Medicare Access And CHIP Reauthorization Act Research Articles

Trends in heart failure costs for commercially insured patients in the United States (2006–2021)

BackgroundAlthough prior research has estimated the overarching cost burden of heart failure (HF), a thorough analysis examining medical expense differences and trends, specifically among commercially insured patients with heart failure, is still lacking. Thus, the study aims to examine historical trends and differences in medical costs for commercially insured heart failure patients in the United States from 2006 to 2021.MethodsA population-based, cross-sectional analysis of medical and pharmacy claims data (IQVIA PharMetrics® Plus for Academic) from 2006 to 2021 was conducted. The cohort included adult patients (age > = 18) who were enrolled in commercial insurance plans and had healthcare encounters with a primary diagnosis of HF. The primary outcome measures were the average total annual payment per patient and per cost categories encompassing hospitalization, surgery, emergency department (ED) visits, outpatient care, post-discharge care, and medications. The sub-group measures included systolic, diastolic, and systolic combined with diastolic, age, gender, comorbidity, regions, states, insurance payment, and self-payment.ResultsThe study included 422,289 commercially insured heart failure (HF) patients in the U.S. evaluated from 2006 to 2021. The average total annual cost per patient decreased overall from $9,636.99 to $8,201.89, with an average annual percentage change (AAPC) of -1.11% (95% CI: -2% to -0.26%). Hospitalization and medication costs decreased with an AAPC of -1.99% (95% CI: -3.25% to -0.8%) and − 3.1% (95% CI: -6.86–0.69%). On the other hand, post-discharge, outpatient, ED visit, and surgery costs increased by an AAPC of 0.84% (95% CI: 0.12–1.49%), 4.31% (95% CI: 1.03–7.63%), 7.21% (95% CI: 6.44–8.12%), and 9.36% (95% CI: 8.61–10.19%).ConclusionsThe study’s findings reveal a rising trend in average total annual payments per patient from 2006 to 2015, followed by a subsequent decrease from 2016 to 2021. This decrease was attributed to the decline in average patient costs within the Medicare Cost insurance category after 2016, coinciding with the implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. Additionally, expenses related to surgical procedures, emergency department (ED) visits, and outpatient care have shown substantial growth over time. Moreover, significant differences across various variables have been identified.

Colorectal Cancer Screening in Rural and Urban Primary Care Practices Amid Implementation of the Medicare Access and CHIP Reauthorization Act.

The Medicare Access and CHIP Reauthorization Act (MACRA) incentivized primary care practices to improve colorectal cancer screening rates. This study examined if colorectal screening rates improved among rural and urban primary care practices amid implementation of MACRA. Colorectal cancer screening data are from a national registry of 139 primary care practices. Repeated measures regression tested for rural/urban differences and changes in screening rates between 2016 and 2020, adjusting for county demographic factors and social deprivation. Screening rates were 64% in both rural and urban practices in the first quarter of 2016 and increased to 80% and 83% in rural and urban practices, respectively, in the last quarter of 2020. In adjusted analyses, screening rates increased by 4% per year and there were no rural/urban differences. Lower screening rates were associated with higher county proportions of persons who were 45 to 74 years of age and Hispanic. Higher screening rates were associated with higher county proportions of persons who were White, Black, and Asian and higher social deprivation. Colorectal screening rates improved among rural and urban primary care practices during implementation of MACRA, but disparities persist among practices serving county populations that are relatively older, more Hispanic, and have higher social deprivation.

Declining trends in Medicare physician reimbursements for surgical procedures in orthopaedic oncology from 2002 to 2018: a retrospective review of payment data

Background: As the United States (US) healthcare system evolves towards cost-containment and value-based approaches, evaluating trends in procedure reimbursements will be critical for assessing and ensuring financial stability of highly specialized fields, such as orthopaedic oncology. Methods: The Medicare Physician Fee Schedule (MPFS) look-up tool was accessed through the official Center for Medicaid and Medicare Services website and used to retrieve average reimbursement rates for 28 common orthopaedic oncologic procedures (radical resections of soft tumors, bone tumors, and prophylactic treatment, nailing, or pinning) from 2002 to 2018. All reimbursement data were adjusted for inflation to 2018 dollars. For each Current Procedural Terminology (CPT) code, average reimbursement percentage change from 2002 to 2018 was calculated. Results: Based on the included codes, physician payment data for 28 surgical procedures from 2002 to 2018 were retrieved from the MPFS database. After adjusting all data for inflation, the average reimbursement for all included procedures decreased by 9.9% from 2002 to 2018, representing an estimated average decrease of 1.1% every couple of years. Reimbursement percentage decreases were the most significant prior to the Medicare Access and CHIP Reauthorization Act (MACRA), with reimbursements decreasing by an average of 5.8% from 2002 to 2014. However, reimbursement rates still declined by an average of 4.3% from 2014 to 2018 (after MACRA). Discussion: Reimbursements for orthopaedic oncologic procedures have steadily decreased over time. With orthopaedic oncology being a highly specialized field with few practicing providers, health policy makers need to understand the financial implications of the declining reimbursement rates to ensure financial stability and viability of the specialty. Level of Evidence: Level III.

Development of a qualified clinical data registry for emergency medicine.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 marked a fundamental transition in physician payment by the Centers for Medicare and Medicaid Services (CMS) from traditional fee‐for service to value‐based models. MACRA led to the creation of the CMS Quality Payment Program (QPP), which bases the value of physician care in large part on physician quality reporting. The QPP enabled a shift away from legacy CMS‐stewarded quality measures that had limited applicability to individual specialties toward specialty‐specific quality measures developed and stewarded by physician specialty societies using Qualified Clinical Data Registries (QCDRs). This article describes the development of the first nationally available emergency medicine QCDR as a means for emergency physicians to participate in the QPP, measure, and benchmark emergency physician quality.

Barriers to participation and success in value-based care (VBC) models.

70 Background: The enactment of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 initiated the transition from a fee-for-service to a fee-for-value payment system in healthcare. Two government-sponsored VBC models (Oncology Care Model [OCM] and Merit-Based Incentive Payment System [MIPS]) were introduced in 2016 and 2017. Several commercial payers followed suit with similar value-based contracts. Implementing and complying with the performance metrics of these models comes with challenges. This qualitative research study sought to assess participation in both government-sponsored and commercial-insurance-sponsored VBC models among oncology providers and their perceptions regarding the ability to perform successfully. Methods: Between February and April 2021, medical oncologists/hematologists (mO/H) from across the U.S. were invited to complete a web-based survey about various trends and critical issues in oncology care. Demographics about the physicians and characteristics of their practices were captured as well in the survey. Responses were aggregated and analyzed using descriptive statistics. Results: A total of 307 mO/H across the U.S. completed the survey: 73% practice in a community setting; 47% identify as hospital employees. The participants spend a median of 90% of their working time in direct patient care, have a median of 16 years of clinical experience, and see a median of 20 patients per day on clinic days. Half participate in a government-sponsored VBC model (21% MIPS and 28% OCM), and 20% participate in a commercial VBC model. A third reported that it is difficult to perform favorably in VBC models (37% government and 35% commercial). Primary challenges deterring favorable performance were navigating the payer landscape and reimbursements (27%), identifying cost-reduction opportunities (20%), tracking costs across an episode (18%), and clinical decision support and compliance (17%). One-third are not satisfied with currently available technology to effectively support their performance in VBC models. Almost half would like to see more seamless integration into practice workflows (49%) and interoperability across platforms including EHRs (42%), and 24% would like artificial intelligence or machine learning features integrated into solutions tools. Conclusions: Oncology practices find it challenging to perform favorably in government and private payer-sponsored VBC models. They are generally dissatisfied with current technology and see an unmet need for interoperability and artificial intelligence to better support their performance in these programs. Further research is needed to determine how best to design and implement VBC programs.

Rescanning the Alternative Payment Model Horizon for Physician Anesthesiologists

Payment & Practice Management| June 2021 Rescanning the Alternative Payment Model Horizon for Physician Anesthesiologists David P. Martin, MD, PhD, FASA; David P. Martin, MD, PhD, FASA Search for other works by this author on: This Site PubMed Google Scholar Vanessa Salcedo, MPH; Vanessa Salcedo, MPH Search for other works by this author on: This Site PubMed Google Scholar Sharon K. Merrick, MS, CCS-P Sharon K. Merrick, MS, CCS-P Search for other works by this author on: This Site PubMed Google Scholar ASA Monitor June 2021, Vol. 85, 38–39. https://doi.org/10.1097/01.ASM.0000754272.06470.61 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Twitter LinkedIn Cite Icon Cite Get Permissions Search Site Citation David P. Martin, Vanessa Salcedo, Sharon K. Merrick; Rescanning the Alternative Payment Model Horizon for Physician Anesthesiologists. ASA Monitor 2021; 85:38–39 doi: https://doi.org/10.1097/01.ASM.0000754272.06470.61 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search Search nav search search input Search input auto suggest search filter All ContentAll PublicationsASA Monitor Search Advanced Search Topics: delivery of health care, medicare, value-based care, fee for service payment plan, accountable care organizations, bundled payments for care improvement (bpci) initiative In the future, you probably won't be paid simply for what you do. Increasingly, physician anesthesiologists receive payment through arrangements that tie dollars to quality, outcomes, and value. This shift toward value-based payment has been accelerated by the COVID-19 pandemic. The Payment and Practice Management column in the August 2019 edition of this publication scanned the Alternative Payment Model (APM) horizon. Much has changed since then and many ASA members remain confused about APMs. This article provides an updated overview about the APM horizon and spotlights what ASA committees and staff are doing to ensure physician anesthesiologists are prepared to participate actively and meaningfully in APMs and other value-based arrangements. This article focuses on Medicare APMs. Commercial APMs will be covered in future articles. The 2015 passage of the landmark Medicare Access and CHIP Reauthorization Act (MACRA) created the Quality Payment Program (QPP). The QPP is pivotal in the attempt... You do not currently have access to this content.

Medicare Access and CHIP Reauthorization Act in Small to Medium-Sized Primary Care Practices.

Despite major efforts to transition to a new physician payment system under the Medicare Access and CHIP Reauthorization Act (MACRA), little is known about how well practices are prepared. This study aimed to understand how small and medium-sized primary care practices in the Heart of Virginia Healthcare (https://www.vahealthinnovation.org/hvh/) perceive their quality incentives under MACRA. This study analyzed data from 16 focus-groups (70 participants), which yielded a range of physician, advanced practice clinician, office manager, and staff perspectives. Focus-groups were audio-recorded and transcribed, then imported into NVivo for coding and analysis of themes. A multidisciplinary research team reviewed the transcripts to maximize coding insights and to improve validity. The main findings from the focus-groups are: 1) MACRA awareness is relatively higher in independent practices, 2) steps taken toward MACRA differ by practice ownership, and 3) practices have mixed perceptions about the expected impact of MACRA. Two additional themes emerged from data: 1) practices that joined accountable care organizations are taking proactive approaches to MACRA, and 2) independent practices face ongoing challenges. This study highlights a dilemma in which independent practices are proactively attempting to prepare for MACRA's requirements, yet they continue to have major challenges. Practices are under extreme pressure to comply with reimbursement regulations, which may force some practices joining a health system or merging with another practice or completely closing the practices. Policy makers should assess the unintended consequences of payment reform policies on independent practices and provide support in transitioning to a new payment system.

MACRA and Accountable Care Organizations: Is It Working?

The purpose of this study was to examine how the Medicare Access and CHIP Reauthorization Act (MACRA) has improved health care delivery and to determine its impact on Accountable Care Organization (ACO) goals. ACOs have provided quality care through the reduction in readmission rates, coordinated care, and cost savings. With the passage of the MACRA, it has been estimated that it would further decrease Medicare spending on physician and hospital services. Also, ACOs have had a positive impact on improving health care delivery and have played a significant role in providing exceptional quality of care while also managing to increase the cost savings.

Correlates and Motivations for Provider-Sponsored Health Plan Ownership in the Post-Reform Era

The rise and fall of managed care in the 1980s and 1990s saw many hospitals and health systems in the United States enter and subsequently exit the health insurance market in the form of provider-sponsored health plans (PSHP). The passage and implementation of the legislation such as the Patient Protection and Affordable Care Act (ACA) and the Medicare Access and CHIP Reauthorization Act (MACRA) has ushered in an era of value-based reimbursement methods and a heightened focus on population health management, which has stimulated health care organizations to contemplate health plan ownership as a logical strategy. This study examined market and organizational factors associated with PSHP ownership in the post-reform era, as well as motivations for engaging in PSHP. This study used a sequential quantitative to qualitative mixed-methods design. The quantitative analysis examined 5,849 U.S. hospitals using binary logistic regression and ordinary least squares regression models for the year 2017. Ten semi-structured interviews were conducted representing eight health systems in five states. Thematic analysis was conducted and results were synthesized with quantitative findings. The results indicated that hospital and payer concentration, percentage of the state population on Medicare, income per capita, unemployment rate, presence of salaried physicians at the hospital, participation in risk-bearing arrangements, absorptive capacity score, participation in a clinically integrated network, profit-status and CBSA indicator were all significantly associated with health plan ownership at p<.05. Interviewees reinforced these findings and described PSHP as the culmination of the journey along the continuum of volume-based incentives to value-based incentives, as well as a strategy to better compete, and diversify revenue streams. Implications for policy and practice are discussed.

Addition of Efficiency Measures to Current Accuracy Measures in the Vascular Laboratory Can Be Used for Future Accreditation and Payment Models

The Medicare Access and CHIP Reauthorization Act (MACRA) brings with it increased regulatory requirements not traditionally addressed by standard vascular laboratory accreditation, which is based on accuracy. The new quality improvement project of the Intersocietal Accreditation Commission (IAC) may satisfy an improvement activity (IA) of the MACRA. We hypothesize that other IAs in the MACRA such as timeliness of test results or patient care quality performance requirements can be met by analyzing data already being collected by the vascular laboratory. After a process improvement strategy, we chose to review progress in our vascular laboratory related to time to interpretation (TI), patient check-in to study completion (study time), wait time for first available outpatient venous duplex scan (wait time), technologist productivity, and critical results reporting. Data from our hospital-based vascular laboratory were collected from 2010 to 2016. TI was collected through our reporting software VascuPro (Consensus Medical), and study time and wait time were obtained from electronic medical records (EMR) (Epic). Technologist productivity was calculated by commercially available productivity tools, and compliance with critical results reporting was calculated quarterly as per our quality assurance program. Appropriateness of carotid duplex scan testing was performed by expert review of International Classification of Disease codes used to request the test. TI analysis comprised 91,352 studies with a mean of 3.3hr between test completion and final interpretation. The TI improved from 5.0 to 2.1hr on weekdays and was longer on weekends (4.9 hr; P<0.001). The study time improved from 29.8 to 27.2min and was 14.9min shorter on the weekends (P<0.001). The wait time ranged from a mean of 1-2.08days. Technologist productivity improved from 90.7% to 93.6%. Critical results reporting quarterly audits showed a 100% compliance rate. On expert review, the International Classification of Disease code on carotid duplex scan requests in the EMR was deemed inaccurate in 17.4% of cases. TI and study time improved; wait time and critical results reporting remained steady. Most of the data are readily available in a vascular laboratory standard EMR. The plan-do-study-act (PDSA or Shewhart Cycle) principle is critical to process improvement and needed as we transition from traditional accreditation mostly based on test accuracy to one demanding efficiency, timeliness, patient satisfaction, productivity, accountability, and appropriateness of testing. Process improvement studies will improve patient care and satisfaction, increase efficiency and throughput, while satisfying changing IAC standards and preparing for upcoming regulatory requirements of the MACRA.

Four years into MACRA: What has changed?

In 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), a policy intended to transition Medicare away from pure fee-for-service care to value-based care. MACRA does this by evaluating the cost and quality of providers, resulting in financial bonuses and penalties in Medicare reimbursement. MACRA offers two tracks for participation, the Merit-based Incentive Payment System and the Advanced Alternative Payment Models. Although the payment rules are different for each of the tracks, common to both is an emphasis on holding providers accountable for high-quality, cost-efficient care. Early data suggest that the End-stage renal disease Seamless Care Organizations, an Advanced Alternative Payment Model, resulted in cost-savings concurrent with improved care quality. Additionally, on July 10th 2019, the President signed an executive order that further attempts to improve kidney disease care by shifting its focus away from in-center hemodialysis toward chronic kidney disease care, home-based dialysis, kidney transplantation, and innovating new therapies for kidney disease. These changes to nephrology reimbursement present a unique opportunity to improve patient outcomes in a cost-effective way. A multidisciplinary effort among policy makers, nephrology providers, and patient advocacy groups is critical to ensure these changes in care delivery safeguard and improve patient health.

2526 Utilizing Quality and Value Metrics to Improve Patient Outcomes Through the Kaiser Permanente Minimally Invasive Hysterectomy Initiative

Study Objective We present a case study in improving quality metrics with the Kaiser Permanente Minimally Invasive Hysterectomy Initiative to address the high rates of abdominal hysterectomies. Design Quality Improvement Project. Setting Route of hysterectomy (abdominal, laparoscopic, vaginal, robotic). Patients or Participants 31,385 patients who underwent surgical hysterectomy at Kaiser Permanente Northern California between 2008-2015. Interventions We initiated a four-pronged quality improvement program to increase the rate of minimally invasive hysterectomies, including: 1) Leadership engagement to set goals and achievable targets; 2) Surgeon education and training; 3) Utilization of targeted medical data to track outcomes and drive performance; and 4) Delineation of Obstetrics and Gynecology surgical teams and establishment of criterion-based credentialing. Measurements and Main Results Total abdominal hysterectomy percentages decreased from 50.5% to 6.9%, and total laparoscopic hysterectomy percentages increased from 21.9% to 61.9%. Robotic hysterectomy percentages only increased from 0.1% to 7.8%, and total vaginal hysterectomy percentages were maintained. Conclusion Our experience indicates that a quality improvement program to reduce abdominal hysterectomies while improving patient care can be successfully instituted on a large scale with limited reliance on less cost-effective robotic technology. The core aspects of the strategy should be highly incentivized under programs like Medicare Access and CHIP Reauthorization Act (MACRA). Moreover, this model can be used to address other quality issues in gynecologic surgery. It is our hope that the future of gynecologic surgery moves towards such a model that prioritizes optimal patient care. Please note that this abstract includes information that was presented in the paper, “Measuring Quality in Minimally Invasive Gynecologic Surgery: What, How, and Why?” by Abel et. al. in JMIG February 2019.

Community oncologists perceptions and readiness to implement Medicare Access and CHIP Reauthorization Act (MACRA).

e18374 Background: The Medicare Access and CHIP Reauthorization Act (MACRA) was introduced in 2015 with the intention of transforming healthcare administration to improve the quality of care and lower its cost. Understanding challenges facing physicians in how to implement MACRA and recognizing their perceptions regarding these challenges are critical steps to the success of this program and future transformation efforts. Methods: In this study, US oncologists attending live meetings were surveyed on their perceptions of MACRA. Data were collected in 2 time periods: period 1 spanned Nov 2016 to Jun 2017 and period 2 spanned Sep 2018 to Nov 2018. Each physician attended a live meeting in each period. Data were collected in period 1 using audience response system technology and web-based surveys; period 2 data were collected using web-based surveys only. We aimed to compare responses between periods 1 and 2 to assess whether perceptions and challenges changed. Results: There were 97 community oncologists and/or hematologists who responded to both periods. Of the responding physicians, 31.2% were participating in the Oncology Care Model program. A greater proportion of physicians expressed some level of confidence in executing MACRA requirements and achieving financial success in period 2 compared to period 1 (74.2% vs 52.4%; P&lt; 0.01). Additionally, more physicians in period 2 reported having the resources and staffing needed to manage changes required by MACRA (24.7% vs 11.4%; P= 0.02). Strategies in place to improve on compliance with MACRA did not significantly change between both periods (34.2% vs. 28.9%; P = 0.45). Confidence that MACRA would improve patient outcomes in the long-term was expressed by 33.0% in period 2, which was significantly higher than in period 1 (17.6%; P= 0.02). However, most physicians in period 1 were not confident that MACRA would reduce cost of care (89.6%), but this improved to 61.9% in period 2 ( P&lt; 0.01). Conclusions: Over time, oncologists seem more confident about their practices’ readiness for implementing MACRA. However, they remain skeptical of MACRA’s likelihood of improving quality or cost of cancer care and appear to need better strategies to assure sustainability.

Wit, Wisdom, and Hard Work Make a Model Medical Director of the Year

Wit, Wisdom, and Hard Work Make a Model Medical Director of the Year

MIPS in Residency? A Look at Merit-Based Incentives in an Internal Medicine Residency Outpatient Practice.

In January 2017, full implementation of the Medicare Access and CHIP Reauthorization Act (MACRA) Merit-based Incentive Payment System (MIPS) inspired us to introduce a similar incentivized model of value-based care into our internal medicine residency's outpatient practice. To provide real-world experience in a value-based payment practice model, we provided monetary incentives to internal medicine residents for meeting inbox management expectations, timely reporting, and improvement in clinical outcome measures. Thirty-seven residents were divided into 6 teams. Over a 5-month period, clinical goals were to reduce by 5% each teams' average number of patients with diabetes who had HbA1c > 9% and to raise by 10% the number of diabetes patients at target blood pressure. Goals for inbox management were established: all forms, notes, medication refills, and patient requests were expected to be complete at the end of each week. Teams received monetary bonuses based on compliance with reporting, management of inboxes, and progress toward clinical outcome goals. Every team improved their patients' blood pressure; however, no one reached the 10% target. Every team improved their patients' average HbA1c, and 2 teams surpassed the 5% goal. All teams met their weekly reporting goal, and half completed the inbox management tasks 100% of the time. Of the 26 participants who completed the survey, 22 (85%) favored continuing the program. Providing monetary incentives in a team-based internal medicine residency model improved patient outcome measures and provided real-world exposure to incentivized value-based care.

Submission of MIPS Quality Metrics via Claims in a Radiation Oncology Practice

Participation in the Medicare Access and CHIP Reauthorization Act (MACRA) involves either Advanced Alternative Payment Models or the Merit-Based Incentive Payment System (MIPS). Most physicians will participate in MIPS, consisting of four performance categories to determine positive, neutral, or negative payment adjustments. The Quality performance category was preceded by the Physician Quality and Reporting System (PQRS) program and now affects physician reimbursement based upon performance rates. The Quality performance category has a high clerical burden on small practices that lack administrative support or access to a Qualified Clinical Data Registry (QCDR). We explored submission of quality data by claims, a method felt to require the least data entry for physicians. With the 4th quarter of the MIPS reporting period (starting 10/2/17 to 12/31/17), we selected seven measures from the CMS Quality Payment Program (QPP) website that could be submitted via claims. Measures were submitted with the appropriate current procedural terminology (CPT) code. Our billing sheet was configured to include these seven measures to be reported for each new patient consult (CPT 99201-5) and follow up visits (CPT 99212-5). Measure #156 was submitted with simulation (CPT 77295). Data on 148 patients was submitted. The measure reported on most frequently was #226 (tobacco use) with 100% of patients being screened for tobacco use and intervention offered for those were current smokers. Measure #130 (current medications) and #110 (influenza vaccination) were tied at 80%. Measure #111 (pneumococcal vaccination) was the next most frequent at 74%. The measures related to screening were the least frequently reported (#112 Breast Cancer Screening at 15% and #113 Colorectal Cancer Screening at 41%). Unlike the PQRS Program, which was a pay for reporting incentive program, the MIPS Quality Performance Category is a pay for performance program. When analyzing the performance rate for each measure, we achieved the following: #110 Influenza vaccination: 80% #111 Pneumococcal vaccination: 52% #112 Breast cancer screening age 50-74: 77% #113 Colorectal cancer screening age 50-75: 88% #130 Current medications 18 and older: 94% #156 Dose limits to normal tissues (for new starts only): 76% #226 Tobacco Use: Screening and Cessation: 97% Our online CMS MIPS Dashboard showed a score of 37.3 out of 60 possible points using this method. Measure #113 did not count towards the score. Participation in the MIPS Quality Performance Category can be successfully achieved via claims submission without the need for purchasing access to a QCDR or other commercially available web-based registry. Computer data entry by physicians was also minimized. Despite only five measures being accepted, our seven selected measures allow radiation oncologists to meet the minimum requirement of six quality measures to participate in the Quality Performance Category of the MIPS Program.

Telemedicine Tools for Patients and Providers: Systematic Review

Background: From the 1991 Institute of Medicine (IOM) Landmark Report, The Computer Based Patient Record: An Essential Technology for Health Care (Dick, Steen, & Detmer, 1997) which called for computer based patient records, to the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, health care has been integrating technology into our delivery systems and transforming the landscape of health care delivery (Wager, Lee, & Glaser, 2017). Telemedicine (also called telemonitoring, telehealth, remote monitoring, eHealth) has brought about new methods of care delivery. These methods will hopefully demonstrate cost effective outcomes as well as new levels of quality. Under the influence of The Centers for Medicare and Medicaid Services, The 2015 Medicare Access and CHIP Reauthorization Act (MACRA) was enacted which pushes the health care industry to improve quality and value. By the end of 2018, it is expected that 50% of alternative payment models will have quality and value tied to them and 90% of fee-for-service will do the same. It is feasible that telehealth could be the link to new health care delivery and payment models. This paper evaluates some of the most recent literature regarding telemedicine to elucidate quality within the domains of cost-effectiveness, hospitalization, mortality, patient adherence, and patient satisfaction. Objective: To evaluate the effectiveness of telemedicine strategies with respect to cost-effectiveness of care, hospitalizations, mortality, patient adherence, and satisfaction. Methods: The Google Scholar search engine was used to find articles published between 2015 and 2018 so that preliminary observations could be made regarding the telemedicine literature. Once this was done, a logical search process was used to locate articles using two research databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed (MEDLINE). The titles and abstracts of the records identified were independently screened by four investigators. Five reviewers screened 58 abstracts to determine relevance and significance relative to the research objectives. The final group analysis was 29 articles. Main outcome measures included economic, clinical, and satisfaction outcomes. Results: Our results showed that examining telemedicine interventions that were either patient or provider driven appeared to improve outcomes related to patient adherence, patient satisfaction, cost-effectiveness, and had a favorable effect in terms of decreasing hospitalizations. Only two articles that were reviewed addressed mortality, so the investigators could not describe results on its effect. Although there are barriers to adherence there is much progress in the field of telemedicine that aids in outcomes, both positive and negative. Conclusions: The literature is clear that telemedicine is linked to improved outcomes when applied with a sound strategic plan. Patients who adhere to telemedicine interventions appear to show significantly better satisfaction, quality of life, reduced hospitalizations, and related health care costs. When providers take greater responsibility and initiative with telemedicine interventions, this contributes to those patient outcomes. Our review of the literature suggests that the quality of the implementation strategy was linked with better outcomes. Telemedicine appears to hold promise as a cost effective, convenient tool for both patients and providers.

Bundled Payments in Otolaryngology: Early Lessons from Arkansas.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 established value-based reimbursement as the new norm in health care. As part of this shift, public and private insurers have adopted bundled payments in an effort to improve quality and control cost. Arkansas recently implemented an otolaryngology-specific bundled payment, which reimburses episodes of care involving adenoidectomy and/or tonsillectomy. In this mandatory model, otolaryngologists have the potential for shared savings or losses based on spending relative to risk-adjusted historical benchmarks and performance on quality metrics. The initiative has resulted in reduced health care costs and rates of postoperative antibiotic prescription and secondary bleeding. However, this experiment also illustrates potential pitfalls with bundled payments, such as emphasis of quality metrics lacking clinical relevance and incentive for increased service volume. The Arkansas initiative offers important lessons for otolaryngologists as ongoing reform under MACRA brings episode-based care to the forefront of our field.

No Permanent Fix: MACRA, MIPS, and the Politics of Physician Payment Reform.

Organized medicine long yearned for the demise of Medicare's Sustainable Growth Rate (SGR) formula for updating physician fees. Congress finally obliged in 2015, repealing the SGR as part of the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA established value-based metrics for physician payment and financial incentives for doctors to join alternative delivery models like patient-centered medical homes. Throughout the law's initial implementation, the politics of accommodation prevailed, with federal officials crafting final rules that made MACRA more favorable for physicians. However, the era of accommodation could be short-lived. The discretion that the Centers for Medicare and Medicaid Services had during the first two years of implementation is ending. Additionally, euphoria over the SGR's repeal has given way to concerns over the new program's value-based purchasing arrangements and uncertainty over their sustainability. MACRA eliminated the SGR, but not the politics of physician payment.

Paving the Path to Value: The Role of Registry Studies in Interventional Radiology

AbstractThe growth rate of interventional radiology (IR) procedures and practitioners has exceeded the pace of evidence development to support evidence-based practice. In the innovative and highly adaptive field of IR, there exists a tremendous need for interventional radiologists to practice evidence-based medicine as a way to maintain and improve quality of health care. Randomized controlled trials (RCTs) are considered to be the gold standard of research, providing level I evidence, but in procedural subspecialties, they remain difficult to design and implement due to challenges in randomization, blinding, and inadequate sample size. To build the foundation of evidence in IR, registry studies can play a complementary role to RCTs. Clinical data registries may offer a more practical approach to gathering outcomes data, important in this era with the advent of the Medicare Access and CHIP Reauthorization Act (MACRA), in comparison with RCTs. Properly designed registries can store an abundance of data with which high-quality observational studies can be performed. Although considered level II evidence, these registry studies will allow the evaluation of both performance and value of IR procedures, particularly in circumstances in which an RCT would not be feasible. This manuscript aims to serve as a guide for developing and participating in IR registry studies.