Payment Reform -- do you
have the tools to be
successful?
What to look for in an EHR.
Presented By: Mary Givens, MRA ,
Product Manager of Compliance,
Agenda
•
EHRs are one of the tools needed for operationalizing payment
reform
•
Elements of a “Payment Reform Ready” EHR
•
Ability to manage a Shared Risk Payment Model•
Integrated Treatment Plan•
Clinical Decisions Support Rules•
Utilization Management Reports•
Flexible Scheduling•
Objective Data Outcomes Measurement•
Golden Thread•
Robust Reporting Capability•
Staff Capacity and Productivity tracking•
Reduce costs and waste in current system to maintain margin•
Assessing a need for change in Level of CareEHRs role in payment reform
•
The EHR is nothing if not a tool. It can be a critical tool for
gathering and reporting on the data for payment reform so the
providers and agency can make informed decisions, change
their behavior in response to data, and provide higher quality
more targeted treatment to individuals served.
•
In payment reform, CMS is investing in INNOVATION,
IMPROVING CARE, and SAVING MONEY.
Healthcare Reform: The 3 Things Your EHR
Should Do
1. An EHR should help you capture, understand, and quantify
your data.
2. An EHR should support interoperability.
Formula for CareValue
Care Value = Quality of Care X Efficiency of Care
____________________________
Shared Risk Payment Module
• EHR should be able to easily generate clean claims and post payments for each of the payment reform models required from your payers. The various model types are
• Fee for Service: predetermined amount is paid for each discrete service
• Episode of Care: single price for all services needed by an individual during an episode of care (also called case rate) • Bundled Payments: single payments for a group of
services related to a treatment or condition that may involve multiple providers across varied settings
• Pay for Coordination: Payment for specific care coordination services to specific types of providers (example Health Homes)
• Pay for Performance: Payment or financial incentives for achieving defined and measurable goals related to care processes and outcomes
• Traditional Capitation: Designed to control the number of episodes; provider receives a single payment to cover all services needed by a patient during a set period of time regardless of the number of episodes. Payment is the same regardless of how ill or healthy the patient is.
• Comprehensive Care/total Cost of Care Payment: A single risk adjusted payment for the full range of healthcare services needed by a specified group of people for a fixed period of time (PM/PM)
Source: “Operationalizing Health Reform”, David Lloyd, Scott Lloyd et al , 2013 MTM Services LLC, Available at www.nationalcouncil.com
Integrated Treatment Plan
• EHR Needs to allow for the recording and tracking of goals from all providers , internal and external, in a single treatment plan.
• EHR needs to capture all Care Team Members including
• Primary Care physicians
• Other specialist (Cardiologist, Oncologist, etc) • Spouse • Parent • Case Manager • Care Manager • Guardian
• Other entity of care (i.e. a hospital) • Ideally, EHR supports a single ,
Clinical Decision Support
• EHR must have the ability to build
referenceable clinical decision support rules based on vitals, demographics, lab results, medications, medication allergies, smoking status, and assessments at a minimum.
• Clinical Decision support rules must fire at the correct and succinct times during the delivery of care so that the provider can utilize them to make a clinical decision.
• Clinical Decision support rules can be part of your prevention program (decrease in
disruptive services)
• Clinical decision support rules should be evidence based and provide source material so provider can make informed clinical
decisions.
• EHR should track/log the decisions and actions made for each firing of a clinical decision support rule.
Utilization Management Reports
• EHR should have reports available or a dashboard to show critical practice
management data such as
• appointments scheduled vs. appointments kept
• days to documentation complete • “did not show” percentages by
consumer, provider, program, type of service (or causality)
• Staff caseload capacity vs. actual caseload
• Claims paid vs. denied by program, payer, provider
• Program capacity vs. actual enrollment • Cancellation vs. backfill rate
• Services ordered in treatment plan verse services delivered
• Days from Intake to Treatment/Referral to Treatment
Flexible Scheduling
• EHR should have the ability to support scheduling for different program models including
• Community Based programs • Outpatient program
• Scheduled and drop in group services • Psychosocial programs
• Residential services • Inpatient services
• Partial hospitalization services • Intensive outpatient services • Respite
• Consultation to long term facility services
• Asynchronous Services
• EHR should have the ability to easily manage walk in appointments and backfill
Objective Data Outcomes Measurement
• EHR should include the ability to conduct standardized clinical assessments and measure and graph the change over time. • Many assessments are more valuable when
you look at change over time. An example of such assessments are
• Vital signs including BMI • PHQ-9 • DLA-20 • BPRS • GAD 7 • CAGE • CANS • ANSA • WHODAS 2.0 • BASIS-24
Golden Thread
• EHR should have the ability to pull diagnosis and assessments into Treatment Plan so goal and objectives can be targeted and specific.
• Ideally, problems identified via assessment can be easily pushed to problem list.
• Services should be able to be tied to specific goals and objectives to support treat to
target practices.
• Provider should be able to include the goals and objectives they are treating to in their progress note.
• Each goal can be easily updated to show progress.
• Services can be easily tied back to treatment plan so it can be determined if services are being delivered as ordered.
Robust Reporting Capability
• EHR should have robust reporting
capability so the user can generate data to reflect practice management success or areas of need. Some Practice Management Reports might include:
• Product Line Break Even Analysis
• Billable hours verses non billable hours • DNS by service type
• Successful collection rate
• Percentage of Discharges with Transition plan (asynchronous services)
• Utilization of services and by whom (by condition, demographics, etc.)
• Greatest Improvement in Functional Assessment by program, by provider • Time from referral to Intake
• Time from referral to first treatment appointment
Need for Change: Level of Care
• EHR should be able to prompt provider when they may want to reassess level of care for a less intense, lower level of care. • EHR should provide some assistance in
determining the best, most appropriate staff to schedule consumer with.
• Through use of treatment plan,
assessments, electronic notes, crisis alerts, scheduling, etc, EHR should be able to help the provider best prepare to “treat to target” at each session.
• Clinical decision support rules should
provide the user information about evidence based practices (EBPs) and protocols for patients with specific conditions. The EBPs should be referenceable.
RESOURCES
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