Spring 2011  
The Intersection of Meaningful Use and Medical Home
By Annamarie Monks, Principal Consultant
Healthcare leaders are constantly hearing about new initiatives and need to prioritize where to devote the organization's limited time, energy and resources. After dealing with day to day operations and responding to mandates, there's little time and attention available for new initiatives. Yet that is where the focus of the leader must be. One initiative that has been quietly growing in momentum is the concept of Medical Home. Is this worthy of the leader and organization's focus and resources?
PCMH Background
The Patient-Centered Medical Home (PCMH) is a model of health care delivery. The Medical Home is designed to strengthen the patient-clinician relationship by improving care coordination, enhancing access and promoting communication with patients and families. The PCMH "coordinates the care" of its patients with specialists, lab/radiology facilities, hospitals, home care agencies, and all other health care professionals on the patient care team. The concept of "medical home" has been around since 1967 when the American Academy of Pediatrics (AAP) first used the term to describe the ideal model of care for children with special needs.
Forty years later, four primary care societies - the AAP, the American Academy of Family Physicians (AAFP), the American College of Physicians (ACP), and the American Osteopathic Association (AOA) - collaborated to publish the Joint Principles of the Patient-Centered Medical Home (AAFP, AAP, ACP, AOA 2007). Working with the four primary care specialty societies, the National Committee for Quality Assurance (NCQA) developed the Physician Practice Connections®—Patient-Centered Medical Home™ (PPC-PCMH) program (NCQA, 2008). At the end of 2010, nearly 7,700 health care providers at more than 1,500 locations met NCQA's standards to receive recognition as a patient-centered medical home.
Primary Care is not the same as Medical Home
There are many providers who think they already practice in a medical home model. While their practice may display some of the characteristics of an NCQA recognized Patient Centered Medical Home, if they dig deep into the culture and communication evidenced daily by the staff and providers, they may look more like the practice described in the first column (right):
This table from Dr. Daniel Duffy at the School of Community Medicine in Tulsa, Oklahoma compares and contrasts a traditional medical practice with a Medical Home practice. Medical Home goes beyond good intentions; it's characterized by having the appropriate information systems, data, workflows, infrastructure, community supports, referral relationships, and data to know exactly where your practice … and your patients …stand.
A number of qualitative and quantitative studies have been done to look at the impact of Medical Homes. Studies have found that patient care in the medical home model improves outcomes, such as health status, timeliness of care, family-centeredness and family functioning. The model itself has been studied as a new concept for primary care redesign, health care delivery and payment. In addition to the health status benefits, some Medical Home practices and providers have seen a financial benefit. Many of the early adopters of PCMH were part of policy and payer efforts to promote demonstrations of new payment models for primary care. Select private and public health plans and employers have implemented projects and demonstration programs to recognize and compensate practices as patient-centered medical homes. In some cases, insurers note practices that have received NCQA recognition with seals of approval in their provider directories. Other plans supplement NCQA application fees for recognized providers. Will it pay off for you? Consider what elements of the Medical Home may overlap with any pay-for-performance programs you participate in. By working on those measures, you may realize bonus payments not directly tied to Medical Home. In addition to the carrot, there may be sticks down the road if NCQA Medical Home recognition is a requirement for entry into high-performance networks.
The Synergy of Medical Homes and EHR
At the same time organizations are examining the Medical Home model, most of them are well on their way in implementing an Electronic Health Record (EHR) and qualifying for incentive payments for successful EHR implementations by demonstrating "Meaningful Use". The good news is that there is a high degree of alignment between PCMH standards and elements and Meaningful Use criteria. The intersection became even closer with the publication of new PCMH standards in January 2011. In the latest standards, specific Meaningful Use criteria are listed verbatim and embedded in the PCMH standards. Most of the elements of a PCMH are supported or made easier if you have an EHR. Each Meaningful Use criteria supports one or more PCMH factors. Physician practices that meet the medical home requirements will be prepared to meet the meaningful use standards, and vice versa.
It's All About the Workflows
Medical Home and EHRs are similar in the emphasis on workflows. While both present a list of standards/features that are required, the key to success is how the feature is used or standard is demonstrated. An EHR can be the information system infrastructure to power the workflows in a PCMH. Meaningful Use defines the information management requirements for supporting a PCMH. As an example, test tracking follow-up comprises a number of different processes and workflows designed to assure nothing falls through the cracks. Health management follow-up requires data and reminder prompts so that staff is alerted and patients are reminded of needed services such as mammography and colonoscopy. The presence of a capability or function is not enough; the feature needs to be used reliably and in a well-tested workflow. The EHR in a PCMH would use health information systems to provide data and reminder prompts such that all patients receive needed services.
Transformative Change
When considering embarking on the Medical Home and/or EHR journey, there is another parallel initiative to consider. Both the Medical Home and EHR are supportive of a third initiative – the Accountable Care Organization (ACO). The ACO model involves groups of providers, physicians, hospital, NPs and PAs and others to promote evidence-based medicine, patient engagement, report on quality and cost measures, and coordinate care through enabling technologies. Medical Home and EHR contain fundamental elements critical to the success of the ACO model. All three have a transformative impact on the medical practice and require significant time and resources to implement successfully. Now they are more complementary and synergistic than ever. That synergy and the promised positive outcomes make the journey more satisfying and the effort more rewarding.
Click here to view a listing of PCMH criteria.
Protect Your Revenue: Prepare for 5010 and ICD-10
News from Rob Culbert, President
Healthcare organizations have been preparing for meaningful use and monies for incentives are becoming available later this year. If you have not completed your evaluation to determine whether your organization qualifies for Medicaid or Medicare incentives, it's not too late to conduct an evaluation to determine which incentive programs your organization qualifies for and to consider the other incentives your providers participate in such as PQRI. IT should be identifying where data is coming from and what data will be used to determine justification of incentive dollars. From an operational readiness perspective, identify who in your organization is responsible for maintaining your process for capturing and reporting accurate information.
As efforts are focused on preparing for qualification of meaningful use incentives, it's important to also make preparations for the implementation of 5010 and ICD-10. The 5010 transactions will change the electronic exchange of financial information between healthcare organizations and the health plans for referrals, claims and remittance as well as have a critical impact on the use of ICD-10. Preparing now for these changes will protect your revenue stream, prevent your organization from losing revenue that could lead to serious financial strain.
Healthcare IT vendors have devoted the majority of their resources towards meaningful use development since the Final Rule was published. While these incentive dollars can amount to significant income for larger organizations, the reality is that ICD-10 will require an even larger investment. Clinical documentation, charge capture, HIM/coding, claim production and ultimately reimbursements will all be impacted by ICD-10. The time for preparing your organization is now. If you have not heard your software vendors ICD-10 migration strategy, we strongly recommend you consult with your support contact so you can plan, prepare and be ready to address this mandate in 2012.
Hand Held Charge Capture
By Michael McAdams, Senior Consultant
Hand Held Charge Capture vendors such as MedAptus or PatientKeeper are now compatible with most smart phone technologies including Blackberry, iPhone and iPad, further simplifying the effort for capturing charges. These charge capture systems allow physicians and staff to accurately bill for any patients seen in the inpatient and outpatient settings. For example, the physician can bill for patients seen in the clinic (outpatient) or in the ICU (inpatient). For medical groups using an Electronic Health Record, these products are effective in capturing inpatient services in those instances where physicians do not have access to the ambulatory EHR running in their practices. These systems generate a patient list for the physician and once a patient is selected they can bill for that particular patient's case by selecting a charge and a diagnosis for the patient.
There are many benefits for the physician to be able to use charge capture solutions running on smart phone technology. A primary benefit is the ability to use the system at the patient's bedside. At the moment that the physician sees the patient they can bill for that patient right away. This eliminates having to write down the patient's information on a card or piece of paper then have to mail it to the billing company, resulting in reduction of lag time for charge entry.
With older charge capture devices, the wireless features would wear down the battery. This is much less of a problem on smart phones. Because the longevity of smart phone battery life , a physician can look up a patient's medical history or medical notes during the patient visit and thereby speeding the diagnostic process.
Ultimately the use of the handhelds will increase the success and accuracy rates of billing for patient's visits and lowering the rate of missing charges. It can also raise the moral of the staff and physicians as they no longer need to rely on paper or information being inaccurately passed down from staff member to staff member. The patient will benefit as well since their physician will have all of their up to date information in the palm of their hand literally.
Managing Revenue from the Beginning
By Scott Kelly, Senior Consultant
The Patient Revenue Cycle starts the minute a patient appointment has been requested. Many clients believe that the process doesn't start until charges are entered into the billing system and is independent of how the customer perceives the organization. However, there are many factors that define a positive revenue cycle process. This is the first installation in a series of articles that explain the direct and indirect influences that determine successful outcomes in a patient revenue cycle. What is meant by a successful outcome? A successful revenue cycle is the result of: timely and accurate information for coding and filing of charges by the provider, data extraction from all sources, filing of charges with payers and supplying supporting documents. Most important is a positive experience by the patient resulting in prompt residual balance payment from the patient and or other third party.
It is critical for health care organizations to have and maintain a current state analysis of the enterprise level patient process flow. Why are these process flows critical to a positive patient revenue cycle process? Many processes must take place before the patient obtains an actual appointment. The Front Desk and or Central Scheduler must be well trained to obtain data from the patient professionally, efficiently and legally in order to process the patient's appointment. Demographics, insurance data and requirements for the actual service being key information needed to facilitate successful collection of the patient's charge activity. Reducing the frustration for both the patient and the scheduling staff is paramount in the design of both the process flows and within the computer systems being used. A positive experience by both parties will increase customer satisfaction.
Effective, efficient and professional customer service becomes the most important aspect of successfully collecting the data needed to inform the patient, the provider and for the patient to have a positive experience. All front desk and central scheduler staffing has adequate professional customer service training. The quickest way to have a breakdown in the patient revenue cycle process is for the customer to have a negative experience. If the patient has a negative experience, even at the point of appointment creation, that negative experience can carry forward throughout the revenue cycle process. Rude behavior by staff, inappropriate data requests or not setting expectations for patient responsibilities when the patient presents will result in frustrating the patient. Additionally, the systems being used must be designed to prompt the user through a professional script that includes patient reminders for authorization or precertification and expected co-payment payment. Making the patient aware that an authorization and/or precertification or co-pay is required by their payer before they can be seen will decrease a third of the total of revenue cycle rejections, increase payments and decrease frustrations throughout the revenue cycle process.
Patient Access: Start the revenue cycle process with these four steps:
  1. Positive Customer Service Training
  2. Effective, efficient and legal data requests
  3. System reminders for required authorizations and co-payments
  4. Training on payer requirements for the appointment type
Spotlight Article
Navigating The Era Of Accountable Care Organizations (Acos): A Strategic Planning Guide
Healthcare institutions striving for long-term growth have a new and evolving care model with which to contend: the Accountable Care Organization (ACO). While many consider ACOs the front line of healthcare reform, others believe the concept faces an uphill battle for viability. Regardless, the ACO has become a dynamic factor that must be addressed by physicians, hospitals, health systems and others as they map out strategic organizational direction. Tactical planning is the key to securing both short-term and long-range competitive advantage as ACOs—as well as other models of population healthcare—begin to proliferate. Click here to read the full paper.
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