MEMGMA Newsletter

Maine MGMA Newsletter
January 2017
Prepare For MIPS/APMS: A Checklist For Practice Leaders

By Robert M. Tennant, MA, and Jennifer McLaughlin, JD

On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) released a highly anticipated proposed rule outlining physician payment reforms as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The proposed rule includes key guidelines for the new Merit-Based Incentive Payment System (MIPS) and alternative payment models (APMs) that will take effect as early as 2017. 
 
MGMA developed this checklist to provide practice executives with action steps to prepare their organizations for the transition to MIPS and APMs. We encourage practice leaders to consider a long-term strategy for the move from fee-for-service to value-based reimbursement by taking steps that not only make sense within the MIPS and APM framework, but that also have an independent benefit for the practice, such as collecting and using patient satisfaction information or extending office hours to generate additional revenue. 
 
Leverage your MGMA membership to educate yourself and network with your peers.
To help members anticipate and prepare for changes as Medicare transitions from fee-for-service to value-based reimbursement, MGMA created a number of practical resources that you can access today.
  • Visit mgma.org/macra for an executive summary of the proposed rule, a guide for small practices and the latest news about MIPS and APMs.
  • Listen to MGMA’s 60-minute, on-demand webinar on the MIPS/APMs proposed rule for a crash course on how the rule may impact medical group practices starting in 2017.
  • Join MGMA’s new interactive e-group, MIPS/APMs Medicare Value-Based Payment Reform, to interact with your peers and ask MGMA Government Affairs staff questions as the MIPS and APM programs unfold.
Assess your practice’s performance under current federal quality reporting programs.
 
Although different, performance in PQRS, meaningful use and the Value-Based Payment Modifier will provide insight into future performance under MIPS. 
  • Access the CMS Enterprise Portal (portal.cms.gov) and download your practice’s 2014 PQRS feedback report to understand your historical quality reporting metrics and identify areas where improvement may be made. While MIPS will be a departure from PQRS, a number of the quality measures are anticipated to remain the same as will the option to report as a group or an individual. Therefore, practice leaders should evaluate which measures best fit your practice’s workflow and decide which reporting option makes the most sense for your group.     
  • Review your practice’s full-year 2014 and mid-year 2015 Quality and Resource Use reports, available at the CMS Enterprise Portal, to gain an understanding of your practice’s relative cost and quality performance as compared to a national benchmark.
  • Research applicable qualified clinical data registries and traditional registries, which may help streamline reporting, particularly of specialty-specific measures. 
Evaluate existing and future HIT vendor readiness and cost.
 
With the MIPS/APM proposed rule, CMS is continuing the movement established by the Meaningful Use EHR Incentive Program of putting a premium on practice adoption and use of health information technology (HIT). As practices begin to transition to new MACRA payment approaches, identifying a cost-effective pathway forward to appropriate HIT will be important to ensure success not just in the reporting program but, more critically, for overall practice performance. As you prepare your organization for MACRA, consider taking the following actions to maximize your HIT: 
  • Discuss with your EHR vendor what its expected timeline is to make all necessary software upgrades to support MIPS and/or APMs following publication of the final rule. Do they anticipate upgrading your specific version of the EHR software, or will you be required to purchase a more advanced version? 
  • Establish when your EHR vendor expects to re-certify its EHR software to meet the government’s 2015 requirements. (Note that the proposed rule requires that practices participating in MIPS or an APM implement an EHR certified at the 2015 level by Jan. 1, 2018.) 
  • Review your vendor contracts and discuss with your vendors all anticipated software upgrades or replacement costs. Determine if the upgrade or replacement will require any computer hardware updates and if staff training will be included as part of the contract or be available at an additional cost. 
  • Determine as early as possible if your current EHR product will need to be replaced with another vendor’s product. If you do require a new system, it is best to begin the selection and implementation process well before the start date for the new reporting program. Take advantage of the MGMA Member Community to discuss technology with your peers in the same specialty and size of practice. Virtual and in-person networking with your MGMA colleagues is an effective strategy to identify the most appropriate HIT for your organization. 
  • Leverage the upgrading or replacing of your clinical EHR to evaluate your administrative HIT. Most of the larger EHR vendors also offer an integrated practice management system module, while some require the purchase of separate practice management system software. Explore incorporating additional automation into your revenue cycle by leveraging electronic functionality for transactions including insurance eligibility verification, claim, claim status inquiry, prior authorization, remittance advice and payment.
  • Review your internal processes related to patient engagement and data exchange.
  • Establish what percentage of your patients currently engage your clinicians in secure messaging and currently view, download or transmit their medical record through your web. These patient engagement methods are required under the current Meaningful Use program and would be required under the MIPS/APM proposed rule. Should they be included in the final rule, practices should consider mapping out a patient outreach strategy to maximize success in these two patient engagement objectives. 
  • Determine what percentage of your external transitions of care-involved data exchanges are conducted via your EHR. Are there local care settings that you currently interact with (i.e., other specialty practices, hospitals, skilled nursing facilities) that you may wish to explore electronically exchanging data with? At the same time, it will be important to evaluate your vendor’s data exchange capabilities and review staff assignment and training needs in this area.
Explore clinical practice improvement opportunities.
 
Practices will be given credit in MIPS for clinical practice improvement activities (CPIAs). 
  • Review the proposed list of CPIAs to determine which activities your practice is already engaged in. Examples of proposed CPIAs include providing transitional care management and consulting prescription drug monitoring programs prior to prescribing certain amounts of controlled substances.  
  • Weigh the costs and benefits of engaging in new MIPS-specific activities. Identify minimally-burdensome opportunities that have clear value to the practice outside of this government program, which may also be leveraged for MIPS and APMs. For example, practices may survey patients’ experience of care and utilize this data for marketing. 
  • Consider participating in a value-based payment initiative that would prepare your practice for an APM.
  • Substantial participants in advanced APMs will receive an annual 5% lump sum bonus from 2019 through 2026 and be exempt from MIPS.
  • Confirm whether you are a participant in one of the payment models CMS considered an advanced APM in the proposed rule. These models include Medicare Shared Savings Program Track 2 and 3 accountable care organizations (ACOs), Next Generation ACOs, Comprehensive ESRD Care Model (large dialysis organization arrangements), Comprehensive Primary Care Plus (CPC+), and Oncology Care Model Two-Sided Risk Arrangement. CPC+ begins in 2017 and the Oncology Care Model is available beginning in 2018. 
  • MGMA strongly urged CMS to expand the advanced APM pathway. Continue to stay apprised of changes to the models that CMS considers sufficiently risk-bearing to qualify physician participants as exempt from MIPS and eligible for the 5% lump-sum bonus beginning in 2019. 
Understand that this is a work in progress.
 
MGMA is vigorously advocating for improvements to the proposed MIPS/APMs rule and submitted detailed comments to CMS, urging the agency to begin the first MIPS performance period no sooner than 2018 to allow more time for preparations and APM development, to shorten the reporting period and to increase opportunities for physician group practices to participate in eligible APMs. 
 
MGMA continues to be a voice for practice leaders in Washington and is engaged in ongoing conversations with CMS and Congress about MACRA. During a recent congressional hearing, CMS Acting Administrator Andy Slavitt told members of Congress a later start date for MIPS and a shorter reporting period were on the table. In response to feedback from MGMA and other stakeholders and in light of Slavitt’s comments, the MIPS and APMs proposed rule is likely to change. A final rule is expected in the fall of this year.

September 2016 MGMA Connection Magazine 
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American College of Medical Practice Executives (ACMPE) is the standard-setting and certification organization of the MGMA-ACMPE association. Through ACMPE, medical group managers can earn the Certified Medical PRactice Executives (CMPE) designation and go on to earn the highest distinction of Fellow in the ACMPE (FACMPE).

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Enhancing The Patient Experience With Stand-Up Check-In
By Gordon G. Massey, MBA and David G. Hunter, MD, PhD
 
Think back to the last time you went to a retailer’s service counter while shopping. Did you notice that when you approached the counter, you felt as if the retailer needed you more than you needed the retailer? Retailers carefully craft your experience as a customer, and part of the reason you feel so special is that the first person to greet you is often standing at a counter and not sitting at a desk. Standing is widely believed to convey availability, courtesy and respect, and that is what you see at most retail outlets. 
In healthcare, the situation is very different and often to the detriment of the patient experience. Consider for a moment any healthcare institution you have visited recently and what happened when you approached the check-in desk. Most likely the first person you saw was sitting down, looking at some paperwork or typing away at a computer. As you approached, perhaps you were greeted with nothing more than a raised index finger indicating, “I’m busy but I’ll be with you when I finish this important thing that I am doing” – that is, if you received acknowledgment at all. You might have even felt guilty for interrupting the person, forgetting that the most important thing he or she had to do that day should have been to take care of you, the patient.
These staff members do not intend to be rude or inattentive. They are all certainly nice people and surely busy with work, preparing charts and handling required paperwork or insurance-related matters. But the very structure of their seating arrangement makes it nearly impossible for them to consistently contribute to making an approaching patient feel welcome. 
Writing on the patient experience in healthcare, James Merlino, MD, past chief experience officer at Cleveland Clinic, says, “Patients too often are made to feel they don’t deserve a superior experience because healthcare is a necessity rather than a luxury.” 
The idea
 
While brainstorming how we could improve the customer experience for families visiting the Department of Ophthalmology outpatient clinic at Boston Children’s Hospital, we decided to focus on our own check-in process. A key suburban location was due for a complete renovation, and since the walls had to be gutted, we saw an opportunity to act. We proposed modifying the check-in desks so that our staff could be standing while working and ready to greet all who approach at eye level, with one lower desk to accommodate wheelchairs. 
But this seemingly simple idea was only the beginning of a long process that was necessary to implement such a profound cultural change in this large, established institution. We needed approvals from multiple parties, including human resources, the legal office, facilities management, occupational health, project managers, architects and, of course, senior management at the hospital. Each asked why we wanted to make this change. Once we explained the customer service value that aimed at enhancing the experience, they were ready to work with us. 
The process
First, you should consider the impact this would have on staff. There are worries that long workdays spent standing without a break could lead to health issues. But there is also evidence that remaining active during the day and spending less time sitting down has real health benefits.1 We proffered that if there were ever a situation where families should receive four-star service, it should be during the sometimes emotionally stressful healthcare visit. That is, it was not only a good thing to do for our patients, it was also the right thing for them.
Once we had the approvals, there was a lot more work to do. We needed to ensure that our front-line check-in staff felt comfortable with and understood the rationale for the stand-up experience. Because this was a newly expanded location, many employees would be new hires. During the hiring process we explicitly conveyed that they would be standing up to greet patients, so that they could decide before accepting the offer whether standing up was going to be a problem for them. 
We then developed a training protocol for our check-in staff. We also developed a policy allowing for breaks or for tall stools to be used, so staff members could rest their feet on occasion when patients were not within sight of the front desk. But we held firm to the vision that no employee would be seated when interacting with a patient at the front desk.
We have certainly had to deal with some employees sitting down when the boss wasn’t around. In these cases, we reinforced the reasons they needed to be standing up, always focusing on what the patients and families deserved during their visit. These discussions and immediate feedback have kept the culture and vision alive and let people know that we are serious about it.
The impact
Since implementing the stand-up check-in, we have discovered the subtle but unmistakable difference in the atmosphere experienced when approaching the front desk. There’s an energy and clear tone of readiness that make the experience more positive. 
We have received many comments from others about the hospitable environment at our check-in desk. Visitors have said they sensed the difference without understanding why the environment was better. Once we pointed out the stand-up check-in, they understood right away. Colleagues or those interested in service innovation are often detoured to our clinic to observe how customer experience has been made a priority with the check-in staff. 
But implementing this model is challenging, even at our own institution. Despite our advocacy and six years of successful implementation at one site, we haven’t yet been able to institute stand-up check-in at our other clinic sites, where employees from different departments work nearly side by side. 
 
The prevailing seated check-in setup at ambulatory healthcare clinics nationwide provides patients with a simple message: “You can wait for us because you need us more than we need you.” But a conceptually simple posture change (albeit a difficult culture change) will reverse that message. With stand-up check-in, we tell our patients, “Welcome! We are glad to see you, and you are the reason we are here.” 
 
Note:
1. Katzmarzyk PT, Church TS, Craig CL, Bouchard C. “Sitting time and mortality from all causes, cardiovascular disease, and cancer.” Med Sci Sports Exercise, Issue 41, No. 5:998-1005. doi: 10.1249/MSS.0b013e3181930355.

October 2016 MGMA Connection Magazine
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