Population Health Management
and
theand
Role
of EHR for
ACOs
Requirements
Reporting Quality Measures
Saeed A. KhanDr.
MD,Saeed
MBA, FACP
Presenter:
Khan
© CureMD Healthcare
© CureMD Healthcare
CureMD Population Health Mission
To create an all inclusive
Population Health EMR by
integrating Clinical Data and
Quality Measures with
Revenue Cycle Management.
2
Goals of US Healthcare Reform
• Increased access
• Reduced costs
• Improved quality
3
Changes in Primary Care
• Shift from individual to population management
• Shift from reimbursement for acute episodic illness
based on E/M criteria to preventive care and chronic
disease management with the new reimbursement
model based on the reporting and monitoring of the
population’s health status
• Move to decrease variance in care by the use of
evidence based medicine and clinical guidelines
4
New Reimbursement Model
Transition from
Volume based care [E/M, Procedure, RVU]
to
Value based care [in addition to acute episodic
illness, quantifying care through defined
measures and monitoring of such with an
emphasis on prevention and minimization of the
complications of chronic illnesses through early
intervention]
5
Reimbursement Model
Based on
• Measuring defined preventive health metrics of a
given patient population
• Measuring and showing improvement in defined
metrics in the management of chronic diseases
• Accurate coding to capture the patient population
true health status and applying appropriate medical
risk adjustments [MRA]
6
Market Segments Involved
• Health Plans/Insurance Companies
• Large physician groups
• Small physician practices
7
Health Plans
Challenges
1. Financial
2. Wellness and Population Management
3. Changing Delivery Models
8
Financial Challenges
• Shifting reimbursement and funding.
• Shrinking profit margins.
• Increasing cost of doing business.
9
Wellness and Population Management
• Move towards proactive prevention and wellness
rather than retroactive management of acute
decompensation in chronic illness
• Increased patient engagement in healthcare
decisions with an emphasis on prevention
• Focus on Population-based care management
• Consistency of care
10
Changing Delivery Models
• Care coordination across the continuum. PCMH and
ACOs
• Transition to less costly platforms of care when
appropriate, with the resultant cost savings and
avoidance of reduplication of tests and services
• Move towards more office-based procedures for
specialties
11
Physician Practices
Challenges
1. Increased cost of business in face of shrinking
reimbursements
2. Wellness and Population Management
3. Consistency of Care to Decrease Variances
4. Appropriate and accurate coding to capture the
patient’s true MRA score
5. Integration of clinical and quality data into the
billing cycle to report required elements for correct
reimbursement
Population Health Process Outsourcing
of tasks that can be consolidated to manage overhead
Care delivery organizations can meet the objectives of reducing operational costs, minimizing administrative overheads
and maximizing profitability by strategically outsourcing their business processes to specialized service providers.
CureMD can help your organization derive efficiencies and reduce costs, improve quality and experience quicker turnaround times while eliminating non-value-adding tasks.
CureMD healthcare processing outsourcing enables your organization to outsource administrative and clinical functions
including patient registration, eligibility verification, scheduling, medical billing, referrals and patient relationship
management. By working with us, you will have the opportunity to free yourself from administrative and operational
tasks so you can better focus on your core business – providing quality patient care. And since CureMD provides a
comprehensive outsourcing methodology, you will not only free your resources but also save more than 40% in
operational costs.
Service packages include:
• Front Desk services
• Patient Registration
• Scheduling & Appointment
Management
• Eligibility Verification
• Referral Management
• Appointment confirmation
• Follow-up Appointment Reminder
& Scheduling
• Back Office Services
• Medical Billing
• A/R management
• Denial management
• Patient Statements
• Trending and reporting
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Consistency of Care
Variances can be decreased by the use of:
Guidelines based on established peer reviewed best
practices
• Hypertension JNC 7
• Diabetes Mellitus ADA
• Congestive Heart Failure AHA and ACC
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Consistency of Care
• Hyperlipidemia
ACEP
• COPD/Asthma
National Heart Lung &
Blood Institute and ATS
• Depression
APA
• Adult Preventive Care
USPSTF
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Appropriate and Accurate Coding
Diabetes with Renal Disease
• Historically coded as 250.00 [DM Type II w/o
mention of complication]
with a MRA multiplier value of 0.18
• Now appropriately coded as 250.40 with MRA value
of 0.508 and with 585.9 CKD unspecified with a MRA
value of 0.368 for a total MRA multiplier value of
0.876
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Correct Coding Tips
Co-Existing Conditions
Chronic Seven Diagnoses
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
DM
CHF
COPD
ASTHMA
EMPHYSEMA
PARKINSONS
A-FIB
These diseases are generally managed by ongoing medication and have the
potential for acute exacerbations if not treated properly, particularly if the
patient is experiencing other acute conditions.
Top Ten Frequent HCCs by Occurrence
(from FFS Medicare data)
HCC108- COPD
HCC80 - CHF
HCC19 - Diabetes w/o complications
HCC105- Vascular disease
HCC92 - Specified heart arrhythmias
HCC10 - Breast, prostate, colorectal and
other cancer tumors
HCC83 - Angina
HCC96 - Ischemic or unspecified stroke
HCC38 - Rheumatoid arthritis & infl cond…
HCC82 – Acute MI
12.17%
11.17%
10.79%
9.36%
8.93%
6.99%
5.04%
3.97%
3.85%
3.82%
Integration of clinical and quality data into the
billing cycle to report required elements
• Quality reporting is Claims based process
• G codes and CPT II codes used
• Auto population of measures groups in subsequent
visits
• Integration into Revenue Cycle Management to
report PQRS and other required quality data to
health plans and CMS
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RCM Business Processes
Revenue Cycle Management -RCM
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Next Steps
•
Preventive Care Modules with clinical alerts
• Hybrid Measures Groups, which will capture the requirements
for HEDIS, 5 Star program (The Medicare Part C pay for
performance incentive program), ACO’s and the PQRS
requirements for MU.
• Incorporation of Evidence-Based Medicine in the form of
clinically accepted guidelines from organizations like ADA, AHA
for the management of chronic illnesses including diabetes,
coronary artery disease, congestive heart failure and so on.
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• Expansion of the existing decision-support systems to
incorporate medical acuity decision trees. This includes but not
limited to the development of medical risk-adjusted [MRA]
coding to identify the true nature of the patient population
under care.
• Extension of the patient portal to include links to popular
wellness sites and similar programs, after input from patients,
physicians, Health Plans and other stake holders.
• Expansion of health information exchange [HIE] to maximize the
interconnectivity between the insurance carriers, providers and
other vendors to maximize flow of information and decrease
redundancy and avoid duplication of testing
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• Continue with the current outsourcing of non value added tasks
which will minimize missed patient appointments improve patient
adherence to care plan and medication adherence through call
centers and automated reminder systems.
• Revenue enhancement by capturing most appropriate MRA
through improved decision prompts and identification and
coordination of care across the continuum through HIE.
• Integrate the G code and CPT II reporting into RCM
• Other initiatives as the market warrants in the future
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Enjoy the festivities!
CureMD Healthcare
55 Broad Street, New York, NY 10004
Ph: 212.509.6200
www.curemd.com