REQUEST FOR INFORMATION

REQUEST FOR INFORMATION

Agency/Office: Department of Health and Human Services

Centers for Medicare & Medicaid Services

Center for Medicare and Medicaid Innovation

Type of Notice: Request for Information

Title: Request for Information: Transforming Clinical Practices

Response Date: Tuesday, April 8, 2014

SUMMARY: The Center for Medicare & Medicaid Services (CMS) seeks information about large

scale transformation of clinician practices to accomplish our aims of better care and better health at

lower costs. CMS seeks responses to questions listed in the “QUESTIONS” section of this Request

for Information (RFI). CMS may use this information collected through this RFI notice to test new

payment and service delivery models.

DATES: Submit comments through the website listed in the “RESPONSE FORMAT” section by

11:59 pm Eastern on April 8, 2014.

RESPONSE FORMAT: Responses to this RFI must be provided via on-line submission at the

following website:

http://www.healthcarecommunities.org/Home/RFI-TransformingClinicalPractice.aspx

Submissions are due no later than 11:59 pm Eastern on April 8, 2014. CMS will not accept

hard-copy responses or other formats.

CMS will consider only those responses that contain the information described below. Submitted

responses must follow the format listed below, with responses divided into three sections. CMS will

not consider additional information submitted beyond these four sections.

Section I Demographic: The following items must be completed by each respondent. Organization

type (practice, association, health plan, consumer organization, etc.), name of organization, mailing

address, phone number, fax number, and name and email of designated point of contact (POC).

Respondents are required to provide a summary of their experience related to practice

transformation. Clinical Practices must identify themselves as specialty, primary care or mixed

(including both primary and specialty). Clinical Practices are required to also provide practice size

including number of providers and size of patient population.

Section II. The name and contact information of the organization whose views are represented in the

submission, if different from the information provided in Section I.

Section III Respondents are encouraged to provide complete but concise responses to the questions

listed in the four sections outlined below. Please note that a response to every question is not

required. Responses will be no more than 2000 characters per question.

BACKGROUND:

Practice Transformation is a process that results in observable and measureable changes to practice

behavior. These behaviors include core competencies: Engaged leadership and quality improvement;

Empanelment and improved patient health outcomes; Business and Financial acumen ;Continuous

and team-based healing relationships that incorporate culture, values, and beliefs; Organized,

evidence-based care; patient-centered interactions; Enhanced access; progression toward population

based care management; State-of-the-art, results-linked, care; Intentional approach of practices to

maximize the systematic engagement of patients and families; and Systematic efforts to reduce

un-necessary diagnostic testing and procedures with little or no benefit.

CMS is interested in opportunities to help promote the transformation of clinical practices to improve

health and health care across the country. With the passage of the Affordable Care Act in 2010, came

renewed efforts to improve our health care system. Guiding these efforts has been the CMS focus on

better health, better health care, and lower costs through quality improvement and the six national

priorities of the National Quality Strategy, which map to the six goals of the CMS Quality Strategy.

CMS is considering initiatives to encourage practice transformation. The questions in this RFI

specifically would address strategies to improve health and make quality care more affordable for

individuals, families, and employers, through the development, implementation and spread of new

health care delivery and value-based purchasing models. The result would be transformed clinical

practices characterized by the delivery of high quality care, population-based care, cost-savings, and

improved workflow.

There are nearly 50,000 providers participating in Center for Medicare and Medicaid Innovation

(Innovation Center) models and over one million physicians and other clinical professionals affected

by other CMS payment policies. While Innovation Center models may include technical assistance

for multiple provider types, many clinician practices need assistance in developing their capacity to

successfully participate in an Innovation Center model or other alternative value-based payment

models (e.g., state or Medicaid models). To begin the process of transforming clinical practice, the

leadership and staff of these practices must assess their success in improving patient health outcome

and systems of care. They must also understand the benefits and the capabilities necessary for

entering value-based payment arrangements. Then, the clinical practices would need to commit to

transforming their practices and processes to adapt to those new business models. Providers who

want to transform their care delivery system must then acquire the data, knowledge and skills that

support high value care, and be prepared to make the infrastructure investments in systems, staffing

and practice work flows and process redesign necessary to be successful.

The literature on practice transformation notes that there are identifiable characteristics of a

transformed organization. (Such characteristics include patient-centered interactions, engaged

leadership and a robust quality improvement strategy.) (The Commonwealth Fund Report: Guiding

Transformation: How Medical Practices can Become Patient-Centered Medical Homes; Edward H.

Wagner, M.D., M.P.H., Katie Coleman, M.S.P.H., Robert J. Reid, M.D., Ph.D., M.P.H., Kathryn

Phillips, M.P.H., and Jonathan R. Sugarman, M.D., M.P.H. February 2012) This is recognized in the

CMS and private sector models that are currently underway. Recognizing the challenge of

transforming practices across the nation, CMS seeks information about strategies that could be the

catalyst for transformation supporting the participation of large numbers of providers in a redesigned

healthcare system via the pathway that makes the most sense for their practices.

Your responses to this RFI will help inform CMS’ continued efforts to improve our healthcare

system through transformation of clinical practices.

QUESTIONS: This Request for Information (RFI) seeks responses to the questions from Clinicians,

Clinician Practices, Quality Improvement Organizations, Regional Extension Centers, Patient

Advocacy Organizations, Health Plans, Employers, Purchasers, Consumers, Professional

Associations and other members of the public about large scale transformation of clinician practices,

to generate better care and better health at lower costs. The feedback from this RFI may be used to

develop future Requests for Proposals and test new payment and service delivery models to assist

practices in their work to prepare for participation in new value-based payment programs.

CMS asks that respondents address the following questions. Please respond to those questions that

are germane to your experience and expertise.

http://www.healthcarecommunities.org/Home/RFI-TransformingClinicalPractice.aspx

A. Practice Transformation Strategies, Resources and Opportunities

1. Based on your organization’s experience and understanding, what does a transformed clinical

practice look like?

The American College of Radiology has launched a campaign called Imaging 3.0™ to drive a

cultural change throughout the specialty and highlight the value that radiologists and imaging

deliver. Imaging 3.0 describes the environment in which radiology services will be delivered in

the near future. It embodies principles of appropriateness, quality, safety, efficiency, and

satisfaction in a constellation of tools and behavioral changes designed by radiologists to

optimize high-value imaging care in the current and future health care delivery systems. In this

age of profound changes in health-care delivery models, radiologists must find new strategies to

stay viable. Imaging 3.0 case studies spotlight radiologists who are already using Imaging 3.0

techniques to transition from focusing on the volume of scans read to the value of the patient

experience. Please click on this link to read the Imaging 3.0 case studies:

http://www.acr.org/Advocacy/Economics-Health-Policy/Imaging-3/Case-Studies

A few examples:

Co-management business transformation: http://bcove.me/994wtsca (video)

• Radiologists at Radiology Associates of Canton, Inc. (RAC) make both operational and

strategic decisions in tandem with hospital administrators.

• Patients are treated more efficiently, reducing length of stay and increasing patient

satisfaction.

• Regular meetings with the hospital’s CEO, CIO, and other leaders allow RAC

radiologists to proactively respond to other departments’ needs.

Maine ACO:

• An accountable care organization (ACO) partnership between Maine General Medical

Center and the State of Maine Employee Health Commission has provided quality

metrics and cost-saving data.

• Radiologists have a seat at the ACO table which is vital to ensure their voices are heard.

• The Maine Health Management Coalition has been an invaluable addition by reporting

on costs as a neutral partner.

2. Clinical practice transformation can occur through many forms and avenues. When you think

about clinical practice transformation, what forms and avenues do you think it should take? Which

avenues would you find most valuable and would maximize quality and outcomes?

Radiology and medical imaging are important in both acute care episodes and in the management

of chronic disease. Coordination with primary care and other providers will be increasingly

essential in ensuring the appropriate use of imaging and in the longitudinal care of patients with

chronic illnesses. Moreover, appropriateness in medical imaging is crucial to the goal of

delivering all of the imaging care that is necessary and beneficial and none that is not.

support tools provide many improvements over current pre-authorization programs.

Decision-support tools are transparent and provide real-time education for referring physicians. They

foster a consultative relationship between local radiologists, referring physicians, and their

patients.

A few examples:

Conducting a survey and working closely with referring physicians:

• Radiologists at Emory University School of Medicine conduct a survey of referring

physicians to gain insight into advancing their roles as “image information managers.”

• Referring physicians desire more direct contact with radiologists to ensure the best

possible patient care.

• Radiology practices should consider conducting their own survey of referring

physicians and use the information to increase their visibility and value.

Partnering with other specialists to transform clinical practice and improve outcomes:

• In Wisconsin, radiologists partnered with the state medical society after disappointment

over a new RBM mandate for imaging services.

• Radiologists convinced the state’s medical director that the program was duplicative

since decision-support technology was already in place.

• Participants urge others to form similar multi-disciplinary coalitions to ensure that

radiologists’ voices are heard and patients receive quality care.

3. What are the existing sources of national, state and local expertise available to assist with

leadership development, clinician engagement and overall transformation? What gaps can CMS help

to close to build upon these efforts?

ACR’s Imaging 3.0 initiative was launched in April 2013 to help radiologists provide

value-based care. Specifically, the ACR provides resources, such as case studies, downloadable

resources for team education, Practice Visitation consulting services, and educational content

through our Radiology Leadership Institute. CMS can assist by serving as a convener of primary

care physicians and specialists to share experiences and best practices and by helping ACR

disseminate the Imaging 3.0 information to non-radiologists through the availability of a Clinical

Decision Support (CDS) portal, medical student education on utilization management via CDS,

etc.

4. What should CMS consider if it were to organize a program of technical assistance to support the

transformation of clinician practices and to prepare for effective participation in value based

payment? What should CMS consider to ensure local “on-the-ground” support to practices? In such a

program, what if any role by the state would you find useful?

CMS should consider including resources, such as ACR’s IT Reference Guide, which provides

insights into key areas of health care and imaging information technology. Please click on this

link for the IT Reference Guide: http://www.acr.org/Advocacy/Informatics/IT-Reference-Guide

5. What key areas of practice transformation require attention?

Radiologists seek to partner with payers, both private and government, to develop metrics that tie

medical imaging to outcomes and create win-win incentives for patients, payers, radiologists,

other health care providers, and facilities alike. We encourage CMS to work with radiologists to

produce quality measures and useful patient outcome metrics that reflect the value of medical

imaging and radiologists. There should be credible payment incentives to encourage appropriate

imaging care and a legal framework for physicians who follow evidence-based guidelines to be

protected from professional liability, thereby avoiding defensive medicine. In addition, there

should be robust support for a continuous program of scientifically rigorous, appropriately

funded clinical research that includes both changes to imaging care delivery and related financial

incentives.

6. What policies or standards should CMS consider adopting to ensure that groups of solo, small

practices and rural providers have the opportunity to actively participate in practice transformation?

ACR strongly supports secure and appropriate exchange of diagnostic images and imaging

information to improve the quality and safety of patient care. We encourage the federal

government, including CMS, to continue to advance and facilitate the ability for physicians,

providers, and patients to engage in this type of information sharing. We believe CMS and other

regulatory agencies should actively promote data exchange between disparate systems and

technologies, and aggressively combat any direct or indirect attempts by hospitals and/or IT

vendors to use donated EHRs to prevent or discourage referrals for diagnostic imaging services

to competitors outside of donor’s systems. Many physicians rely on the EHR exception/safe

harbor to self-referral/anti-kickback requirements to obtain access to the certified EHR

technology and IT support needed for eventual participation in the Medicare/Medicaid EHR

Incentive Program (or “meaningful use”). On the other hand, CMS and HHS OIG must be

conscious of, and take steps to thwart, potential abuses that would directly contravene the

important intent of the EHR exception/safe harbor.

7. What practice transformation strategies, resources, and tools are most needed to prepare smaller

practices to successfully participate in private and public sector pay for value arrangements?

8. Are there private sector organizations interested in providing practice transformation support if

matching federal dollars were available?

Yes, the American College of Radiology has launched a campaign called Imaging 3.0™ to drive

a cultural change throughout the specialty and highlight the value that radiologists and imaging

deliver. Imaging 3.0 refers to a new era in which radiologists use improved communication and

information technology tools to ensure that only appropriate imaging is performed, re-engage

with their referring physician colleagues, and more than ever before, connect with their patients.

Imaging 3.0 marries improved quality with reduced cost to deliver system-wide, patient-focused

value. The first step, ACR Select™ or consultative clinical decision support, integrates and

connects radiologists across institutions and business settings at the beginning of the care process

when imaging is being considered by offering consultation and guidance through an

evidence-based clinical decision support tool for referring physicians. Once a study has been ordered and

the patient has been imaged, the second step occurs when the interpretation is delivered in a

standardized and structured actionable radiology report. Structured reporting allows for

quantitative measurement and data discovery supporting the determination of patient-specific

value connected to actual outcomes. The third step is the cloud-based portal that gives patients

and referring physicians geography-independent access to imaging and reports. Imaging 3.0 rests

firmly on an information technology platform that has been developed by radiologists in

partnership with industry and proven in clinical practice to ensure widespread interoperability

and adoption.

The ACR submitted this concept as a project to be demonstrated during Round II of CMS’

Innovator Awards program. To date decisions have not yet been made on who will receive these

awards. Additional federal funding would allow us to fully develop and implement the Imaging

3.0 concept.

9. What should CMS consider as it relates to beneficiary and caregiver experience of care when

practices transform?

10. Which existing educational and assistance efforts might be examples of “best in class”

performance in spreading the tools and resources needed for practice transformation? What evidence

and evaluation results support these efforts?

In addition to the Imaging 3.0 initiative, the ACR established the Radiology Leadership Institute

(RLI), a professional development and leadership academy that prepares leaders who will shape

the future of radiology to ensure quality, elevate service and deliver extraordinary patient care.

Featuring a stair-step learning approach, the RLI delivers advanced leadership courses designed

for various levels of professional experience that build to high proficiencies of leadership

acumen. An introductory Imaging 3.0 track within the RLI provides ACR members with

baseline preparation for participation in an evolving delivery and payment environment.

11. How useful is the rapid sharing of results in facilitating practice transformation and improving

health outcomes?

The ACR’s Commission on Economics developed the Radiology Integrated Care Network

(RICN) to collect, analyze, and disseminate information on all facets of economic issues and to

specifically bring together radiologists who work in new payment models. The RICN’s rapid

sharing of information through discussions of members’ experiences with integrated care and

new payment models has been an invaluable resource to ACR’s Imaging 3.0 initiative.

12. What general quality improvement strategies should practices employ to build a sustainable

continuous quality improvement program (e.g., programs that rely on input and involvement from

patients and staff, proven improvement processes and performance measures)?

13. How are practices using Health Information Technology (HIT) and Electronic Medical Record

(EMR) technology to improve patient health outcomes? How have various organizations supported

HIT integration in practice transformation?

14. How are practices addressing race, ethnic, primary language, and disability status health

disparities in their work to improve patient health outcomes? How have organizations leveraged

practice transformations to support reduced racial and ethnic disparities?

15. How are practices using population-based strategies to improve patient health outcomes? How

have organizations supported population-based strategies in practice transformation?

B. Challenges and lessons learned in Practice Transformation engagement.

16. What are the most significant clinician challenges and lessons learned related to transforming a

practice and what solutions have been successful in addressing these issues?

Decision-Support Systems:

The use of decision-support in daily clinical practice provides an evidence-based methodology to

ensure the right imaging examination is performed for the right reason for each patient every

time. Preliminary experience from recent CMS Medicare Imaging Demonstration Projects

supports the contention that Appropriateness Criteria-based decision-support systems have

clinical, educational and cost benefits and, unlike radiology benefit management programs, have

not been associated with cost shifting to the health care providers.

An example:



In Minnesota, after a successful pilot involving over 5,000 physicians from five

Minnesota medical groups and the Department of Human Services, the Institute for

Clinical Systems Improvement (ICSI) now coordinates and promotes the use of a

statewide diagnostic imaging decision-support approach based on ACR Appropriateness

Criteria. The pilot demonstrated the value of real-time decision-support and shared

decision making between the patient and provider as compared to radiology benefit

management programs and yielded an estimated $28 million per year in health care cost

savings. At the completion of the pilot, the program was disseminated to over 100

additional organizations in Minnesota.

Quality and Safety Programs for Medical Imaging Professionals and Their Practices:

The safe practice of medical imaging requires the implementation of practice based quality

assurance programs, and radiologists are trained to deliver the highest quality care possible to

their patients. Radiologists enhance patient safety by monitoring and reducing radiation exposure

for patients.

An example:



Radiologists are increasingly participating in the CMS Physician Quality Reporting

System (PQRS) and are involved in the development of national level performance

measures. In fact, in 2010, eligible radiologists participated in PQRS at a rate higher than

most other physician specialties.

17. What are the operational challenges, lessons learned, and successes in developing an

infrastructure to support transformation?

18. How can physician/clinician affinity groups be leveraged to strengthen the care process and for

improve patient outcomes?

19. What are the essential lessons learned from other industries where best practices on systems

transformation and learning culture have been adopted?

20. What challenges that have not been successfully addressed to date need to be addressed to

achieve desired outcomes in health, healthcare, and more affordable care?

21. What information privacy challenges are anticipated or have been experienced in the

transformation of practices? How have these challenges been addressed? What specific local, state or

federal requirements presented these obstacles?

C. Engagement, Partnership and Continuous Learning in Practice Transformation.

22. What should CMS consider when spreading innovations through learning systems?

23. What should CMS consider regarding how QIOs, Regional Extension Centers, States and other

existing entities can support practice transformation?

CMS should consider seeking input from specialists, such as radiologists when developing these

entities and programs.

24. What should CMS consider when working with private payors in practice transformation?

25. What should CMS consider as it works with States in practice transformation?

26. What should CMS consider when aligning public and private clinical transformation efforts?

27. How has the use of knowledge management systems facilitated effective communication in

learning environments (i.e., through sustainable sharing of improvement results, providing virtual

technical assistance, interactions amongst large communities of practice, and the provision of on-line

resources and tools)?

CMS should consider allowing professional medical organizations to share their publicly

available resources through this structure and by utilizing existing successful non-profit and

commercial programs, such as the Radiology Leadership Institute, Khan Academy and

Brookings/Merkin Initiative.

28. What would motivate clinicians to participate in any potential future initiatives relating to

practice transformation and value-based purchasing?

29. What would motivate new partners to enter the field of practice transformation as a prime

contractor, subcontractor, or consultant?

30. Are there other successful mechanisms that support engagement in practice transformation that

could be considered?

D. Current Engagement in CMS Models.

31. What is your current relationship with CMS initiatives related to practice transformation (e.g.,

Accountable Care Organizations (ACOs) participating in the Shared Savings Program or the Pioneer

ACO model, and the State Innovations Models (SIM)?

32. In your transformation efforts, have you seen any program integrity issues and if so what

strategies did you use to assure that your transformation efforts did not foster program integrity

problems?

33. Even if you did not see any program integrity problems or issues during your transformation

efforts, did you actively design strategies to mitigate any such issues? What were the mitigation

strategies?

34. Are there particular program integrity issues that you think you need to address as you pursue

transformation? What are these issues? What barriers do they pose to successful transformation?

35. How could CMS possibly use patient satisfaction surveys or report cards regarding practice

transformation?