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Big Impacts Meaningful Use: What?s Next? Jose Lopez walks you through what you need to know for the proposed changes to MU and what you can do to prepare for MACRA.

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Industry News

Your Practice's Operations Manuals Jose Lopez explains why having an Operations Manual is a wise move and offers some tips on getting started, what to include and how to keep it updated.

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Pro Tips

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Welcome The Buzz on Operations

Operations span an enormous amount of subject matter. This issue we are focused on the nuts and bolts of policies and procedures and how the right technology solutions can help support your practice.

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Art of . . .

CONTENTS

Operations

Whether your practice is large or small, and no matter what your specialty, how you manage your operation is critical to success. Read why Susanne Madden thinks good operations being with solid processes.

Mitigating Risk in Value-Based Payments Guest columnist Terry Chesser discusses new options for mitigating physician risk in the new world of 'value-based' and risk-shared payments.

Volume 2, Issue 2 - SUMMER SOLSTICE EDITION 2016

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RollcallSolo Pediatric Start-Ups

We assist many physicians with starting their new practices. Meet 3 independent female pediatricians who decided to break out and create their practice THEIR way.

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MU & MACRA

Highlights: World Health Conference Susanne Madden attended the WHC in April to see what is trending in the world of Payers, Hospitals, Employers and Government Programs. She shares the highlights here.

Connect with us online.

Here you'll find details on the key events and conferences that we'll be attending this Summer and Fall and handy links to all of our media streams.

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Connect

A quote from the first Pediatric Super Group Conference in New York, hosted by Physicians Computer Company. A lively and informative couple of days with plenty of take-aways.

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Overheard

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TEAM AND CONTRIBUTORS

Renée Hartleib Scott Hodgson Ahmed Nawaz Terry Chesser Joe Paduda

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NCQA News

Medical Home Policies & Procedures. Julie Wood, Cofounder of Patient Centered Solutions, outlines how to develop policies & procedures that make sense for your practice and meet the NCQA's documentation requrements for the medical home.

Susanne Madden Jose Lopez Heidi Hallett Julie Wood

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Check Up Private Practice & Workers' Comp Guest columnist Joe Paduda makes a compelling case for why you may want to take a second look at participating in Workers' Compensation for your practice.

PODCAST: Susanne Madden and Brent Caldwell, MD, discuss the challenges and opportunities inherent in running a busy independent pediatric practice while also creating and growing one of the only pediatric IPAs in the country.

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Frontlines

Technology Best of Breed George Rogu from RBK Pediatrics worked with private tech firms to develop clinical tech for independent practice that rivals the big box tech used in big hospitals.

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Spotlight

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HR Matters Overtime: New Rules. The US Department of Labor recently announced its final rule updating overtime regulations. Renée Hartleib spells out the new overtime pay protections and examines the impact of on your Practice.

Health Insurance Company Policy Changes Ahmed Nawaz, COO of The Policy Authority, explains what drives policy changes, why it's important to track those changes, and examines recent upheavals in genetic testing.

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Payer News

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About t he images in t his issue:

Throughout the pages of ViewPoint, you will find pictures of nature taken by our team and our clients. Some are

from personal trips, others were taken on business trips and some when we were together as a team. 

These images remind us of the ever-changing landscape of the health care industry and inspire us to adapt to and grow in the midst of that constant change. If you'd like to see more of the photography that inspires us, please visit

the Graphic Viewpoint section of our website.

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? WELCOME ?What better time to focus on the topic of Operations than when we have summer?s busy bees to inspire our thinking about it?

As I contemplate all of the busy work that is involved in running any business, let alone medical practices, I can't help but examine the foundation upon which that is built. We see that most clearly when we help practices transition through medical home projects, as much of that work lies in developing the policies and procedures that allow for an efficient practice. When process is clearly defined and outlined, it provides the framework for staff to know what to do and how to do it.

Companies that spend the time working through defining these process are the ones that gain the most from better performing staff and less costly operations, as it eliminates much of the non-productive busy work inherent in responding reactively rather than proactively to workflows.

This issue we are discussing how to develop an operations manual, looking at tips for writing policies and procedures consistent with medical home principles (for both primary and specialty care) and examining the role of technology in supporting practice operations. In addition, we?re sharing highlights from the World Health Congress held in Washington, DC, last April and highlighting some of our intrepid solo female pediatrician start-ups too!

I wish you a bountiful and productive summer. We?ll be back to reap the harvest with you in September.

SUSANNE MADDEN | EDITOR-IN-CHIEF

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? INDUSTRY NEWS ?

WORLD HEALTH CARE CONGRESS Highlight s f rom #WHCC2016

Every year I attend the 'World Health Care Congress' in Washington, DC. 'World' is a little misleading; this conference is where various U.S. sectors of the health care market come to meet and discuss the latest trends, strategies and goals happening in their respective markets. Of all the conferences attended throughout the year, I look forward to attending this one the most because it provides an opportunity for insight into the thinking of U.S. employers, health insurance companies (Payers), government and a host of service companies and policy makers. About the only folks that aren't attending are physicians themselves, which is why I go - to find out about the forces shaping the physician landscape and incorporate that thinking into strategies for our physician clients going forward.

This year the focus remained on costs and value-based payment models, but there was new focus on the role of the consumer and how best to meet demand (hint: start acting more like other service industries). Of particular note was the launch of IBM's new HEALTHCorps program to help address patient disparities, utilizing Watson. The CEO of IBM herself, Ginny Rometty, announced this during her keynote on Cognitive Systems & the Future of Health Care. Rometty said that we have moved into a new data era entirely - the merging of digital health data with business data to produce cognitive systems, and apparently it's already here in the form of the Watson Health cloud.

So how is this used? Think of Watson as a second opinion for patients, or more accurately, for physicians that are looking to find better information

Susanne MaddenFounder & CEO, The Verden Group

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on outcomes and treatments. According to Rometty, "Watson can "reinvent discovery; it's great at looking for hidden hypothesis, perfect for genonomic, drug discovery / repurposing, clinical trial matching. . ." By way of example, Rometty discussed 'Watson for Oncology' where IBM teamed up with Memorial Sloan Kettering to deploy Watson to analyze structured and unstructured patient data, identify clinical plans, rate and rank treatment options, and then present the options to the physician for decision-making. "Reimagining discovery is one part; reimagining delivery is next", says Rometty.

The IBM HealthCORPS program is being rolled out pro-bono to help increase access to health care around the world, where health care teams anywhere can have access to Watson. Piloted in the UK on obesity, Watson has designed fitness programs for those patients. Soon to be rolled out in DC, it will be starting with Unity Healthcare to help deliver better behavioral health with primary care. In addition, IBM?s Watson has teamed up with the American Cancer Society to offer 'Watson Patient Advisor' which aims to provide cancer patients, survivors, and caregivers with trusted ACS resources and guidance personalized to an individual?s unique journey against cancer.

Payer Perspectives

Dr. Wales of CIGNA and Mohammed Diab, VP at Aetna, discussed the shift of risk to providers under value based payments. Balance between regulatory requirements and provider needs is a delicate one in terms of what can be done in these programs. CIGNA says that its goal is to pay for quality and encourages that by providing resources and bonuses, rather than withholding payment for lower performance as some other Payers do. It was noted that this seems to be

moving right in sync with what CMS is doing in Medicare, paying for meeting measures and targets, and developing value-based payments through the 'value-based modifier' (which rolled out last year) and MACRA and MIPS (coming soon).

Aetna's Diab said that they are taking the long view on value based payment strategies. Diab says a cultural shift is underway but can only be achieved as a continuum - P4P (pay for performance) to ACO (accountable care organizations) to joint venturing between plans and providers to achieve the triple aim - and it's a journey that will take time. To illustrate, Diab said that Aetna works with ACOs in three year contracting cycles, moving from opportunity to implementation and working closely with providers to make sure that the plan can be realized in terms of care management, tools needed, ability for change and so on.

Both Aetna & CIGNA agree that physician leadership is the key ingredient for making ACOs

IBM's President & CEO, Ginny Rom et t y, at t he

Wor ld Healt h Care Congress 2016

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work. Structural organization is important, and being able to provide actionable items for improvement peer-to-peer is considered most effective. When asked if there is one particular structure valued more than other types of organizations in terms of developing partnerships, Cigna says that even though there are different structures with IPAs (independent physicians associations) than with ACOs, provided that there is sharing of best practices across physicians and some control over finances to help reward what's important and pay attention to improvement, then it doesn't really matter.

I asked Aetna's Diab what they are doing to acknowledge the role of pediatrics in long term opportunities for better population health - according to him, the strategies are focused primarily on funneling value through ACOs and larger groups, rather than focusing on network-wide programs. While Cigna's Dr. Wales said that it is working with independent practices through aggregation - ACOs, IPAs and third parties aggregating providers, which

supports the movement that we are seeing toward 'supergroups' and CINs (clinically integrated networks) across the country, an area of particular focus at the Verden Group these days.

In a panel convened to discuss New Health Care Models to Meet Rapidly-Emerging Market Needs, Cigna's VP, Aneesh Kumar, says it is focused on moving health care from B2B (business-to-business) to B2C (business-to-consumer) and that we must meet consumers needs that same way as other (service) industries. Blue Shield's Senior VP, Kristen Miranda, stated that health care is a fragmented, silo-ed system that increases inefficiencies and was never designed with the patient at the center. That is changing, and they are trying now to address "what's under the hood" driving costs. Riverside Health's VP, Jose Vazquez responded that they can't just focus on B2C; they also have to be B2P (business to provider). I wholeheartedly agree!

There was also some discussion about the collaboration between United Healthcare and Blue Shield in California and that more Payers will likely follow. At least that's the vision for 'Cal Index', California's integrated data exchange. Cigna's Kumar noted that "real-time clinical data sharing is the new frontier" for managing costs, care and interventions and that is where industry has to be headed if we are to be successful in changing health and costs significantly.

Telemedicine

The hottest topic this year, telemedince featured predominantly at the #WHCC2016.

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Dr. Robert Pearl of Kaiser Permanente, which is both employer and provider, noted that it had 13 million virtual visits versus 16 million in-person visits and Kaiser is on track for there to be more virtual visits than in-person visits by end of next year.

Amerihealth NJ's VP, Ryan Petrizzi, stated that all Members have access to telemedicine 24/7. While that seems helpful in creating better access for Medicaid populations, Amerihealth has contracted with a third-party telemed company for those services, rather than engaging its existing physician network. I can't help but think how this can only create further fragmentation in care, particularly at a time when we are investing heavily in developing the medical home model to achieve the triple aim . . .

During the Disrupting Primary Care with Novel Delivery Models Keynote, Rushika Fernandopulle, MD, CEO, Iora Health, says that fee for service is entirely the wrong model to pay for primary care. That may be true, but I also believe that delivery is all wrong too - it's not just payments that have driven the way patients are seen and cared for. Fernandopulle, was quick to note that "not every physician is a good fit for the models in care - those that are on board will come along fast; those that are not will be outside of what is happening."

Ellen-Marie Whelan, NP, PhD, FAAN, Chief Population Health Officer, CMS, stated that "in looking at the nurse [RN] component in a new

care delivery model, they found that the role of the transition nurse was huge", as well as having big impacts in triage, intensive care management and managing to metrics. From the research that CMS is conducting there, I expect to see CMS strategies hone in on the possibilities of a greater RN role in care delivery in the future.

Martin G. Kistin, MD, Professor of Medicine, Division of Gastroenterology, and Hepatology, University of New Mexico stated that "nurses are not utilized up to the scope of their practice. Doing so would help to hold the line on costs and improve care."

The panel agreed that technology is an extender, but not a replacement, for physicians. We have a shortage in primary care in the traditional fee-for-service model; that may be counteracted with a shift to new models that incorporate care coordinators, nurses and technology to extend the range and capability of primary physicians., they all concluded.

During the Move Behavioral Health Integration Forward: Where Are We Today? discussion, Bernadette M. Melnyk, PhD, Dean and Professor, College of Nursing, The Ohio State University gave the example that many pediatricians don't screen for anxiety and depression in 12-18 year olds only because there is no system in place - and few behavioral health providers to send them to - in the event that issues are uncovered. Cigna's Doug Nemecek, MD, said they are helping to fill the mental

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health gap with telemedicine. Dr. Melnyk responded that having dually prepared nurse practitioners (mental health plus specialty) to provide mental health services embedded right into primary care medical practice is the way to go (and many of our pediatrician clients at Verden are doing exactly that, bringing mental health into their practices directly).

The wrap up keynote was by Ezra Klein. He had a lot to say about Health Care and Policy - Decoding Washington beginning with: "people in Washington work with very poor, very incomplete information all the time" . . . "they are not evil plotters", rather "they are just wrong and under-informed". But the bigger problem is that the "game is structured in a zero sum" way.

He went on to note that health care is rife with political polarization, and that overrides people's common sense and has caused huge problems in getting things done for the common good.

He referenced Raj Chetty's recent work 'The Association Between Income and Life Expectancy in the United States, 2001-2014' to highlight that we are focused on the costs of health care rather than what value can be derived from spending. Chetty's research showed that medical spending has little importance. Lifestyle, economics, and environmental factors are much more relevant.

In conclusion, Klein wrapped up by saying that public health is more important to focus on than drilling away at health insurance reform. State and local policies are playing a much greater role than we may realize - for example, California has been much more aggressive on smoking bans, NY on trans fats, and that these appear to have really made a difference. I tend to agree.

The 14th Annual World Health Care Conference will be held April 30th - May 3rd in Washington, DC.

Perhaps I'l l see you there!

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In many industries, it is essential to any company's success that it has standard operating procedures from which to work. In manufacturing, textiles, finance (to name a few), companies in these industries would under-perform - and perhaps not perform at all! - if it weren't for operating manuals guiding employees to follow tried and true processes.

How does this apply to independent medical practices? Most practice are homegrown entities that develop processes over time. Often one employee trains another in how they like a task to be done, rather than figuring out the best and most efficient way to do it.

Here's where the medical home model (for both primary and specialty care) has been very beneficial. By following standards and documenting processes, focusing on areas for improvements and training staff to address disparities, independent practices have reaped rewards for transitioning to a more deliberate and structured framework directing the daily workflow.

Therefore, our focus in this issue is to highlight the need for tighter operations; for practices to run on standard operating procedures and improve productivity and efficiency in the process.

Setting protocols may seem to be more science than art, but how you develop a living manual requires a creative focus indeed!

Susanne Madden | Founder & CEO of The Verden Group

The Art of Operat ions

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www.verdenviewpoint .com

GRAPHIC VIEWPOINTCurious about the images you see in our magazine? You can read more about where these pictures were shot and who took them here.

Online at www.VerdenViewpoint.com you'll find expanded content, video, images, tips, interviews and more. Watch for links throughout the magazine or simply click on the link above to explore.

VIEWPOINT MAGAZINE ONLINE

Want th is art icle 'to-go'? Dow nload a PDF version of i t f rom

the View Point si te here.

Look for this 'button' throughout the magazine for downloadable PDF versions of articles.

Look for the microphone icon to hear entertaining & informative audio podcasts.

WHAT CAN YOU FIND ONLINE?- engaging audio podcasts- video interviews and industry commentary- our Graphic ViewPoint image gallery,- popular articles from the Verden Group's blog - Susanne's 'Pearls' from Physicians Practice magazine

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? MU & MACRA ?

MEANINGFUL USE

What 's Next?

The Medicaid and Medicare EHR Incentive Programs were established in 2009 to encourage the adoption and ?Meaningful Use? of Electronic Health Records. With the passage of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), CMS will consider quality, cost, and clinical practice improvement activities when calculating how Medicare physician payments are determined, beginning January 1, 2017. As part of these measures, the Medicare EHR Incentive Program will transition into measures for the Merit-Based Incentive Payment System (MIPS) program.

As a result of these changes, many providers are confused and wondering what?s next for their EHR reporting requirements (the Meaningful Use program). Adding to the confusion are the recent changes to the MU requirements based on provider feedback. Below is an outline of what you need to know for the proposed changes to MU, based on which government programs you are participating in.

Medicaid Providers

Since MIPS is a Medicare based program that will not be implemented by States anytime soon, the timelines and measures for the existing EHR incentive program has not changed and will continue to be determined by the States administering them. As we previously reported, many States are still adapting to the updated MU requirements and as a result many have not yet opened their provider attestation portals this year to report on 2015 measures. One important change for 2015 reporting is that the reporting period has been reduced from a full calendar year to ?any 90 day period? in 2015.

Jose Lopez| Senior Consultant

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Per the table on the next page, Medicaid State EHR Incentive Programs will pay incentives through 2021. The last year for eligible providers to begin to participate in the Medicaid EHR incentive program was 2015 (for receiving an Adopt-Implement-Upgrade incentive payment in 2016). Keep in mind that incentives follow the provider, not the practice, so if you have started working in a new practice, or started your own, you can still receive MU incentives, but you will need to meet the criteria for the Stage of Meaningful Use that you are eligible to attest for. Also, you can skip payment years and still receive the full total incentive amount of $63,750. In fact, many providers did not meet the requirements for Stage 2 in 2014 ? resulting in no payment in 2015, and the corresponding changes to the MU requirements by CMS that lessened these requirements. But as the table below illustrates, the later you started participating in the Medicaid EHR Incentive program, the shorter the timeline.

Dual Medicaid and Medicare Providers

If you receive Medicare Part B payments but also see enough Medicaid patients to be eligible for your State Medicaid EHR incentive program, things will be complicated for a while. You should continue to participate in the State Medicaid EHR program but you will also need to report some of these measures as part of MIPS. This will result in some double reporting and undoubtedly be an administrative burden to smaller practices.

Medicare Providers

Nothing will change for 2016 and eligible providers should continue to attest for incentives and avoid payment penalties in 2018 (Medicare adjustments are based on a 2 year look back). By 2017, the Medicare Meaningful Use Incentive program (MU) is scheduled to transition into the ?Advancing Care Information? component of the Merit-Based Incentive Payments System (MIPS).

The Advancing Care Information (ACI) Component will change several things about MU measures:

- Meaningful Use will no longer be a standalone program. ACI will account for 25% of MIPS score (100 points), the total of which will determine payment adjustments (Year 1 adjustment would be negative 4 percent, with the maximum upward adjustment is 12 percent).

- The ?all or nothing? approach to MU incentives has been abandoned in favor of scaling performance under ACI, so providers don?t need to meet all of the goals. The scoring is split up into 2 categories: ?participating? and ?performance?:

1. By simply ?participating?, providers will receive 50 points of the total possible 100-point ACI category score. In order ?participate?, providers need to complete a security risk analysis, be in active engagement with an immunization registry (or qualify for an exclusion), and report a numerator (of at least one) and denominator for all remaining measures.

2. The 'performance' score consists of additional points awarded for certain objectives (maximum of 50 points). CMS focuses the score on the Stage 3 Patient Electronic Access, Coordination of Care through Patient Engagement, and Health Information Exchange objectives. The nice thing about this is that providers can select to report on measures in which they perform well.

MEANINGFUL USE: What 's Next? (cont inued)

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© Marvel Studios/ /Paramount Pictures

Medicaid EHR Incent ive Payment Schedule for El igible Professionals

Source: https:/ /www.healthit.gov/providers-professionals/ehr-incentive-payment-timeline

- Removes Clinical Decision Support and the Computerized Provider Order since these are consistently above 90% and therefore considered widely adopted. It also reduces the number of measures to an all-time low of 11 measures, down from 18 measures, and no longer require reporting on the Entry measure

- Simplifies reporting requirements for Health Information Exchange and Public Health and Clinical Data Registry reporting measures to a simple yes/no attestation.

- Eliminates the 90-day reporting period for first-time attestations, instead requiring a full calendar year reporting period for all stages and all providers.

Meaningful Use: It?s Here to Stay

Whether you?re a Medicaid, Medicare, or Dual provider, Meaningful Use will continue to be available in order to receive incentives, and required for Medicare providers to avoid penalties. As Medicare transitions into a quality based payment system under MIPS with Meaningful Use transitioning into Advancing Care Information, it?s more important than ever to continue to stay aware of the proposed requirements and remain in close contact with your EHR vendor to ensure successful compliance. You can view the full proposed law which contains all aspects of MIPS here. It will become law on January 1, 2017. Find more information on the MACRA program from the American Medical Association here.

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What can I do to prepare for MACRA?

- Click here to review and comment on the proposed Quality Measure Development Plan along with informational resources provided by CMS.

- Review your practice?s Quality and Resource Use Reports (QRURs) for the 2014 as well as the first part of 2015. Your QRUR will show you how you are being rated on both cost and quality.

- Click here to review your profile on the Physician Compare Site which is based on your QRUR.

- Ask your Medical and Specialty Association for their feedback and response to the proposed Quality Measure Development Plan.

BREAKING NEWS:

HHS ANNOUNCES QUALITY PAYMENT PROGRAM ASSISTANCE FOR SMALL PRACTICES

One major criticism of the Quality Payment Program created under the Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) has been that it places an administrative and financial burden on small practices. CMS anticipates the vast majority of small practices will participate through the Merit-based Incentive Payment System (MIPS) rather than Alternative Payment Models. This will require small practices to allocate resources to identify, measure, and report the various components of MIPS to avoid payment adjustments and to receive payment incentives. With an upward/downward payment adjustment of +/- 9%, small practices cannot afford to ignore these requirements, but they continue to struggle to find the resources to report them.

To help address this issue, the Department of Health and Human Services (HHS) recently announced that they will fund training and education for Medicare clinicians in individual or small group practices of 15 providers or less. HHS will continue funding this initiative at a rate of $20 million each year over the next five years, providing $100 million in total to help small practices successfully participate in the Quality Payment Program.

Similar to the model to create and sustain the Regional Extension Centers, funding will be awarded to organizations who provide customized training to clinicians. The awarded organizations will then provide education and consultation about the Quality Payment Program at no cost to the clinician or their practice, such as identifying which quality measures may be appropriate for their practice, selecting electronic health record (EHR) measures, determining new clinical practice improvement activities, and helping practices evaluate their options for joining an Alternative Payment Model.

This program is aimed to keep small practices focused on what they do best: providing high quality care to their patients. Awardees and more details will be announced by November 2016.

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MITIGATING RISK IN A NEW PAYMENT MODEL WORLD

?Don't stand in the doorway. Don't block up the hall. For he that gets hurt will be he who has stalled? ? Bob Dylan

Change often comes in incremental steps and significant industry change requires more than just time to get through it; change requires effort, growth and maturity to adapt successfully to it. With big change already at our doorstep, the time to adapt is now. Change is coming from all fronts:

- Government/Legislation Change - Medical Provider Change - Marketplace Change: Consumption, Technology & Telemedicine, New

Payment Models for Providers - New Solutions: Protection Models, Reinsurance, Funding Models,

Captive: the ?401K? for Managed Care

It?s important to take a fresh look at change through the lens of experience and perspective. Adapting and adopting operational and financial solutions to foster survivability is key.

New Day, New Dollars

I believe it?s a new day and that the new value-based payment models being thrust upon the provider community offers new opportunities to earn new dollars. The question is, what will your new day look like? Let?s take a closer look at where all the change is coming from and what that means for you.

The Affordable Care Act (ACA) is changing the industry landscape for medical providers. Our healthcare world is being molded and reshaped before our eyes with the transfer of financial risk to providers. The original purpose of the ACA

? BIG IMPACTS ?

Terry Chesser| Principal US Advisors

.Want th is art icle 'to-go'?

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the View Point si te here

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was to give patients greater access to healthcare for those who could not afford it. However, the consequences and unintended results of paying for the cost of healthcare is squeezing providers, making increased efficiencies paramount through new payment models built on increasing risk to providers. We thought this would happen at glacial speed but in retrospect, we recognize it has been happening at hyper speed.

In fact, taking on this ?provider-sponsored risk? and following the volume-to-value model can result in doctors earning less per fiscal year. The ?transfer of financial risk? models of the ACA may be the most disruptive and least understood aspect of the act. The government is now using more restrictions, regulations and penalties.

Doctors and accountable care organizations (ACOs) are now increasingly looking for ways to both adapt and thrive under these new at-risk contracts, and to protect themselves from this new financial risk. The premise of the shift from fee-for-service to value-based payment (or ?volume to value?) models is that patients receive better care, healthcare cost is slowed, and the providers who excel under the new value formula receive more dollars versus their peers. At least, that is the premise! In reality, it is creating a financial dilemma for most doctors due to unprecedented angst in the medical community arising from less income, more restrictions, more confusion and increased oversight from Payers and the government on a go-forward basis.

Change introduced by the government is also creating marketplace pressures. Payers are becoming providers and providers are becoming payers, blurring the lines between the two. Providers moving into insurance have the medical/clinical expertise of delivery but not the infrastructure, claims administration know-how, IT knowledge, and risk assessment tools to manage and respond to risk on a sustainable basis.

Providers will have to find an intersection for participation while still engaging the Payers for these management needs.

New Payment Models for Providers

Payment changes are coming in all shapes and sizes and for all classes ? Commercial, Medicare and Medicaid. They include ACOs, NextGen ACOs, Bundled Payments, Value-Based Contracts, etc. Fancy names are used to make them more palatable like ?Provider-Sponsored Risk? (or PSR) or ?Value Based? or ?Shared Savings? or ?Bundled Payment? contracts but the result is the same - providers are asked to do more and at more risk.

Risks associated with value-based arrangements may include missed star ratings, missed benchmarks and performance metrics, loss of a Physician and/or HMO contract or hospital contract, and contracts that are Direct-to-Employers, etc. and many doctor groups are transitioning from "shared savings" to "upside/downside at-risk" commercial value based contracts from national payers. But risk does not have to be a dirty word! But it should be cautiously measured and evaluated to prevent financial peril. Remember that the goal of Provider Sponsored Risk (PSR) is to shift financial risk to providers via value-based contracts from Payers. This change to alternative / value-based reimbursements may seem rife with peril but solutions exist to help mitigate that. Advanced Captive Models can provide more doctor income with predictable and manageable risk through reinsurance.

Reinsurance

Reinsurance is a tool to integrate with a ?Captive? fund to reduce and remove risk for greater and safer predictability and control. Risk is less with Reinsurance since it acts as a ?safety valve? to prevent and avert financial loss from catastrophic high-cost medical events or missed attainment of

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performance. Using Reinsurance, the Captive can now morph and become a funding vehicle to allow less risky exposure and safer returns as providers navigate in this new at-risk world.

Of course, many providers would prefer no risk at all, but as we move further and further into these new payment models, there is little choice but to assume some of it. Reinsurance can be a bridge in migrating to "reasonable risk" and upside profits for providers. Reinsurance mitigates the risk and acts like a safety net to eliminate the downside risk so the contract becomes break-even or upside risk to the physician group. The proper reinsurance can be a sound and economical financial investment. Its use is becoming increasingly important to protect physicians under value-based contracts.

Who Should Consider Reinsurance and Captives

If physician groups have operated successfully over the last few years under at-risk contracts or shared savings arrangements then this establishes a proven track record that will serve to keep their reinsurance cost low.

For full risk providers, such as ACOs, other unique Reinsurance solutions can be tailored to an ACO?s medical loss ratio (MLR) on an aggregate risk basis. Specific reinsurance is warranted for any high cost medical claims that are rare, infrequent, and out of the ordinary but costly.

Reinsurance can be over-engineered and under-engineered. The challenge is to over-engineer for rigidity, sustainability, strength, and resilience, and then to under-engineer for greater flexibility, adaptability and ease of use while allowing for change as new needs and goals emerge over time. It is then and only then that the right amount of Reinsurance can be combined with the best method of paying for it through the Captive for maximum financial results.

How It Works

While many healthcare firms and medical practitioners are just beginning to employ Captives in these new methods under ?at-risk and capitated contracts?, other industries have used Captives successfully for many years. This marrying of the healthcare world?s risks with the existing captive world is an advanced financial solution with strong money management impact. These unique financial vehicles coupled with reinsurance serves to reduce the tax consequences on risk that already exists for ACOs and other at-risk organizations. It is just a newer iteration that takes advantage of ?medical risk from contracts? in a more

BIG IMPACTS cont inued

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creative and advanced fashion for maximum savings. The Captive model that was typically reserved only for malpractice and based on negligence of the hospitals/doctors is now the financial ?go-to? model for mitigating risk in the new at-risk contract and payment models. In reality, it actually resembles and functions like a 401K model for Managed Care At Risk Contracts by insulating the income stream of providers, and funds at a faster rate for savings and dollar accumulation that can later be withdrawn at a much lower tax rate. This analogous concept and understanding is key since the Captive provides a level of coverage (protection against loss) while being sensitive to cost/cash flow (paying/funding of risk) for best combination of protection and cost over the long term.

In addition, the cost of forming, managing and owning your Captive is tax deductible and is minimal compared to the profit return. The Captive model can be a real financial solution for protecting providers from new risk contracts from both commercial and government Payers.

Medical providers can now manage and mitigate these risks with Captive/Reinsurance options to maximize profits, and offset risks while continuing to provide quality medical care to patients. By forming their own insurance (the Captive), providers can more efficiently manage the financing of risk and provider reinsurance. While the money goes to the Captive to fund losses, it remains under the provider?s control and at their bank. Premiums paid to the Captive are tax-deductible. The provider?s profits under a Captive may become tax-exempt, reduced or delayed. This advanced Captive Model may pay great dividends to you (and your doctor network) in managing risk you already have. The main benefit is that you manage risk you already have but fund it with the same dollars on a ?tax reduced? basis. This applies to ACO and similar organizations risks (for all lines ? Commercial, Medicaid & Medicare).

In Summary

We are in a tug-of-war between what we know has worked in the past and what the government is hoping will work in the future. But are these changes sustainable and, if so, at what cost to providers? Physicians are asked to care for the patient. But is anyone asking or concerned about who will care for the physicians and their future livelihoods? In the end, physicians control the pen, prescriptions and their practice of quality medicine and can thrive under these new PSR / value-based and capitation risk arrangements, once they know how. The solutions described through reinsurance and captives can smooth the road ahead for less risk and make the new risk contracts more attractive with less potholes and bumps.

Terry Chesser

Terry is principal at US Advisors, one of the most respected, oldest and largest Managed Care intermediaries in the US, serving over 4,000,000 lives nationally and have experience from the genesis of Managed Care Reinsurance since 1984 in serving HMOs, ACOs, COOPs, Insurance Exchanges, Cap Providers, Employers, Physicians and Hospitals for their Commercial, Medicare & Medicaid members. As former reinsurers it has the models and analytics to extract the best coverage at the best cost to protect and safeguard your bottom-line.

To contact Terry Chesser via email cl ick here.

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AAP NATIONAL CONFERENCE

- VISIT THE TEAM AT THE PATIENT CENTERED SOLUTIONS BOOTH #1738

- Oct 22-25, San Francisco

OVERHEARDat the Pediatric Supergroup Conference

JOIN US AT THESE EVENTS. CLICK ON EVENT TITLES & LOGOS BELOW FOR MORE INFO.

PCC USER'S CONFERENCE

- PRE-CONFERENCE SEMINAR ON PCMH

- PCMH AND YOUR COMMUNITY

- July 26-29, Burlington, VT

"What everyone needs to understand is that if you've seen one supergroup, you've seen one supergroup. I t depends on the players, the market, the culture and the governance structure" - Herschel Lessin, MD

Read more about the conference here.

- CONNECT -

Connect with all our social streams here:

The Verden Group is an innovative consulting firm focused on shaping the landscape of advocacy by empowering medical practices to navigate through the increasingly complex business of healthcare, and to advocate on their own behalf with insurers and regulators.

The Verden Group delivers expert services and advice to meet needs across your practice. From contract management to social media management, start ups to super groups, PMCH to research studies, we are your Partner In Practice. To learn more about our services visit www.theverdengroup.com Subscribe to ViewPoint to stay on top of all our news and views on the business of health care.

22

At The Verden Group, we assist many physicians with starting their new practices. Our favorites are the independent female pediatricians who decide to break out and create a practice THEIR way.

Here are some of the latest, greatest, female solo pediatricians to launch this year.  Congratulations to you all and many successful years ahead!

Read their stories online here.

- ROLL CALL-

Hiral Lavania, MD One Family Pediatrics Cumming, GA www.onefamilypediatrics.com Launched: February 2016

Irma Tackie, MD Goldstar Pediatrics Fontana, CA www.goldstarpediatrics.com Launched: April 2016

Alethea Allen, MDGrace Point Pediatrics Winchester, VA www.gracepointpediatrics.com Launched: June 2016

23

?If you?ve seen one medical practice, then you?ve seen one medical practice?.

You?ve probably said or heard this old axiom a million times, but for good reason and rightly so: each practice is different not only because of their specialty, providers and staff, but also their patients and community.

With a growing emphasis on patient-centered services designed to meet their unique needs, how do we ensure that the services we provide are consistent, meet high quality standards, and are also efficient to deliver? By developing standards and then utilizing them in the form of an Operations Manual. In other industries, many companies literally would not be able function without their standard operating procedures in place. How come? These standards provide the framework from which every employee knows what they need to do and how to do it.

The Purpose of Your Operations Manual

An Operations Manual is NOT an Employee Handbook. An Employee Handbook sets human resources policies for personal and professional conduct and performance in the workplace. Your Operations Manual needs to focus on everyday 'how to's' and the Employee Handbook needs to focus on human resource issues and labor laws.

THE OPERATIONS MANUAL

An Over looked Resource t o Ensur ing An Ef f icient Running Pract ice

? PRO TIPS ?

Jose Lopez | Senior Consultant

24

Why YOU Need An Operations Manual

- Create standards across your practice. Developing a consistent set of procedures for various tasks ensures that no matter who carries them out, they are likely to perform them the same way. No more variation in how messages are handled, how patients are roomed, how medical record transfers are handled. And from your perspective, knowing that the staff know how to get the job done right sets expectations for your employees to live up to them. It also creates a better patient experience, as there is less variation visit to visit, and this often results in the perception that employees are competent and well trained.

- Better trained employees. Who train new employees? It's likely that there is a lot of variation in not only what a new employee is told but also differences in which person is telling them. It can be confusing and provide a poor result.  Using your standard operating procedure as a written training plan will ensure that all new hires are given the same information to help create consistency among all of your employees.  It will also allow you to delegate some training responsibilities to other employees without diminishing the impact of that training.

- Make your business more valuable. Whether you are intending on selling your practice, or grooming junior partners to buy it over, having tangible, efficient standards reinforces that your practice is operating wisely and is fiscally sound. It also creates an effective way to ensure that the framework of the practice does not fall apart when a key partner or employee leaves the company. The Manual is the glue that holds the operation together.

What Should You Put In Your Manual?

The most important thing is for it to be useful, otherwise it won?t get used. Start with the processes that are most critical to your practice, such as clinical care and front desk operations, and build from there. Any tasks that are repeated over and over should be captured in your Manual, from how to answer the phone, to what to do with faxes, to how to room patients, even how to take phone messages.

Use What You've Got

Utilize existing materials already developed in your office. Sources can include billing sheets, phone scripts, patient surveys, etc. Don't hesitate to include information and reference material from external sources such as your EHR, billing service, payers, vendors, etc. If you have been recognized as a Patient-Centered Medical Home or Specialty Practice, then you should already have a number of processes and procedures documented and in use. Don't hesitate to incorporate those into your Manual. If you are not NCQA recognized yet, you can find tips for setting processes on page 38.

Utilize The Staff Who Perform The Tasks

Next, delegate each section to your 'subject matter experts': providers and staff who perform these tasks on a routine basis. Staff should record their steps as they perform these tasks, identifying how and why the process is performed. This process will provide drafts from which management can review how such tasks are being performed - do they need to be revised or overhauled? Now is a great time to do that.

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- Organization Chart and Staff Roles/Duties- Provider Biographic Summary- Nearby Patient Resources (Pharmacies,

Provider Referrals, Financial, Medical Supply, etc.)

- Ancillary Services- Hospital Affiliations- Insurance Plans Accepted- Payment Policy- Important Updates for Patients (Narrow

Networks, High Deductible Plans, Medical Conditions)

Communication Protocols

- Telephone- U.S. Mail - Faxes - E-mail - Text Messages- Social Media

Charts & Electronic Health Records

- EHR & Vendor Contact Information- Guidelines- Preparation for visit- Discharge/Closing visit

Clinical Operations

- Vitals- Procedures- Vaccine Administration- Crash Cart- Test Orders- Labs Management- Referrals and Care Coordination- Billing and Coding

If there is more than one person performing a set of tasks, have multiple staff complete the drafts, then compare and reconcile the differences. Often this can be an eye opening experience for managers and ownership to reveal the true workflow of their practice. Often, medical and office staff are not proficient in programs such as Word, so having them write this out on paper many be necessary. If you are lucky enough to have staff that can utilize Word, encourage them to use screen shots for processes that involve the use of software too.

Once you've got these processes documented and have identified areas that need improvement, you can finalize the process and commit it to the Manual for future use and guidance. Update your Manual anytime a process is revised or changed. This will ensure that it is kept up to date and at the ready for the next new employee that needs to be trained.

Utilizing Your Operations Manual

Keep a digital copy of your Manual on a shared drive where staff can have access to it anytime. Better yet, host your Manual online (using Google Apps or a similar software) to avoid any version control issues. Anytime you update the Manual, send a memo to all staff to review those specific changes and institute a process whereby staff members sign off that they have read and understood it.

Following are topics to get you started:

Overview of Your Practice

- Philosophy (Mission, Vision, Values)- About Your Practice (Name, Locations,

Address, Phone, Website, Driving and Parking Directions, etc.)

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It may seem a little overwhelming to get started, but you just have to start. Making the Manual relevant to your practice and employees is the key. The Manual will never be complete, it will always need revising and updating to keep up with your busy practice, so don?t think of it as something you need to do all at once.

For more tips and advice on drafting policies and procedures, read Julie Wood's article on how to meet NCQA documentation requirements for policies and procedures.

Administrative Operations

- Payer Contracts - Security Procedures- Emergency & Disaster Preparedness Plan- Pharmaceutical/Medical Device

Representatives- Inventory Management - Vendors and Contact Information (Medical

Waste Disposal, Cleaning, etc)- Staff Scheduling and Coverage- Electronic Health Record Manual- Meaningful Use Standards/Guidelines- Regulatory Records, Certifications, etc.

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27

? SPOTLIGHT ?on technology support ing

operat ions

Susanne Madden sat down

with George Rogu, MD, of RBK

Pediatrics in Long Island, NY,

to discuss the impact of

technology on operations at

his busy pediatric practice,

and how he has effectively

pushed technology partners to

deliver better solutions.

Click t o wat ch video int erview

28

WORTH CONSIDERING ADDING WORKERS' COMPENSATION TO YOUR PRACTICE?

The workers? compensation (WC) world is changing rather dramatically ? and those changes will affect health care providers in disparate ways. While many providers don?t see a high volume of WC patients, practitioners who specialize in musculoskeletal conditions may see several workers injured on the job each week. As healthcare rapidly evolves, providers are once again considering payer types that they may have ignored, or even avoided, in the past.

Here?s what?s happening in workers? compensation today: for the first time ever, medical costs actually decreased in 2015, helping the industry hit historical highs in operating gains. These details were reported at the National Council of Compensation Insurance by Chief Actuary Kathy Antonello in her State of the Line presentation last month. As the largest workers? comp rating organization in the nation, NCCI has a unique grasp on the industry. Antonello began with a couple of important introductory points ? while medical cost trends are well under control, drug costs are increasing at a troubling rate. In my view, with opioids continuing to plague the industry, this could have significant, and negative downstream effects. Overall the WC insurance industry is doing pretty well. Net written premiums for

? CHECK UP ?

Joe Paduda | Health Strategy Associates, LLC

.

Want th is art icle 'to-go'? Dow nload a

PDF version of i t f rom the View Point si te here

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private insurers rose 2.9% to almost $40 billion in 2015. State funds (quasi-governmental insurers) accounted for $5.8 billion in premiums, for a total of $45.5 billion ? that?s up from $44.2 billion in 2014 and largely driven by increased employment. Payroll is up 23% since 2010, with construction employment leading the way, up 17%. This is significant because the trades have higher injury rates ? and those injuries are typically more severe ? making it harder for employers to return tradespeople to light duty on job sites. Nevertheless, the industry?s combined ?medical loss ratio? (claims paid + administrative expenses) improved to 94, a six-point drop from 2014 and the second best combined ratio since 1990.

What Does All This Mean for Practices?

The biggest news is what happened to medical costs. As medical accounts for 58% of total benefits, any move can have significant effects on employers? rates. In what can only be characterized as shocking, medical costs per lost-time claim actually decreased 1 percent in 2015. To my knowledge, this has never happened before. Not only did costs decrease, the trend rate actually tracked BELOW medical CPI increases, a major change from prior years when we could

expect medical costs to consistently come in a couple points above the CPI. As an employer, and all practices are employers too, that means the premiums may go down. From a medical practice perspective, WC business accounts for only about 1.25 percent of total US medical spend, so in the overall scheme of things, it?s just not a big player. However, workers? comp pays better than most other insurance lines and health plans. But, that extra compensation comes with extra work. And depending on the state, there may be requirements for documentation, support for return to work, and communications with the employer and/or insurer that may require extra administrative time.

Do Your Homework.

While the extra work can be bothersome at times, once practices have a staff expert in workers? comp, the higher reimbursement can significantly offset that extra work. That said, reimbursement varies greatly by state, with fee schedules ranging from very low in Massachusetts to very high in Connecticut, Hawaii, and Wisconsin. Do your homework by checking with your state?s workers? comp agency on reimbursement and managed care requirements? you may just decide it?s worth it to take the leap.

30

? HR MATTERS ?

A fair day?s pay for a fair day?s work.

In 2014, President Obama directed the Secretary of Labor to update the Fair Labor Standards Act, with specific attention to overtime pay protections. This move was in response to the growing number of American employees working more hours and not being compensated for them. Obama said he wanted to ?build real, lasting economic security for more hardworking Americans? and ensure ?a fair day?s pay for a fair day?s work.?

Fast forward two years and the US Department of Labor has recently announced its final rule updating the overtime regulations. It raises the overtime exemption threshold for ?white collar? workers from $455 a week (or $23,600 annually) to $913 per week (or $47,476 annually) and the exemption for highly compensated employees from $100,000 to $134,004 annually. This means that an estimated five million American workers will now be eligible for time-and-a-half pay for hours worked above and beyond the standard 40 hours a week. In the world of medicine, this will likely apply to office managers and medical assistants in practices like yours.

The effective date of the final rule is December 1, 2016.

OVERTIME PAY PROTECTIONS:

The Impact on Your Pract ice

Renée Hartleib | Writer & Researcher

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What are people saying?

Proponents of this major overhaul say the change is long overdue. The initial white collar exemption level was set in 1975 and had not changed in forty years. For a family of four today, that $23,600 per-year salary is actually below the poverty line. Supporters also say the new rule will help those who need it the most, namely women and minorities who historically have lower than average median incomes.

But critics say small business will suffer increased costs, tighter budgets, and unexpected layoffs of valuable employees. This will be especially true in workplaces with fewer staff who routinely put in long hours due to the nature of the work. Looking at a survey performed in 2013, for solo practices with up to five non-physician staff members, 30% of doctors said they have cut or frozen salaries in the past five years. In an era when overtime violation claims already top the U.S. Department of Labor complaints list, there is a fear that this change will result in even more lawsuits being filed over wages and hours.

Are you ready?

Everyone agrees that this new overtime compliance challenge is second only to the Affordable Care Act in terms of preparation and thoughtful response. But research is showing that most small business owners aren?t anywhere near prepared. According to the web link above, ?only 25 percent of small businesses owners and 50 percent of midsized employers in the United States say they?re aware of and taking actions to comply with the new overtime regulations.?

Simply put, the new overtime rule requires you, as an employer, to start tracking hours for salaried employees who are at or below that $47,476 threshold. If they exceed 40 hours per week, you will need to pay them overtime. We?ve outlined a series of action steps below that can help you manage this big shift in how your employees are compensated for their work.

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1. Know your exemption facts

First things first. You need to understand which of your employees this new rule will apply to. Under the Fair Labor Standards Act, employers must pay overtime (1.5 times the regular rate of pay) for each hour worked over 40 in a week, unless an employee is classified as ?exempt.? Since 1975, there have been three exemptions (see below). The only one that has changed is the one related to salary level.

Who is exempt?

- Employees who are paid a fixed salary that is not subject to reduction based on quality or quantity of work performed.

- Employees whose duties are primarily executive, administrative, or professional.

- Employees who are paid more than $913 weekly (up from $455).

2. Start tracking hours

HR and payroll experts are advising employers to begin accurately calculating the number of hours worked per week by each employee. As you seek to comply with the new regulations, a paper trail that includes each employee?s current salary, their role, and the number of hours they work, will be essential. Accurate hourly data will allow you to pay your employees fairly according to the new rules. It also means that if an employee ever reports you to the Department of Labor for not following this regulation, you will have clear records you can show in the event of an audit.

3. Explore your options

The new rule will undoubtedly affect your bottom line. HR and payroll experts are advising employers to assess each employee?s labor situation individually. In order to do this, you will need to have accurate employee time data, as suggested above. The amount of hours your employees currently work directly impacts the decisions you make. Here are some cost-minimizing options to consider:

Implement an automated time and attendance system. You may want to consider using a system that tracks the number of hours worked and sends you a message when an employee nears the 40-hour-per-week threshold. This would give you the opportunity to make staffing shifts and avoid overtime payments.

Convert to Hourly Pay. If you have exempt employees who aren?t consistently working 40 hours a week, you may want to convert them to a non-exempt, hourly status. This shift from salaried to hourly might save money if your employees don?t usually put in overtime.

Raise salaries. Some employers may decide to raise salaries to the new higher threshold, so their employees will continue to be exempt from the overtime rule. You may choose to do this with employees who consistently work more than 40 hours per week, as it could be a less expensive option than paying time and a half for overtime.

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Split the job into two part-time positions. This option would mean significant upheaval for your employees and must therefore be considered Create new policies. If you do none of the above, and your business requires your non-exempt employees to work overtime, you will definitely be out of pocket. There are, however, ways to manage how much this costs you. Consider setting policies in place that your employees need to adhere to when accounting for their time (e.g., using time cards that need managerial approval; prohibiting overtime unless authorized; guidelines for work from home, travel, or meal periods).

4. Be transparent

Although this change to the Fair Labor Standards Act is public knowledge, your employees may not know how the new rule affects them. Communicating clearly and honestly with your employees, especially about how you may need to change the way you do business, will be of the utmost importance. If you have managers, prepare them to answer employees? questions.

And be clear, preferably in writing, about anything new that your employees need to be aware of or need to do differently (e.g., processes for tracking hours or policies around overtime).

5. Educate Yourself

Depending on the size and complexity of your practice, you may need to seek assistance from human resources and employment law experts. For the do-it-yourselfers, there are online guides from companies such as ADP, available to help you understand what you need to do in order to comply with the changes to the Fair Labor Standards Act.

There are also online calculators to assist you in figuring out what your costs will be.

Start now!

The new rule goes into effect on December 1, 2016. Once the final rule is issued, employers will have 60 days to comply.

This means the time to start tracking hours and making important decisions is now!

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-PAYER NEWS -

HEALTH INSURANCE POLICY CHANGES What I t Means To Your Pract ice

Arnold H. Glasow once said, ?In life, as in football, you won't go far unless you know where the goalposts are.?

I am not too sure if we can ever be completely certain about the whereabouts of the goalposts in life at all times, but in football, the rules about goalposts are explicitly defined; the whereabouts, the height, and the distance between the goalposts. These rules have certainly evolved over the period of the game?s lifetime but any changes are incremental, well evaluated and agreed upon by all parties. But what if one day you walked out onto the pitch and the size of the field is suddenly a lot bigger and the goal posts look a lot smaller too? Then the coach informs you that any rule can be changed at any time once the referee blows the starting whistle. Chaos would likely ensue.

At The Policy Authority (a subsidiary of The Verden Group), we track changes to health insurance medical and administrative policies. These policies are the ?rules? that govern coverage and determine how physicians get compensated for providing medical services. In tracking the changes made to policies every day, we attempt to make order out of the chaos.

As data from scientific literature changes, or the criteria developed by specialty societies alters, or economics dictate that some coverage cuts are in order, the insurance companies review and change their medical policies. How can that be?

Ahmed Nawaz, COOThe Policy Authority

35

Take the example of a typical Payer disclaimer, in this case from Wellmark BCBS' (Iowa and South Dakota) website. It states that medical policies are ?subject to change without notice, except as required by the law? and policies may be added or removed from use ?from time to time?. These ?rules? are frequently changing but physicians are not necessarily informed when they do. In some cases, a monthly or quarterly newsletter of changes may be emailed to network physicians, but only if you have previously signed up for such communications. If you haven?t, you can look up policies on most plan websites, but those policies may or may not provide you with details about how each policy has changed. It is not surprising then, that many participating providers may be unaware of such rule changes? that is until they receive a claim denial. It is therefore important to stay on top of such changes, or at the least have access to policies, in order to frequently review the ?rules? that apply to your services and specialty.

Let me share with you some examples of recent changes and how they may affect physicians.

Subtle (Or Not So Subtle) Changes

Aetna has a relatively easy website to navigate and medical policies (known as Clinical Policy Bulletins) are fairly easy to find. Typically included in each policy are the revisions, updates and any additions made, and the time stamp that each change occurred. This is helpful, particularly in case of claims denials, where rules changed on a certain date and you can either support the request for payment or determine that payment will not be forthcoming (and hence not waste further time on the appeal) due to the new rules.

However, from time to time, some updates go unrecorded. For example, in their batch of updates on June 3rd, in addition to the typical time-stamped and annotated revised policies,

Aetna quietly updated three additional policies; Daratumumab (Darzalex), Mepolizumab (Nucala)? and Talimogene Laherparepvec (Imlygic), by adding a note of 'precertification required' in each of the coverages. No other notification appeared on the website. No change to the review date of the policies, as is the usual practice for updates at Aetna, was noted.

Now, it may be that precertification was always required for these services, and perhaps Aetna was simply making things clearer by adding that requirement directly to the clinical policy but, if not, then this presents a potentially significant impact to physicians that may continue providing services without knowledge of the change, and subsequently will receive denials for such services due to no precertification on file.

Major Changes: Genetic Testing

Over the last few quarters, we have seen policies pertaining to Genetic Testing changing for ALL of the insurers that we track and this is primarily due to updates to the scientific literature, the availability of new tests, and greater awareness and information about such options. According to industry research, there are more than 7000 different genetic tests now available that can identify genetic variants and about 60,000 testing products developed by different laboratories, with clinical labs introducing 8-10 new testing products every week! And these tests range in

36

price from $250 to more than $6000. With all of this new technology and testing, it is forcing insurers to find ways to keep up to date on their coverage criteria.

Typically Cigna?s policy changes usually roll out on, or around, the 15th of every month, and we anticipate anywhere between 10-12 percent of policies being revised during each cycle, i.e. around 35-40 policies updated out of more than 350 policies. However, on February 15th, this Payer made changes to 61 policies, removing 25 policies pertaining to different forms of genetic testing alone. Did the removal of such policies mean that these tests were no longer covered? We needed to take a closer and more detailed look, and in doing so we found that they had overhauled their genetic testing policy section by consolidating and merging policies into four existing documents, introducing sections within the coverage policies that explained the coverage for specific tests. Moreover, Cigna has since added a future version of each of the four policies; two on April 15th and two on May 15th, and introduced a comprehensive table with description of tests, indications, related policies and Cigna?s coverage positions. However, any updates or changes made in the table or policies would be difficult to capture unless compared with the previous policy versions , making it tricky for

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physicians to track movement in coverage. Cigna does not address either Neurofibromatosis or PALB2 Mutations yet, but we have picked these up as being introduced by other insurers, and so anticipate that Cigna will add those policies in coming months too.

BCBS of North Carolina has 55 policies related to Genetic Testing; and two new policies, Genetic Testing for PALB2 Mutations and Genetic Testing for Neurofibromatosis which were added to the list on April 29th, with the latter having the policy of ?may be considered medically necessary?, while the former is ?considered investigational?. Similarly, BCBS of South Carolina added ?Genetic Testing for Neurofibromatosis? policy on May 4th, also having the policy status of ?may be considered medically necessary.? Genetic Testing for PALB2 Mutations was introduced by the same company in February of 2015 and, despite revisions and updates, is still ?considered investigational.? This illustrates the complexity of coverage policies between Payers too.

It?s not an easy job to do, but we figure someone has to track these changes, notify physicians and keep the insurers ?honest? with their updates. If you would like more information on how we can help, please visit www.ThePolicyAuthority.com.

37

SEARCH MEDICAL POLICIES ANYTIME, INSTANTLY.

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38

? NCQA UPDATE ?

MEDICAL HOME POLICIES & PROCEDURES

Whether navigating a project for Patient Centered Medical Home (PCMH), Patient Centered Specialty Practice (PCSP), or Patient Centered Connected Care (PCCC), all of these require that you document policies and procedures in order to meet the standards.

Writing a set of Policies & Procedures can be challenging (you can learn more about writing an Operations Manual here), but a good place to begin is by cataloguing what you?ve got and then reviewing each one to see if they meet NCQA documentation standards, and if they follow a consistent layout with content organized in a step-wise process.

If you are writing policies from scratch, start by asking the staff that are actually performing the tasks to write down all the steps involved in their processes. This will be your first draft of policies and should be dated as the initial effective date.

Julie Wood | Co-Founder, PCS

How To Meet NCQA Documentat ion Requirements

CLICK HERE FOR TIPS TO HELP YOU GET STARTED.

- Read adv ice on how t o com p i le a m anual .- See an ex am p le of how a pol icy should be

laid out . - Dow nload a handy Docum ent at ion Tips

f or PCM H-PCSP-PCCC.

39

Compare your documented processes to the Standard requirements, and decide which processes need to be modified based on the factors for which you wish to attest. Revise your policies to align with the factors and document the revision date.

You must have policies in place for at least 90 days prior to submission to NCQA. Therefore, it is beneficial to begin focusing on your policies and procedures at the beginning of your project, allowing for plenty of time to fine-tune your procedures well in advance of submission.

The chart below details the Factors for which you will need documented processes for the PCMH Standards.

The MUST PASS Elements are highlighted in red and the Critical Factors are highlighted in blue. We?ve also marked some Factors as ?recommended? ? these are not requirements for submissions but are processes that will benefit from being documented for purposes of training and consistency.

For docum ent at ion t ab les f or PCSP and PCCC, cl i ck here.

40

? FRONTLINES ?

Susanne Madden spoke with Dr. Brent Cardwell, owner of Cedar Park Pediatric and Family Medicine in Cedar Park, a suburb of Austin, Texas, as well as the President of the Central Texas Primary Care Alliance and the chair of the Texas Pediatric Council, about some of the challenges and opportunities inherent in running an independent pediatric practice, as well as simultaneously building and leading a predominantly pediatric Independent Physician Association (IPA).

You can read an excerpt from their conversation here. To listen to the whole pocast (approximately 20 minutes long) or read the transcript, click on the microphone above.

SM: With nearly 90 physicians that are predominantly pediatricians, I would suspect that you probably have a very large percentage of the pediatricians in the Austin area, and certainly no insurance company, no payer is going to want to have you excluded from any of their offerings.

Speaking of payers, Brent, do you feel that the large ones? like Blue Cross Blue Shield of Texas, United Healthcare and so on? are they keeping pace with the demands of a community like yours? You're in the new Silicon Valley, in Austin, Texas, and tech is king. Certainly we're seeing everywhere across the country there is more of a consumer market where patients are driving a lot more of the demand. For example, looking for telemedicine, looking for convenience, looking for access outside of different hours, but not necessarily wanting convenient care, wanting to have the connection with their primary care doctors. Do you feel that the Payers are inhibiting some of the things that you would like to do as independent practices to meet those consumer demands, or do you feel like maybe they're coming along and finally keeping pace with some of the demands of the community like yours?

PODCAST: A Conversat ion wit h Brent Caldwell, MD

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MICROPHONE TO LISTEN Susanne Madden| CEO & Founder

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BC: Thus far, I think that they're really inhibiting what we're trying to do, especially on the pediatric side. Our negotiations with the major Payers have been really dissatisfying, to be honest. They all know that the money and the cost savings are on the adult side, and so they really have not placed significant value on the pediatric aspect of health care at this point. Many times, they don't even know what to do with pediatrics.

One of the things we're trying to focus on going forward is providing the Payers in the area with very pediatric-specific quality metrics, and Pay-for-Performance ideas, and our hope is that we'll give them what's important to pediatrics? just reimburse us for those things. Pay us for those types of things so that we can go out and hire some case managers for our group. So we can do those things that will actually save money, even in pediatrics, and that's what we're really trying to get across to them, but the main focus is almost solely on adult medicine, at least in the central Texas area at this time.

SM: Yes, and that's always been a challenge. We experience that across the country and with every Payer that we talk to. It's like intrinsically they understand that pediatrics is highly valuable and really there should be some support for that, but to your point, because there aren't these high-ticket items, such as controlling adult diabetes, COPD, those sorts of things that come along with drugs, and acute events, it's very difficult for them to

make the economic leap, I think, to understanding that short-term financing isn't always where it's at.

There's a longer-term view that shows if you invest in the health and well-being of younger patients? children? then certainly you can ensure that they become healthy adults.

We keep waiting for that other shoe to drop, for them to finally get this idea that if we invest now,

it will pay large dividends in the future, but I think to your point, too, there are

also some short-term savings that can be found in this, as well. If you're able to coordinate the care more effectively for asthmatics, and for pediatric obesity, ADHD, et cetera, then those costs obviously go down.

There just isn?t as big a ?chunk of change? as we see in the

adult medicine side of it.

SM: Certainly there are some opportunities shaping up in the Austin area. I wonder what's next. You had touched on self-funded employers earlier in the conversation. What is next for the IPA? What are the big carrots that you want to go after at this point? . . .

Listen to the full podcast by clicking on the microphone.

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Edit or-In-Chief : Susanne Madden | Edit or ial, Design and Product ion Manager: Heidi Hallet t | Cover Design: Scot t Hodgson

Cont r ibutors: Susanne Madden, Julie Wood, Ahmed Nawaz, Jose Lopez, Terry Chesser, Joe Paduda, Renée Hart leib,

Photography by: Susanne Madden, Heidi Hallet t , Jose Lopez

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