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Medicare Shared Savings Program: What To Do Before You Start

Doctors and Nurses

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) passed last April ended the Sustainable Growth Rate (SGR) formula for determining Medicare payments to health care providers, creating a new pathway to value base payments. Future fee schedule adjustments will be driven by participation in either (1) a Merit-Based Incentive Payment System (MIPS) that combines existing quality reporting and incentive programs or (2) qualified Alternative Payment Models (APMs) that require providers take on a yet to be defined "more than nominal" financial risk. Given the complexity of MIPS and long-term potential higher earnings under APMs, many physicians are interested in preparing for participation in APMs and see the current Medicare Shared Saving Program (MSSP) as a logical stepping stone.

As more physicians in the U.S. move into Accountable Care Organizations (ACOs) and the MSSP their peers are watching their successes and struggles, trying to discern what drives the difference in the 28 percent that are reaping shared savings and the great majority that are not. MSSP requires ACOs to hit savings targets benchmarked from their existing spending patterns, as well as score well on 33 quality measures. What is needed to prepare to successfully engage under these new payments models? A useful reference is the Brookings white paper on "Adopting Accountable Care: An Implementation Guide for Physician Practices". This toolkit identifies four capacities critical for success: (1) identify and managing high-risk patients; (2) develop high-value referral networks; (3) receive notifications of acute events such as emergency room (ER) visits or hospitalizations; and (4) engage patients in self-management and shared decision-making.

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Will, Ideas and Execution: A recipe for change

Change letters

Earlier this month I had the pleasure of attending the Centers for Medicare & Medicaid Services (CMS) Quality Conference in Baltimore, Maryland. This annual conference held in the inner harbor and heart of Baltimore, is where quality professionals and CMS contractors from all over the country gather every year for three days to learn from experts in the field and to join together as colleagues, all pursuing the same vision; improved health of our population, improved delivery of care and smarter spending of health care dollars. On the final day of the conference attendees had the great pleasure of hearing from one of the most widely recognized individuals of health care improvement, Dr. Donald Berwick. Dr. Berwick shared stories of how change and improvement in the health care system have impacted everyday people in our local communities and shared his personal experience working as the administrator of CMS in 2012 and how CMS' commitment to value-based care is a pivotal, unprecedented and necessary shift in the evolution of the Medicare program.

Dr. Berwick framed his presentation on the need for change using three simple words: will, ideas and execution. One must first have the will or desire to change. One must also have an idea or thought about the change. And finally, one must act or do something to create that change. Dr. Berwick spoke of this basic principle and how all change ever takes is these three elements, and that all great improvements start and end with this key principle.

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“What is Important to You?” Take Time at the Holidays for Important Conversations about End of Life Wishes

Holding hands

Holidays are a time of family and togetherness with some of the people closest to us. We send greetings and try our best to catch up with people that we love. We honor traditions, we engage in meaningful reflection, we love to share meals and we share gifts. This season, I am committed that my family adds an important conversation to our holiday activities, a conversation about our wishes for end-of-life care.

In last week's blog, Fern mentioned several resources to help in end-of-life care planning and making your wishes known, but how do we begin?

I'd like to share a resource that can make these conversations easier to start.

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Hearing the Patient’s Voice

Mother with daughter

My dear friend Carol is very ill. She's been in the hospital in the intensive care until (ICU) for over two weeks, and though there are small signs of improvement in some areas, there are also setbacks in others. What is most frustrating for me is the inability to communicate with her. Although she is sometimes aware loved ones are with her, she's unable to participate in her care—unable to speak, write or let us know what she's thinking.

As is the case with many who end up in the ICU, she didn't have an advance directive, living will, Physician Orders for Life Sustaining Treatment (POLST) form, medical power of attorney, do not resuscitate or other instrument that contains the voice of the patient.

As I concern myself about what Carol would want, I also think about what I would and wouldn't want under similar circumstances. I know I wouldn't want my husband and sister to have to "guess" my wishes.

  • I would want them to have a starting place
  • I would want them to know there is a plan I have thought about that provides a guideline for their decisions
  • I would want to help make their choices as easy as possible

It's confusing though—does a person need to have all of the documents mentioned above? What's the difference between them? How are they used?

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Keep Calm and Innovate with Technology

Doctors with laptop

Innovate - to make changes in something established, especially by introducing new methods, ideas, or products. -Merriam Webster Dictionary

Here at HealthInsight we often work with a wide variety of clinics, settings and providers to help them to evaluate their internal processes and potentially improve them through the use of technology such as electronic health records (EHRs). Establishing these systems is often times a difficult and time-consuming experience. For those involved, it can be a very disruptive task. During those times though, I imagine motivations and possibly some internal mantras often reflect on the potential improvement the providers are moving towards to help keep people calm and focused on the future.

Technology can be, all by itself, a disruptive medium. It can cause delayed meeting starts as we attempt to get everyone connected, it can experience failures that impact communication and collaboration, and it can impede learning, as well as cause numerous other negative impacts. On the flip side, however, technology champions positive disruptive innovations such as EHRs, patient portals, data sharing and accessibility, mobility and the blooming field of the Internet of Things that's increasing our interconnectedness to everything.

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Helping Caregivers Cope

Couple

Family caregivers are the most important source of support for people with chronic or other health conditions disabilities or functional limitations. Millions of family caregivers help their loved ones live at home and in their communities, providing the bulk of this assistance. There are about 40 million family caregivers currently caring for adults in the US.

Family caregivers help with activities such as eating, bathing, dressing, transportation and managing finances; perform medical and nursing tasks such as wound care and managing multiple, complex medications; arrange and coordinate care among multiple providers and settings; and pay for home modifications, transportation or home care assistants. This helps to delay or prevent their loved ones from needing more costly nursing home care and helps prevent unnecessary hospital readmissions. On average, family caregivers spend 24 hours a week caring for their loved one for four years; almost one third of family caregivers provide an average of 62 hours of care a week.

Family caregivers experience more injuries, anxiety, depression and poorer health than non-caregivers. Family caregivers generally do not receive training and other assistance to help them provide care. Navigating, locating and coordinating fragmented services is too often bewildering, complex and very time-consuming. There is nothing worse than watching someone you love suffer and not knowing what to do.

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Bright and Hot: Spotting Success

Report Card

What do you do when your child comes home with a report card? Do you celebrate the A's or do you narrow in on the F's? If you're like most people, you probably narrow in on the F's. It is common for our rational brains to focus on problem areas, and problem solving in health care is no different.

In their book, "Switch: How to Change Things When Change is Hard," Dan and Chip Heath promote an idea called "bright spots." The idea is to look for instances of success in order to learn what is working so it can be applied to areas that are struggling. The report card is an example from their book. The Heaths contend that during times of great change, there will never be a perfect report card. However, there will be successes. In the example, the A is a bright spot, a success. Parents may zero in on the F, but what can they learn from the A that can help improve the F? And, how does this apply to health care?

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W. Edwards Deming - Let's Not Miss the Quality Boat Twice

W Edwards Deming

I have a couple quotes from W. Edwards Deming, an American engineer, statistician, professor, author, lecturer, and management consultant, on the white board in my office that read "drive out fear" and "encourage effective two-way communication and other means so everyone in the company can be effective." I was intrigued by how many of my health care quality improvement co-workers commented on the quotes and in return, shared one of their own favorite Deming quotes. One co-worker shared "Inspection is waste"; another co-worker shared "A bad process will beat a good person every time." Another shared "In God we trust; all others must bring data" and "If you can't describe what you are doing as a process, you don't know what you are doing."

We take Deming seriously at HealthInsight. Deming has been given the title of "philosopher of quality" and championed the cause of "statistical process control." Deming was largely ignored by the production-focused United States during the 1960s and1970s. Deming took his quality message to the Japanese industrial leadership and the results produced placed him on a path to stardom in Japan. The Japanese automotive and electronic industries skyrocketed in sales due to higher quality products which were reliable over time. Most experts feel the United States missed the quality boat during this time frame as Unites States sales were down and their products did not last as long. Many industries in the United States have warmed to his quality message over time. In health care, the Institute for Healthcare Improvement (IHI), among others have championed many of Deming's ideas.

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Achieving Our “True North” Vision for Health Improvement

Compass

Just two weeks ago in the beautiful setting of Santa Fe, New Mexico, we met for our annual board retreat. The retreat included HealthInsight's four boards, senior staff, and the invited boards of three other health improvement organizations whom we count as partners. We came to learn, to share, to envision and to consider new plans and approaches.

Over the course of two days of meetings, something special and significant seemed to happen. Perhaps the best way to characterize the outcome of the retreat is that this group of almost 100 leaders-already highly engaged and committed to achieving better health outcomes for our communities-became even more committed; even more motivated to fully realize transformational change. The level of rapport and engagement was palpable and energizing!

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Three Good Things

Change Agents - Learning and Action Network

I recently had the great pleasure of serving as the regional host for a HealthInsight-sponsored learning and action network (LAN) event, "Be the Change: Strategies for Health Care Transformation".

I have been a HealthInsight employee for nearly two decades. Part of my reasoning for continuing to work for HealthInsight for all these years is that I am still able to learn and grow, and think about new possibilities to change the health care system.

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