Meetings and keep them updated on current events
• Let them know you appreciate what they do

Kimberly D. Stone, Director of Medicare Revenue Management, Government Programs Administration, Presbyterian Healthcare Services

There seems to be huge divide among practicing physicians in primary care about the possible changes the HCR will bring. We physicians are a group of people as a whole who do NOT like change. I think we look to the impending upheaval with a blend of hopefulness, uncertainty and apathy. We are definitely caught up in the business of seeing patients. We are very "grindstone cloistered" as General Petraus described the military leadership- hard working in our own respective silos. I think there is a pervasive sense that "we won’t be able to change anything anyway" so we grumble and go in to the next patient room. I think there are undoubtedly some changes down the road that physicians can be involved in- some we may even (gasp) appreciate. No one can predict what health care reform will look like in "real life". There are general changes in the wind of healthcare that I think will affect the way a typical physician’s office functions. There seems to be trends toward things such as standardization, data interchange, transparency and reportability and a greater focus on disease groups. Let’s talk about standardization of care.

Our clinical care is coming under greater scrutiny- by health plans, IPA’s, CMS, etc. There is no escape from this (reform or no reform) We practicing physicians will have to show that we are abiding by established clinical guidelines. The increased transparency of and access to information means that patients will evaluate whether they are candidates for a daily aspirin, or a daily glass of red wine or a mammogram this year or in 2 years. Many physicians are not able to pursue accessing this information in a timely way. Any healthplan or IPA that we work with has a vested interest in getting this info to us. It would have tangible benefits to P4P and PQRI scores to always know the most up to date screening guidelines and to be able to compare them to each other. I had to make up my own side by side comparison chart of mammography and Pap smear guidelines recommended by the American Cancer Society, ACOG and the US Preventive Services Task Force. Having said that, impersonal information has limited uses. Physicians are obliged to see how general population based guidelines apply to the intricacies of their individual patients. Health plans will have to think creatively about how they can facilitate these guidelines making their way into our exam rooms. The letters from health plans telling us to start ACE inhibitors on our already barely compliant, multiple medication using diabetics without kidney disease are not helpful. Actually they’re annoying. For CMS, health plans and IPA’s to impact physician behavior , they will have to work with physicians, not on them.

Preedar J Oreggio MD