The Centers for Medicare and Medicaid Services’ (CMS) Interoperability and Patient Access E-Notifications Condition of Participation (CoP) deadline is rapidly approaching for hospitals and health systems. From the smallest rural hospitals to the largest health systems, compliance with this CoP brings varying levels of complexity. Apart from the CoP, small-sized hospitals face several unique challenges daily – whether it be limited physicians or more limited access to financing than larger institutions. Variables like these, combined with a global pandemic and looming deadline for achieving compliance with the new CMS CoP, make for a challenging scenario.

For CIOs and IT professionals working in a small-sized hospital, who often lack the compliance and technical support of larger hospital systems, the time to prepare is now. It is critical for small-sized hospitals to understand the intricacies of the new rule and adjust their practices accordingly to ensure 100% compliance with the e-notifications CoP. Below is a list of common Q&A’s to consider when assessing what, if any, changes your hospital needs to make. These questions can be used as a resource to help clarify any misconceptions and provide advice for implementing a CoP solution that addresses the unique pain points that small hospitals deal with every day.

Does my hospital’s existing relationship with our EHR vendor ensure 100% compliance with the e-notifications CoP?

While most EHR vendors typically provide solutions to enable Direct Messages upon inpatient events, in particular discharge events, as was specified under Meaningful Use, the new CoP notification requirements are expanded where hospitals must send notifications upon all inpatient and emergency department events. Furthermore, those notifications must not only be sent to providers identified in the EHR but also to those providers with attributed patients that request notifications to support treatment and care coordination activities. To do so, solutions need three key components: 1) manage notification requests from patients’ attributed providers across the care continuum, 2) accurately match patients’ care events, and 3) send notifications based on the matches in real-time to the appropriate practitioner or entity. Any hospital that aims to rely on its EHR vendor to meet compliance requirements should assess whether the vendor can indeed offer a complete solution and how it might guarantee compliance.

Most of our patients are local. Is our HIE able to ensure 100% compliance with the e-notification CoP?

The CoP requires e-notifications be sent at the time a patient event occurs to any established practitioner, practice group/entity, or post-acute regardless of their geographic location. While most care events in your smaller system may be local, the CoP requires that your hospital account for all scenarios to ensure care coordination both within your system and beyond so you must account for scenarios such as a patient traveling across state lines. Since most HIEs send notifications only within their state or regional borders, they may not have the required dynamic roster or census capabilities developed to service in the full range of providers as required by the CoP. Such limitations would prevent notifications to be sent in real time on behalf of the hospital to all providers that must receive them. Since hospitals will be ultimately held accountable for meeting compliance requirements even if they use an intermediary, hospital leaders should evaluate their HIE’s capabilities and assess if they might face non-compliance risk and undue exposure. As a small hospital system, we’re looking to save costs as much as possible.

What kind of increase can our hospital expect to see in our operating budgets by setting up this process?

Can we handle the requirements internally? The CoP intends for hospitals to adopt a more comprehensive information sharing solution, so hospitals must understand and address all requirements to avoid deficiencies on surveys. Hospitals planning to set up a process to handle the requirements internally will need to plan for a moderate to a significant increase in their operating budgets, as it will require a full assessment of their current capabilities compared against the CoP requirements. Meeting these requests will require hospitals to manage patient rosters and match patient care events to those rosters, which then trigger notifications. Because care relationships can change daily, especially in the post-acute setting, patient attribution information from rosters will also need to be updated accordingly, which can increase the technical complexity of managing e-notifications. In addition, any necessary data share agreements need to be in place between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. Hospitals should consider the workflows, processes and human resource requirements for establishing this type of infrastructure to determine if they can adequately address them. In most cases, an alternative solution can be more cost-effective and provide more insight than implementing a manual approach.

We can afford to take on more risk than a larger hospital system, so why do we need to prioritize this requirement now?

Every hospital from small to large is governed by this rule, so the necessary data share agreements need to be in place between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. Given the significant consequences of non-compliance, hospitals of all sizes need to assess their existing notification capabilities and identify any gaps as quickly as possible as building a solution or vetting a third-party intermediary will require time. As the May 1, 2021 compliance deadline approaches, hospitals need to consider the workflows and processes they have in place to meet these requirements and whether they can adequately address them.

The Centers for Medicare and Medicaid Services’ (CMS) Interoperability and Patient Access E-Notifications Condition of Participation (CoP) deadline is rapidly approaching for hospitals and health systems. From the smallest rural hospitals to the largest health systems, compliance with this CoP brings varying levels of complexity.

Today’s mid-sized hospitals can face their own set of challenges ranging from the increased demand for service lines, growing patient populations, and the need to share data with regional health exchanges while complying with expanding regulatory requirements. Considerations like these, combined with the COVID-19 pandemic and impending deadline for achieving compliance with the CMS Interoperability and Patient Access Rule E-Notifications Condition of Participation Provision, make for an overwhelming task, especially for CIOs and administrative professionals who typically have more complicated systems than small hospitals, with fewer compliance and technical support staff than larger hospital systems.

With the May 1st deadline rapidly approaching, we’ve compiled a list of Q&As to help guide you through the process. These questions can be used as a resource to help clarify any misconceptions, avoid deficiencies that could jeopardize your CMS certification status, and provide advice for implementing a CoP solution that addresses the unique pain points that mid-sized hospitals face on a daily basis.

As a mid-sized hospital, we have a large local network of providers. Is our HIE able to ensure 100% compliance with the e-notification CoP?

Even though most care events in your mid-sized hospital network may be local, the new CoP requires e-notifications be sent at the time a patient event occurs to any established practitioner, practice group/ entity, or post-acute regardless of their geographic location. This means that your mid-sized hospital must ensure care coordination both within your system and beyond, which requires the consideration of scenarios such as a patient traveling across state lines. Because most HIEs send notifications only within their state or regional borders, they may not have the required dynamic roster or census capabilities developed to service in the full range of providers as required. Limitations such as these would prevent real-time notifications from being sent on behalf of the hospital to all necessary providers. As a result, it is critical for hospitals to evaluate your HIE’s capabilities in order to avoid non-compliance risk and undue exposure, as even if you use an intermediary, hospital leaders are ultimately held accountable for meeting compliance requirements.

Our mid-sized hospital already has an existing relationship with EHR vendor(s). Do we already have the capabilities to field all external requests for e-notifications from community providers?

Most EHR vendors typically provide solutions to enable Direct Messages upon inpatient events, in particular discharge events, as was specified under Meaningful Use. However, the new CoP notification requirements are expanded where hospitals are required to send notifications upon all inpatient and emergency department events. To support treatment and care coordination activities, this rule expansion also makes it so those notifications must be sent to providers identified in the EHR as well as to those providers with attributed patients that request notifications. As a result, your hospital’s solution must: 1) manage notification requests from patients’ attributed providers across the care continuum, 2) accurately match patients’ care events, and 3) send notifications based on the matches in real-time to the appropriate practitioner or entity. This means that it is most likely not enough to rely on your EHR vendor to meet compliance requirements. You can assess this by approaching your EHR vendor directly. Ask them if your existing EHR solution has the ability to guarantee compliance with the new rule.

We don’t want another layer of technology to log into to send and receive data. Can we handle the requirements internally?

The ultimate goal of the new CoP is for hospitals to adopt a more comprehensive information sharing solution. As a result, it is critical for mid-sized hospitals to fully understand and address all requirements in order to avoid deficiencies on surveys. Hospitals should plan for a moderate to significant increase in their operating budgets if they wish to establish a process to handle the requirements internally because it will require a full assessment of current capabilities compared against the requirements of the CoP. To meet CoP requests, your hospital will need to have the capability to manage patient rosters and match patient care events to those rosters, which then trigger notifications. Also, since care relationships can change daily, your mid-sized hospital will need to plan for an increase in the technical complexity of managing e-notifications as your patient attribution information must be updated from rosters accordingly. To determine if your hospital can adequately address the requirements, you will need to consider the added workflows, processes and staffing requirements for establishing this type of infrastructure, as well as account for any necessary data share agreements between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. Due to this level of complexity, many mid-sized hospitals are finding that an alternative solution can be more easily integrated with existing technology and is often more cost effective to implement a manual approach.

Amidst COVID-19 and other initiatives, our hospital has a lot going on. Do we need to prioritize this requirement right now?

Necessary data share agreements need to be in place between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. As a result, hospitals of all sizes need to assess their existing notification capabilities and identify any gaps as quickly as possible, as building a solution or vetting a third-party intermediary will require time, and there will be significant consequences of non-compliance. Mid-sized hospitals assessing their priorities should consider the workflows and processes they have in place to meet these requirements and whether they can adequately address them in time for the May 1st compliance deadline.

The Bundled Payments for Care Improvement Advanced Model (BPCI-Advanced) is a voluntary advanced alternative payment model that began in October of 2018, and is set to continue through 2023. The model serves Medicare fee-for-service (FFS) beneficiaries and allows participants to take on risk for the 90-day duration of up to 31 eligible inpatient clinical episodes and 4 eligible outpatient clinical episodes. Total Medicare FFS expenditures for the 90-day clinical episodes are reconciled against Target Prices, enabling participants to receive a single retrospective payment for their attributed clinical episodes, with payment reconciliation done on a semi-annual basis.

In September of 2020, the Centers of Medicare and Medicaid Services (CMS) released updates to Model Year 4 of BPCI-Advanced, which went into effect in January of 2021. The model changes were designed to help ensure the program achieves its goal of providing Medicare savings without sacrificing patient care quality. The changes will mitigate participant clinical episode selection bias, improve Target Price accuracy, and help CMS ensure reconciliation payments are made as a result of true cost reductions versus participant regression to the mean.

Below is a breakdown of the five major changes made by CMS to Model Year 4, and the impact these changes will have on BPCI-Advanced participants.

Change #1: Clinical Episode Service Line Groups (CESLGs)

The first major change to Model Year 4 is the creation of clinical episode service line groups. With this new change, the 35 BPCI-Advanced clinical episodes are bucketed into 8 clinical episode service line groups; cardiac care, cardiac procedures, gastrointestinal surgery, gastrointestinal care, neurological care, medical and critical care, spinal procedures, and orthopedics.

With this change, participants are now required to select clinical episode service line groups and must participate in all the clinical episodes within each grouping unless they do not meet the minimum volume threshold for any component clinical episode during the baseline period. Additionally,  participation in clinical episode service line groups will be locked in for three years, meaning participants cannot drop these groupings and still remain in the program.

Change #2: New Clinical Episode Overlap Methodology

The second major model change is the introduction of a new clinical episode overlap exclusion methodology. In Model Year 4, CMS is excluding any clinical episodes that would have been normally triggered while a beneficiary has an ongoing separate clinical episode. This in effect means that no BPCI-Advanced clinical episodes will be overlapping. It is important to note that overlapping clinical episodes will be excluded regardless of whether the initial ongoing episode was attributed to a BPCI-Advanced participant or not.

Change #3: Realized Peer Group Trend Adjustment

The third major change to Model Year 4 is the introduction of a retrospective peer ground trend adjustment. With the new update, CMS will adjust final Target Prices at Reconciliation for peer group trends found in Performance Period Clinical Episodes spending. This means that CMS will cap the difference between the realized retrospective peer-group trend factor from the preliminary prospective peer-group trend factor at 10% of the preliminary prospective trend. Peer groups are based on relevant hospital characteristics, such as region, size, academic medical center status, safety net status, and urban versus rural status.

Change #4: Removal of Physician Group Practice (PGP) Offset

The fourth major model change in Model Year 4 is that CMS will remove the PGP offset used in PGP target price construction. This means that each clinical episode category will have a single target price that does not vary irrespective of the individual PGP that triggered the episode.

This change will create the same Target Prices for PGPs as acute care hospitals (ACHs), except for their respective patient Case Mix Adjustments (CMA), simplifying the program’s pricing methodology and easily allowing for program scale. In terms of participant impact, this change could lead to possible increases in savings for historically efficient PGPs and a possible reduction in savings for historically inefficient PGPs.

Change #5:  Major Joint Replacement of the Lower Extremities Risk Adjustment

The final major program change is that CMS will add procedure flags to the Model Year 4 risk adjustment model for the Major Joint Replacement of Lower Extremities (MJRLE) clinical episode. This includes flags for; partial knee arthroplasty, total knee arthroplasty, partial hip arthroplasty, total hip arthroplasty and hip resurfacing, ankle and reattachments, and others. CMS will use these flags to improve the precision of the MJRLE clinical episode category risk adjustment and Target Prices.

In light of these recent changes, BPCI-Advanced participants should keep in mind two key considerations; the requirement of rapid financial assessments and decision making, and the likelihood that CMS will introduce mandatory bundled payment programs after the initial program conclusion in 2023. To help ensure they meet their programs’ clinical and financial goals, participating organizations should incorporate proper workflows and supporting infrastructures, and prepare for the future mandatory bundled payments value-based care programs that are to come.

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.