May, 2017:

MACRA Overview- Is Your Organization Prepared?

Part 1 of a 3 part series

The Medicare Access and CHIP Reauthorization Act, commonly known as MACRA, was signed into law in April of 2015.  This legislation both reflects and propels changes already underway in the healthcare industry, repealing the Sustainable Growth Rate formula and establishing a new federal program called the Quality Payment Program (QPP).

The Quality Payment Program went into effect on January 1, 2017, signaling the end of the old “fee-for-service” model and the beginning of a mandated industry-wide shift toward value-based care.  MACRA seeks to ensure Medicare’s sustainability by moving away from a reimbursement model that relies on the quantity of treatments provided by physicians, thus cutting overall Medicare costs over time.

The Centers for Medicare & Medicaid Services (CMS) has laid out six strategic objectives for the Quality Payment Program[1]

  1. Improve patient outcomes and engagement through patient-centered policy development.
  2. Enhance clinician experience by incentivizing the use of tools that make accurate data available, modernize payment systems, and provide big picture insights that will help clinicians make informed decisions that add value to their practice.
  3. Increase the availability and adoption of a diverse range of Advanced APMs to reduce overall healthcare costs and improve quality of care.
  4. Promote education, outreach, and support for patients and communities.
  5. Improve sharing of information to ensure clinicians are empowered to make decisions based on accurate, timely, and actionable EHR data from multiple sources
  6. Ensure “operational excellence” in program implementation and ongoing development.

The QPP provides a choice of two paths for Medicare reimbursement: Merit-based Incentive Payment Systems (MIPS) or the Advanced Alternative Payment Model (AAPM).

An eligible clinician may become a Qualified Professional (QP) or a Partial QP by participating in an Advanced APM in which the eligible clinicians as a group meet specific payment or patient thresholds.  During each QP Performance Period CMS would determine if an eligible clinician met one of the thresholds to become a QP or Partial QP.

MIPS combines three previous programs — the Physician Quality Reporting System (PQRS), the Medicare EHR Incentive Program (also known as Meaningful Use), and Value-Based Payment Modifier into one program that evaluates providers in four performance categories1. The categories are Quality, Cost, Improvement Activities, and Advancing Care Information.




Scores for an organization’s performance in each category will be combined into a Composite Performance Score (CPS) with 100 potential points.

The financial decision-makers at hospitals must work closely with their provider groups to determine which of the three paths, MIPS, AAPM, or Partial Qualifying APM, will yield the most return for their specific organization.


These categories are weighted for the 2017 performance period, which is also the MIPS transition year. The weights are as follows:

  1. The Quality category replaces the Physician Quality Reporting System (PQRS) and is weighted at 60% of the CPS in performance year (PY) 2017. Its CPS weight decreases to 50% in PY 2018 and 30% in PY 2019, and beyond.
  2. The Cost/Resource Use category replaces the Value-Based Modifier and will not be counted for PY 2017. It will be weighted at 10% of the CPS in PY 2018 and 30% in PY 2019, and beyond.
  3. Clinical Practice Improvement Activities (CPIA) is a new MIPS category that did not exist previously. It is weighted at 15% of the CPS in PY 2017 and beyond.
  4. The Advancing Care Information category replaces the Meaningful Use/Medicare EHR Incentive Program and is weighted at 25% of the CPS in PY 2017 and beyond.

MIPS payment adjustments occur two years after the performance year.  As such, payment adjustments will begin in 2019 for PY 2017.  While Advanced APMs have a fixed bonus incentive of 5% through 2024, MIPS payment adjustments are variable.  Depending on how well a group’s Composite Performance Score ranks against scores nationwide, physicians can see no adjustment at all, a positive adjustment, or a negative adjustment up to a determined percentage each year.


It’s very possible that these weights will change over time, but right now, these are the weights that we’re working with.


Organizations that fail to prepare for MACRA may be faced with the financial stress of a negative payment adjustment in an already harsh economic climate.

Once the financial decisions have been made about which path is most suitable and which measures should be reported on, the organization must develop and implement a strategy for gathering that data in an accurate, timely, and cost-efficient manner.

MACRA compliance calls for a high level, strategic reevaluation of IT systems and processes. Hospitals and APM entities that have fallen behind the MACRA schedule must take immediate action to assess their organizational needs and develop a strategy that will drive both financial and quality of care growth under MACRA.



Healthcare On-Demand: An Experience with Epic MyChart

Today’s consumers live in an “on-demand” world. A benefit coming from this societal shift to self-service is unique in the context of healthcare, where increased patient engagement can correlate with improved patient satisfaction. One way in which we can be more engaged in our healthcare is by enjoying the benefits of mobile applications for smartphones – staying connected and able to act wherever we go.

Many companies are racing to provide the on-demand convenience of scheduling, results review, telemedicine, but for me, Epic has already provided a product that goes above and beyond meeting that need. As a result, my healthcare experience has changed dramatically since Epic MyChart was implemented in my community. Not only does MyChart make communication with my physician readily accessible from my smartphone, it also provides a portal to quickly access my recent medical records and lab results. Additionally, the app is well designed to be user friendly, a bonus when the user base varies in age from millennials to baby boomers.

I recently needed to schedule an urgent doctor’s appointment, something which ordinarily might have required a phone call and lengthy wait time until I could be seen. However, now that my physician’s office offers MyChart, I was able to simply log in via my smartphone and select the next available appointment that was compatible with my schedule. Additionally, when I logged in, I received a notification letting me know that I was soon due for an annual physical, which I was able to conveniently schedule via the app. Without this reminder, I probably wouldn’t have scheduled the physical until far past its due date, if at all. A few days later, when my illness was not responding to medication, it was a relief to be able to simply send a MyChart message to my physician letting her know of some new symptoms, rather than having to call and ask front desk staff to relay the communication. My physician quickly received my message and was able to prescribe the correct antibiotics, helping my symptoms to improve within a few hours, rather than over the course of several days.

This ease of use and increased communication promoted the feeling that my healthcare experience was personalized and attentive to my specific needs as a patient, it was truly “on-demand” healthcare access. It left me eager to engage with the healthcare community in order to promote health and minimize the delay between onset of symptoms and presentation at the clinic. Knowing I have the opportunity to review my records, carry them with me, and interact at a higher level with my healthcare team is incredibly reassuring and reduces the stress of care. I overwhelmingly enjoyed the experience of being an empowered consumer of healthcare, a feeling I am passionate about sharing with my community and my clients.

Training Coordination – The Overlooked Project

I just wrapped up a project as a training coordinator, and I have tremendous respect for those who are tasked with this important responsibility. Until taking on this role, I underestimated how much work goes into planning the right classes, at the right time and with the right equipment.  When working as a Connect analyst, I would point staff to the right person to get scheduled prior to the go-live date.  Scheduling hundreds of staff for a major go-live is a tremendous task.

One of the first tasks is getting your staff volumes and class size determined. Use of the Epic Training Calculator aides in determining how many training staff are needed based on the number of staff in each role, the number of classrooms available for training, number of seats in the room and length of the class.  For certain classes, there may be a need for peripherals such as signature pads, scanners, etc., that must be included in the training room configuration and verification that they are functioning properly.  Once these numbers are known, you can then ramp up the training staff accordingly and work with internal and 3rd parties.

Once you have trainer staffing complete, one of the first tasks early on in the process is the onboarding and credentialing of the trainers, whether you are using internal or external staff. A good program involves working with the organization’s team to get ID badges, emails, network logins, and access to the appropriate applications.  Then you must work with the principal trainers (PT) to set up times to go over the curriculum that these new CTs will be teaching.  This position is also responsible for development of the schedule for the new CT’s training, teach-backs, and credentialing panels with key stakeholders (i.e., department leads).  It is essential to have strong credential trainers that all participated in your program.

After everyone is credentialed, the schedules need to be set up and entered into the organization’s LMS (Learning Management System), listing out dates, times, location and length of class based on the results from the training calculator. Additional classes are normally added at the beginning to accommodate varying schedules, and added “on the fly” for last minute registrants.  Depending on the size of the roll-out, the number of staff to be trained will determine how far in advance training should start prior to your go-live.  End users (or their manager) would be responsible for ensuring that staff are registered for the appropriate class or classes.  Once training is completed, reports are generated through the LMS and the appropriate security is provisioned based on the training completed and the employee is then able to access the system.

Another critical assignment is the development of a course catalog for training offered for new staff trainees (ex. patient access staff, revenue cycle staff and practice managers). Information should include synopsis of course, intended audience, time commitment, prerequisites, and frequency of course offering.  This is also intended for those areas that are already live with Epic and are getting new staff at the location.  These classes are set on a standing schedule and in conjunction with new employee orientation.  That way, we can get the employee into training as soon as the day after their new employee orientation class.  Standing schedules are also developed for the hospital’s post go-live again to accommodate new hires at these locations.

Training has always been one of the most critical components to successful impressions of the EMR, adoption, initial cultural implications and more. Training coordination is an integral aspect of any system roll-out and managing your training program closely with strong project managers and coordinators will ensure smooth, adaptive programs keeping all training on track for success.


Do You Have a “Culture of Safety” in your Ambulatory Setting?

Safety is no longer a problem just for executives. Much is said at conferences by health organizations and is in the literature about having a “culture of safety.”  This term embodies the application of safety and quality as a primary and overarching goal in the medical practice.  Safety becomes part of the daily work in which leaders and staff proactively solve problems, reduce risk and improve care.  Organizations turn to the safety tools from the “culture of safety” movement.  Using these and other tools, team members of all levels communicate about safety, ask questions and learn without the barriers of title, status or a fear of retribution. In this setting, leaders, physicians and staff are equally empowered to make changes during the course of their work.

One might be surprised to learn that there is a greater risk for harm in a routine office visit than some inpatient admissions. With the number of outpatient encounters significantly growing the risk becomes even more pronounced.  This blog provides guidance to leadership regarding strategies to reduce risk in the medical office by having clearly defined care guidelines and using the tools and tones of the culture of safety.

As you begin thinking about your environment, consider the overall approach to staff training. Review your on-boarding process and consider how you introduce safety principles in your culture.  Practices need to outline expectations early to avoid issues at a later date. Too many offices make the mistake of not having designated staff trainers which leads to inconsistency.  Ensuring physician and staff training is adequate, reduces the likelihood of performance improvement issues, stress from being understaffed, improves quality, as well as staff and provider satisfaction.

Next, consider the value of pre-visit work. Staff should learn a standardized pre-visit preparation process to identify gaps in care.  This will help staff to close all gaps during the office visit.  Ensure staff and providers know and understand the expected testing, the referral circle (internal vs. external) and the process for ordering required studies.  The employee probation period should provide support, coaching and instruction in the employee’s clinical setting.  Augment this training with online and classroom training.  Leaders can review paid claims and use business intelligence tools to analyze the cost and services provided, conduct audits and intervene when care is provided outside of the protocol.

Diagnostic errors can include missed care opportunities, delays in care, or more seriously, an incorrect diagnosis. Patient care should be consistent with evidence-based care guidelines.  A variety of approaches such as, decision support tools, order sets, electronic tasking, pop up messages, care coordination staff and evidence-based protocols, can reduce errors. Certified medical assistants can alert a provider to sign off on a pending order created by them, help to monitor the test that has been performed and the result delivered to the patient.   Encourage staff to use the culture of safety tools to ask clarifying questions to validate the follow-up plan when there is a deviation from the protocol.

Once diagnostic testing is ordered, it is important to provide clear information to the patient regarding the delivery of the result. The follow-up plan should be consistent as expressed by providers, staff and even the ancillary service.  Patients should either have a scheduled follow-up appointment to review the findings, be told they will receive a call or they should expect a letter within a number of pre-defined days.  It’s important to avoid saying to the patient, “if you don’t hear from us, then everything is okay.”

This type of discharge planning can result in miscommunication and delays in care.  Staff could use the culture of safety technique of “STAR” technique (Stop, Think, Act and Pause) to confirm they understand the follow-up plan for each patient and confirm it is consistent with office protocol.

Staff not updating the family history section in the patient record during the history taking can contribute to an important detail being missed. Staff learn differently and training materials may need to be in multiple languages or in various formats such as a written article, a checklist, or a routing slip. Encourage staff to utilize the culture of safety technique of validation and verification to ensure they understand what is required for each patient.

Communication errors may occur if an electronic system is not being used effectively to communicate or if active listening is not occurring, such as when a staff member is rushed or when a practice is chronically understaffed. Best practice includes future appointments being noted on the routing slip or a workflow which includes electronic orders being entered prior to the patient reaching check-out.  Consider if “pod” check-outs would help to ensure the discharge plan is reviewed/activated in the exam room, thus reducing hand-offs.

Errors or delays can inadvertently occur if a specific diagnosis is lacking or an incorrect diagnosis is entered. Using the culture of safety tool, such as practicing with a questioning attitude, staff can help to eliminate/reduce these errors.

With value-based care, the emphasis is on improving quality, safety and patient satisfaction. Practice leadership should continuously review their internal workflows and processes to shine a light on potential quality and safety issues from a variety of perspectives.  Consider holding a daily huddle with your team or identifying a safety coach in the practice to increase recognition, decrease harm to patients and employees while improving care.

Jill Berger-Fiffy , MHA, FACMPE
Senior Consultant

Consultants as Mentors?

Working in any industry, you encounter people with various backgrounds and degrees with little or no knowledge of the business. You run into the young graduate who just entered the workforce, the established employee who is set to retire or the ambitious employee who is thirsty for more knowledge. In a hustle and flow environment, where do you find time to encourage your employees to master their skills, prepare them for management level or assist in adapting to a new environment when the industry changes around them?

Consultants continuously walk into organizations where change is in the midst, an established business is not working as efficiently as it could, or an open position needs an interim replacement. We observe as an outside party and want to help to create efficiency, structure and indicate where we identify the gaps, but we also know we are there for a specific task.  During engagements, it isn’t uncommon to form relationships with the company staff – listening to their concerns, providing limited feedback if necessary and amusing the ones that just want to complain, even when there isn’t anything to complain about.  Many times, we are perceived as a wealth of knowledge – a golden ticket to show them what they want to learn or to help do some of the work no one else has time for.  When we as consultants have the time to share that knowledge and mentor the existing client staff, success is exponential.

In a recent article with Fortune.Com, CEO and Co-founder of AirBNB, Brian Chesky, explains “you’re the average of the five people you surround yourself with. So the question is, how mature are the people you surround yourself with?  If you surround yourself with the right people, you can grow up pretty quickly.”  Imagine making a decision based on just your thoughts rather than thoughts that are inspired by interactions with insightful individuals or groups.  That could heavily impact a place of business, how you interact with staff, and your own psyche.

Consultants that have the skill of mentoring or coaching are able to provide more of a service to the client rather than just the task at hand. This type of consultant will flourish, as they build a rapport with the client which could allow future interaction together, providing knowledge transfer, understanding the client outside of the assigned task, and creates an abundance of new relationships.  Mentoring is a silent skill – some people have it and others don’t, which is perfectly fine.  Consultants are there to provide a service and this is just an added bonus during a client engagement.



Jim Lachner joins Culbert as Regional Executive -Advisory Services

Culbert Healthcare Solutions is pleased to welcome Jim Lachner as the newest member of our business development team. Jim will serve as Regional Executive – Advisory Services, where he will be responsible for supporting clients located on the west coast.

For the past 30 years, Jim has delivered software and service solutions to medical groups, hospitals, integrated delivery networks, and academic medical centers. Prior to joining Culbert, he held senior sales executive roles at Cerner, First Consulting Group and KPMG.


Joel Szymanski Joins Culbert as Regional Executive -Advisory Services

Culbert Healthcare Solutions is pleased to welcome Joel Szymanski as the newest member of our business development team. Joel will serve as Regional Executive – Advisory Services, where he will be responsible for supporting clients throughout the Midwest.

For the past 12 years, Joel has delivered software and service solutions to medical groups, hospitals, integrated delivery networks, and academic medical centers. Prior to joining Culbert, he held senior sales executive roles at Nuance and Allscripts.