COVID-19’s impact on physician organizations has amplified the risks of variability with fee-for-service (FFS) payment models, and highlighted the importance of shifting towards value-based care and alternative reimbursement models. Primary care physicians will have increased opportunities to embrace value-based care models in 2021, with CMS’s Primary Care First Model Options scheduled to begin in January for the Primary Care First (PCF) component, and April for the Seriously Ill Population (SIP). The voluntary payment builds on the existing Comprehensive Primary Care Plus payment model, with the goals of reducing Medicare spend and improving quality and patient access to care for patients with complex conditions.

Model Payment Structure

In an effort to reduce organizational administrative and billing burdens, CMS has intentionally focused on making the Primary Care First Model’s payment mechanisms simple and straightforward for participants. A monthly population-based payment and flat primary care visit fees make up a “Total Primary Care Payment” for participants, which is then adjusted by up to 50% based on performance measures.  Below are the details for each component of the model’s payment structure:

Monthly Population Payment:

• Monthly population payment that supports practice enhancements and services to effectively care manage patient populations
• Monthly payment per beneficiary ranges from $28 PBPM to $175 PBPM, with the amount standardized for all patients within a practice and dictated by the risk level of a participant’s population
• Monthly payment amount is reduced with a leakage adjustment, accounting for if patients receive primary care outside of participant’s practice

Flat Primary Care Visit Fee:

• Payment for in-person treatment, simplifying billing process and payment projections
• Flat visit fee of $40.82 per face-to-face encounter

Performance-Based Adjustment:

• Quarterly performance adjustment to the Total Primary Care Payment of up to 50% upside or 10% downside
• Specific performance measures depend on participant’s risk level
• Acute Hospital Utilization will be a key measure for lower-risk participants in year 1 and Total Per Capita Cost will be a key measure for higher risk participants in year 1

Preparing for Success

Primary Care First Model Options offers participants the opportunity to meaningfully increase practice revenue, remove the variability of FFS reimbursement, and strengthen relationships between patients and providers. As participants plan their strategies for success, it is important to consider capabilities that maximize the performance-based adjustment measurements as they support optimal patient outcomes and can drive up to 50% more revenue for practices. Real-time admission, discharge, and transfer (ADT) data that provides actionable insights into patient care events will be a critical resource for success, as it drives targeted intervention to reduce avoidable hospital and post-acute utilization. This real-time data will enable participants to excel in the Acute Hospital Utilization or Total Per Capita Cost performance measures included within this model.

Bamboo Health supports provider success in Primary Care First and other value-based care models by optimizing encounter efficiency, reducing avoidable utilization, and ensuring patients are receiving critical care when they need it.

For more information on how Bamboo Health can support success in Primary Care First, contact us at [email protected], or complete our contact form.

In February, the Centers for Medicare and Medicaid Services (CMS) released Part II of its 2021 Medicare Advantage and Part D Advance Notice, and the Medicare Advantage and Part D Program Technical Changes proposed rule, which included several updates to the Medicare Advantage Star Rating program. The CMS Star Rating program is used to evaluate the quality of patient care and experience for Medicare beneficiaries, and rates health plans using a five-star system based on their performance against 30+ quality measures, including both clinical HEDIS measures, and survey measures.

Beginning in measurement year 2021, which will impact health plans’ 2023 Star ratings, two additional HEDIS measures will be included for scoring; Transitions of Care and Follow-up after ED Visit for People with Multiple Chronic Conditions. Both measures will be worth one point of health plans’ performances in the Managing Chronic (Long-Term) Conditions domain and will impact their overall ratings on the five-star quality scale. With these new measures, and especially as the Transitions of Care measure is expected to be weighted more heavily in the future, it’s critical that health plans have the tools and resources needed to efficiently monitor members’ care transitions and ensure timely follow-ups.

Transitions of Care Measure

Coordinating care for members following a hospital or ED discharges is critical for health plans in order to avoid unnecessary readmissions and ensure proper care delivery. However, transitions from acute care settings are often subject to poor care collaboration. To overcome these challenges, the Transitions of Care Measure will rate health plans on the percentage of Medicare beneficiaries 18 years and older where following discharge from an inpatient facility, the following criteria were satisfied:

• Notification of Member Admission:
  Health plans will need to provide documentation in members’ medical records of a receipt of notification (via phone, email, fax, EMR, or ADT notification), the day of or day following members’ admissions.
• Receipt of Discharge Information:
  Documentation must be made in members’ medical records with a receipt of discharge information on the day of, or following the member’s discharge. Documentation must include information on the member’s treating provider, procedures and/or treatment(s) provided, diagnosis at discharge, current medication list, testing results, and treatment instructions for ongoing care providers.
• Patient Engagement:
  Organizations must show proof of engagement provided to members in the 30 days following their discharge. Member engagement includes office, at- home, telehealth, or telephonic visits.
• Medication Reconciliation:
  Medication reconciliation must occur and be documented on the day of discharge through 30 days post-discharge (31-day window) by a prescribing practitioner, clinical pharmacist, or registered nurse.

Follow-up After Emergency Department Visit for Patients with Multiple Chronic Conditions Measure

With high-risk patients and those faced with multiple chronic conditions often being at risk for readmission, health plans need to ensure timely and proper follow-ups post-discharge from the ED or hospital. To further support these efforts, health plans will now be measured on the percentage of ED visits for members 18 years and older who have multiple high-risk, chronic conditions, where the members had a follow-up service within 7 days of their ED visit.

• Member eligibility criteria:
  Eligible members must have two or more of the following conditions: COPD and asthma, Alzheimer’s disease and related disorders, chronic kidney disease, depression, heart failure, acute myocardial infarction, atrial fibrillation, and stroke and transient ischemic attack.
• Follow-up services criteria:
  Follow-up services can include outpatient visits and encounters, telehealth and telephonic visits, transitional or complex care management services, case management visits, and behavioral health visits.

How to Prepare for These Changes

With these new measures, health plans should consider their existing performance measures with similar requirements, especially those that require timely follow-ups and close coordination of care. Organizations should determine real-time care coordination solutions that will enable adherence to the timeliness requirements with these two measures, and allow them to monitor member discharges to ensure coordinated follow-ups.

Additionally, organizations should look for solutions that enable close collaboration with community providers and, at the same time, improve quality performance for the Star Rating program and beyond. Additional HEDIS measures that can directly benefit from real-time member admission, discharge, and transfer data to trigger workflows and drive interventions and timely care include: 

• Plan All-Cause Readmissions (also included as a Star Ratings measure)
• Acute Hospital Utilization
• ED Utilization
• Hospitalization for Potentially Preventable Complications
• Follow-Up After Hospitalization for Mental Illness
• Follow-Up After ED Visit for Mental Illness
• Follow-Up after ED Visit for Alcohol and Other Drug Abuse or Dependence
• Prenatal and Postpartum Care

For more information on how to prepare and succeed with the newly-released measures, contact us at [email protected], or complete our contact form.

Bamboo Health recently hosted a webinar for hospital executives and providers on the new e-notifications Condition of Participation (CoP) requirement that the Centers of Medicare and Medicaid Services (CMS) published on May 1, 2020, in the Federal Register.

Under the new CoP, hospitals, psychiatric hospitals, and Critical Access Hospitals must send real-time ADT-based e-notifications to patients’ established practitioners, practice groups and entities, and post-acute providers and suppliers.

Both during and after the webinar, our team received several important questions from hospital CIOs and heads of compliance about the specific requirement details, and what it will take for them to achieve compliance by the May 1, 2021 deadline. Below are ten critical questions answered by our team to help support hospital executive teams as they navigate this new requirement.

1. HOW IS “REAL-TIME” FOR SENDING NOTIFICATIONS DEFINED IN THE FINAL CMS? IS THERE A SPECIFIC TIMEFRAME (E.G. 24 HOURS) THAT CMS SPECIFIES?

Hospitals are required to send e-notifications at the time of a patient’s inpatient admission, discharge, and transfer event and at emergency department presentation/registration and discharge. CMS was deliberate in requiring e-notifications be sent in real time, i.e. “at the time of” an event occurring.  Real-time delivery of the e-notification not only eliminates information delays and improves current information sharing practices, but also guarantees the information is actionable, which maximizes care coordination opportunities across the care continuum and improves patient outcomes. An e-notification delay lasting hours or days or sending batched e-notifications will not meet the rule requirements to send notifications “at the time of” events occurring.

2. IS THERE A LIMIT ON THE NUMBER OF PROVIDERS A PATIENT CAN HAVE THEIR DISCHARGE INFORMATION SENT TO BY THE HOSPITAL?

The only limitation is that notifications need to be sent to practitioners, practice groups or entities, and applicable post-acute care providers and suppliers that have an established care relationship with the patient and that need the information for treatment, care coordination, or quality improvement activities. Therefore, the number of e-notification recipients will vary by the number of providers a patient has and there is no prescribed limit. Of course, a patient is able to specify their data sharing preferences and hospitals or their intermediaries must send e-notifications in a manner that is consistent with those privacy preferences and with all applicable federal and state laws and regulations.

3. WILL HOSPITALS THAT ALREADY SEND THEIR ADT FEEDS TO HIES BE AUTOMATICALLY COMPLIANT WITH THE COP?

Compliance will depend on whether the HIE, as the hospital’s intermediary, can fulfill the minimum requirements specified within the final rule. Those requirements include the ability to send e-notifications:

• For all required patient events – inpatient admissions, discharges and transfer events as well as for emergency department presentation/registration and discharge events
• In real time – at the time of admission, presentation/registration, discharge, and transfer
• Including, at minimum, patient name, treating practitioner name, and sending institution name
• To the practitioners, practice groups or entities, and post-acute providers and suppliers identified directly by patients and that are not otherwise fulfilled through a hospital’s existing technology solution
• To the established primary care practitioners, established primary care practice groups or entities, and applicable post-acute providers and suppliers that have an active care relationship with the patient and request information for treatment care coordination, or quality improvement activities irrespective of geographic location
• Consistent with patients’ privacy preferences – no e-notifications must be sent for patients that do not want their information to be shared
• To recipients that have required data sharing agreements in place and consistent with all applicable federal and state laws and regulations.

In addition, to minimize any potential security incidents and inaccurate notifications, a high accuracy match rate should be in place to ensure notifications are sent to the appropriate providers.  Any intermediary, including HIEs, should have capabilities to frequently update provider-patient care relationships given they often change, especially in the post-acute setting.

Ultimately, hospitals are accountable to meet compliance requirements even when they delegate the e-notification functions to HIEs or other intermediaries and should therefore ensure that all minimum requirements are met.

4. WHAT IS THE PENALTY FOR NON-COMPLIANCE WITH THE NEW COP REQUIREMENT?

Conditions of Participation are the most significant and consequential regulatory lever that CMS has to authorize or terminate a hospital’s certification. CMS certification determines whether hospitals can receive Medicare and Medicaid payments, which often make up more than 50% of a hospital’s payer mix. To receive or maintain certification, hospitals must meet all CoPs, making compliance with CoP standards and conditions essential to hospital operations.

If deficiencies in complying with the e-notification CoP are found during the survey process, those deficiencies will be formally documented by the survey team on the CMS “Statement of Deficiencies and Plan of Correction” form and hospitals must follow time-bound processes to correct them. Unless hospitals remediate deficiencies, termination of CMS certification will go into effect after a maximum of 90 days.

5. HOW WOULD POST-ACUTES OR PCPS RESPOND TO A NOTIFICATION? CAN THEY SEND A REPLY TO THE HOSPITAL SYSTEM?

There is no prescribed way or method for post-acutes or PCPs to respond to e-notifications they receive from hospitals. CMS also does not require a “read receipt” from e-notification recipients.  However, the goals of the CoP are for recipients to use the information to support their care coordination efforts, enhance communication across the care continuum and thereby improve patient outcomes.  CMS hopes to support providers through added access to important information about their patients so these goals can be realized.

6. WILL ADDITIONAL INFORMATION BE PUBLISHED BY CMS THAT SPECIFY FORMAT OR OTHER DETAILS ABOUT THE RULE?

There will not be any foreseeable modification to the CMS Interoperability and Patient Access Final Rule given it has already been finalized and published in the Federal Register. However, the CMS Center for Clinical Standards and Quality will publish interpretive guidelines for the e-notification CoP that will give additional information and instructions to the survey teams as they prepare to assess hospital compliance.

7. WOULD PROVIDERS SUCH AS SNFS THAT RECEIVE E-NOTIFICATION FROM HOSPITALS ALSO NEED TO BE RESPONSIBLE TO SEND E-NOTIFICATION TO HOME HEALTH AGENCIES AND HOSPICES?

This e-notification CoP only applies to hospitals, psychiatric hospitals, and Critical Access Hospitals and does not include e-notification provisions or requirements for other types of providers.  There are currently no CMS requirements in place that would require SNFs to send e-notifications to other post-acute providers or care settings.

8. ADT FEEDS CAN GO DOWN FROM TIME TO TIME. WHAT IS THE ALLOWABLE RECOVERY PROCESS AND TIME THAT AVOIDS PENALTIES?

Any downtime should be minimized but in cases where downtime does occur, it should be documented and resolved as quickly as possible.  For audit purposes, it will be beneficial to document information about downtimes so that any e-notification lapses can be justified and explained.  Hospitals or intermediaries should always address the root causes of any downtime to ensure that there are no systematic gaps in information sharing introduced and/or perpetuated.

9. DO HOSPITALS HAVE TO HAVE A SPECIFIC EHR FOR THIS COP?

Hospitals are not required to have a specific EHR under the e-notification CoP.  In fact, hospitals included as part of the e-notification CoP can have any EHR or other electronic administrative system that is conformant with the HL7 2.5.1 content exchange standard.

10. WHAT ABOUT NOTIFYING THE PATIENT’S INSURANCE CARRIER?

Under the minimum CoP requirements outlined in the final rule, hospitals have to send notifications only to the patient’s established primary care practitioner, practice group or entity; the practitioner, practice group or entity identified by the patient as primarily providing his or her care; and applicable post-acute providers and suppliers. Insurance carriers are not included in this minimum set of recipients. However, CMS states in the final rule that the CoP requirements only represent a minimum floor and do not prohibit the sharing of information with additional parties for treatment, care coordination, or quality improvement activities as long as required data sharing agreements are in place and all state and federal laws and regulations are followed.

What Can You Do To Be Ready?

To assess compliance readiness and required solution functionality, we strongly encourage hospital CIOs, compliance executives, and others responsible for ensuring CoP compliance to review the Key Considerations and the Compliance Checklist. These resources can help executive teams learn more about the CoP requirements and help them navigate their path to compliance.

For hospitals that will use third-party intermediaries to meet the e-notification compliance requirements, Bamboo Health’s Route solution offers a compliance guarantee and meets all the published requirements.  Visit our Route page to learn more.