Raghu Vir

CMS launches ‘Pick Your Pace’ options for physicians as part of Quality Payment Program

money-tighteningAs part of CMS’ move to link physician payments to patient outcomes, the Quality Payment Program put in place by CMS is set to begin on January 1, 2017. CMS has shared plans for the timing of reporting for the first year of the program. It allows Quality Payment Program to allow physicians to pick their pace of participation for the first performance period that begins January 1, 2017. During 2017, eligible physicians and other clinicians will have multiple options for participation. Choosing one of these options would ensure you do not receive a negative payment adjustment in 2019.

First Option: Test the Quality Payment Program

With this option, as long as you submit some data to the Quality Payment Program, including data from after January 1, 2017, you will avoid a negative payment adjustment. This first option is designed to ensure that your system is working and that you are prepared for broader participation in 2018 and 2019 as you learn more.

Second Option: Participate for part of the calendar year

You may choose to submit Quality Payment Program information for a reduced number of days. This means your first performance period could begin later than January 1, 2017 and your practice could still qualify for a small positive payment adjustment. For example, if you submit information for part of the calendar year for quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a small positive payment adjustment. You could select from the list of quality measures and improvement activities available under the Quality Payment Program.

Third Option: Participate for the full calendar year

For practices that are ready to go on January 1, 2017, you may choose to submit Quality Payment Program information for a full calendar year. This means your first performance period would begin on January 1, 2017. For example, if you submit information for the entire year on quality measures, how your practice uses technology, and what improvement activities your practice is undertaking, you could qualify for a modest positive payment adjustment. We’ve seen physician practices of all sizes successfully submit a full year’s quality data, and expect many will be ready to do so.

Fourth Option: Participate in an Advanced Alternative Payment Model in 2017

Instead of reporting quality data and other information, the law allows you to participate in the Quality Payment Program by joining an Advanced Alternative Payment Model, such as Medicare Shared Savings Track 2 or 3 in 2017. If you receive enough of your Medicare payments or see enough of your Medicare patients through the Advanced Alternative Payment Model in 2017, then you would qualify for a 5 percent incentive payment in 2019.

Saince offers healthcare providers a suite of solutions and services to improve and protect reimbursements in an rapidly changing environment. For more information, please call (888) 472 4623.

Here are 10 questions to ask before you buy CDI software

blog_2015_08_25-11)      Does the software minimize data entry? If your CDIS have to enter all the codes and DRGs manually and also analyze that data for reimbursement manually it severely hampers their productivity. You want your team to be more efficient and productive.

2)      Does it come with built-in ICD-10 compliant query templates or do you have to manually enter them? Manually creating query templates is a time consuming task and you need to spend a lot of time and resources in creating these queries and making sure that they are ICD-10 compliant. You also need to ask if the vendor updates the provided queries periodically to incorporate all the changes like sepsis definitions etc.

3)      How easy is it to customize the query templates to meet the needs of your hospital? Can you do it yourself or do you have to depend on the vendor? Many times the queries that are available out of box do not meet the needs of your hospital. In such cases, you want the process of query template customization to be easy and quick. You do not want to depend on the vendor to do this for you because that will be too expensive. Also once you customize the templates you should have the ability to roll it out to the entire CDI department.

4)      Does the software provide for education and training of CDI staff and the physicians? Ideally whenever you query a physician the relevant educational information should be included as part of the query so that the physician can document better going forward. Similarly, the CDI specialists and the coders also need to be continuously informed and kept up to date about CDI information.

5)      How easy is it to run any reports that you want – CDIS productivity, CMI, CC/MCC capture rates, Query Response Rate, HACs, Physician compliance etc.? As a manager you want to run all type of reports to monitor performance, productivity and efficiency. Such reports should be available easily and on-demand.

6)      Can you run the reports or do you have to depend on the vendor to run the reports? You do not want to wait on the vendor to run the reports and then get on a conference all so that they can explain the reports back to you. You want the reports to be informative, insightful and easy to understand.

7)      How easy is it to navigate the software? Is the workflow intuitive or too cumbersome? The more complex the software the slower the learning curve and lower the productivity. If a new CDI cannot become productive in a couple of days, that software is too cumbersome. If the software has limitations on browsers, operating system versions etc it is not easy to manage.

8)      Does the software support in-house as well as remote CDI specialists? Many hospitals have hybrid work environments – some of the staff are in house while others work remotely. You want to make sure that your software can easily adapt to such an environment.

9)      Can the software be integrated with our EHR? Many hospitals want the queries to be pushed into the inbox of the physician in the EHR. Make sure your software is capable of doing that.

10)     How much does it cost and what is the total cost of ownership? The upfront cost of software is only one aspect of total cost. You also need to look at implementation costs, integration costs, IT infrastructure costs, annual maintenance costs etc.

If you are in the market looking for CDI software or if your current software license is expiring, please watch this 5 minute video that gives you an overview of Doc-U-Aide, the industry’s most intuitive, insightful and intelligent CDI software. Doc-U-Aide comes in three flavors – Enterprise, Lite and Network editions, to meet the budgetary needs of hospitals and health systems of all sizes.

Four reasons why hospitals have to start outpatient CDI programs now

graph1-hospital revenues are shifting from inpatient ot outpatientHere are four reasons why hospitals have to start their outpatient CDI programs now and not later.

1) Hospital revenues are shifting from inpatient to outpatient
Historically, 92 percent of Medicare revenues to hospitals have come from inpatient and outpatient services. Over time, however, the share of revenue coming from the outpatient setting has increased, and the share coming from the inpatient setting has decreased.

From 2010 to 2014, the share of revenues coming from the outpatient setting increased from 21 percent to 27 percent. The increase resulted from several changes: a shift in services from the inpatient to the outpatient setting, a general increase in beneficiary outpatient service use, a shift in the billing of physician office services from the physician fee schedule to the OPPS, and changes made to the outpatient payment system that packaged many lab services into outpatient payment rates that were previously paid on a fee schedule rather than the OPPS

The share of revenues coming from the inpatient side fell from 71 percent in 2010 to 60 percent in 2014. This decline results from (1) a shift in services from the inpatient setting to the outpatient setting, as just discussed, and (2) changes in Medicare DSH payments.

As hospitals see increased revenues from outpatient services, they need to put in processes and procedures in place to protect their revenues.

2) Rate of growth of outpatient visits far outpaces inpatient discharges
CMS data shows that between 2006 and 2014 outpatient visits per beneficiary have increased by a whopping 44% while inpatient discharges per beneficiary have decreased by almost 20%. And projections show that this trend is going to continue well into the future.

As hospitals see a faster rate of growth in outpatient visits, they need to put processes in place to maintain revenue integrity.


3) Hospitals have aggressively acquired physician practices to offset the decrease in inpatient revenues.
This is resulting in increase in hospital revenues as payments shifted from Physician Fee Schedule to OPPS which generally pays higher. Now CMS is working aggressively to streamline the payments and make the payments equal for Hospital Outpatient Departments and Physician offices. CMS has already moved some of the clinical laboratory fee schedule services into OPPS resulting in a saving of $2.4 billion in a year. Now CMS is also working on bundling more services into Comprehensive-APC to further reduce reimbursements under OPPS.

As hospitals see the outpatient revenues get more and more streamlined, and as they lose the advantage of seeing increased revenues from OPPS compared to Physician Fee Schedules, they need to focus on outpatient CDI programs to protect revenues.

4) The HCC Risk Adjustment Model under the Affordable Care Act
The Hierarchical Condition Categories for risk adjustment has also become complicated from jumping from 3000 codes in ICD-9 to over 11000 in ICD-10. This degree of specificity requires appropriate documentation and as the CMS moves to value based reimbursement models, this aspect of documentation becomes critical for revenue integrity.

Hospitals have to out in place outpatient CDI programs to ensure that the physician documentation is truly reflective of the acuity and the chronic conditions of its patient population.

Most of the hospitals have a mature CDI program in place to take care of their inpatient population, but over 90% of the hospitals still haven’t put in an outpatient CDI program. Outpatient settings is where all the action is. Hence the time to think of outpatient CDI is now and not later.

PracticePerfect CDI from Saince is the industry’s first fully featured outpatient CDI solution that integrates, CMS and HHS HCC capture, risk score calculation, integrated querying, dedicated ER workflows, PQRS measures and many more.

Starting next week all hospitals have to start serving the MOON to patients

templatesThe Notice of Observation Treatment and Implication for Care Eligibility Act (the NOTICE Act), which was enacted on August 6, 2015 law requires hospitals and critical access hospitals (CAHs) to provide written notification and an oral explanation to individuals receiving observation services as outpatients for more than 24 hours. This notification must be provided no later than 36 hours after observation services are initiated or sooner if the patient is being transferred, discharged, or admitted as an inpatient. CMS then details their proposal in the form of possible scenarios of when the MOON would or would not be given. if released from the hospital or CAH.

CMS expects there will be times when an individual has received more than 24 hours of observation services that has not yet received the MOON, and there are imminent plans for discharge to home, another facility, transfer to another unit or facility to receive care that does not include observation services, or admission to the hospital or another facility as an inpatient. In these cases CMS is proposing “that the MOON must be given sooner than the 36-hour time limit for delivery because the MOON must be delivered before the individual is discharged, transferred, or admitted. When there are no plans to transfer, discharge, or admit an individual who receives observation services for more than 24 hours, we are proposing that the MOON must be provided within 36 hours of the initiation of observation services.”

CMS also believe that in the “rare circumstances where a physician initially orders inpatient services, but following internal utilization review (UR) performed while the patient is hospitalized, the hospital determines that the services do not meet its inpatient criteria and the physician concurs with UR, orders the discontinuation of inpatient services and initiation of outpatient observation services (that is, a Condition Code 44 situation), the MOON would be delivered as required by the NOTICE Act (when outpatient observation services have been ordered and furnished for more than 24 hours).”

When a CMS reviewer determines that an inpatient admission was not medically reasonable and necessary after the beneficiary has been discharged making the stay not appropriate for Medicare Part A payment, “the beneficiary’s patient status remains “inpatient” as of the time of the inpatient admission. The patient’s status is not changed to outpatient because the beneficiary was formally admitted as an inpatient, and there is no provision to change a beneficiary’s status after he or she is discharged from the hospital.” In this scenario there would be no need to issue the MOON as the patient’s status remains inpatient regardless that it was an improper admission.

Similar to Scenario 3, when a hospital determines through Utilization Review after the beneficiary has been discharged that the inpatient admission was not reasonable and necessary there would be no need to issue the MOON as the patient’s status again remains inpatient. 

This proposed rule requires CMS to develop a standardized form known as the Medicare Outpatient Observation Notice (“MOON”).

CMS is proposing that hospitals and CAHs would be required to use a proposed standard notice (the MOON) for written notification. This standard notice would:

  • Explain that an individual is an outpatient receiving observation services and not an inpatient, and the reason(s) for this patient status.
  • Provide an explanation of implications of receiving observation services as an outpatient, such as implications related to cost-sharing requirements under Medicare and post-hospitalization eligibility for Medicare-covered Skilled Nursing Facility (SNF) care.
  • Include a blank “additional information” section so hospitals and CAHs may add “additional information.”
  • Be in “plain language written for beneficiary comprehension.”

The NOTICE Act sets forth that the written notice must be:

  • Signed by the individual receiving observation services as an outpatient, or
  • Signed by a person acting on the individual’s behalf to acknowledge receipt of the notice, or
  • If the individual or person refused to provide a signature, “the written notification is to be signed by the staff member of the hospital or CAH who presented the written notification and certain information needs to be included with such signature.” The “certain information” to be included is the staff member’s name and title, a certification statement that the notice was presented, and the date and time the notice was presented.

Definition of Observation Services

“Services that are reasonable and necessary, specifically ordered by a physician or other non-physician practitioner authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient services, and meet other published Medicare criteria for payment.”

At this point in the proposed rule, CMS makes the distinction that “individuals receiving observation services will always be registered as outpatients; however, not all outpatients receive observation services.”

CMS is set to release single star hospital overall quality ratings soon


More than 74% of the hospitals in the country score less than three stars in this new Five Star Rating system.

Hospital Compare is a consumer-oriented website that provides information on how well hospitals provide care to their patients. This information can help consumers make informed decisions about their health care. In a major step to educate and inform consumers about hospitals’ quality rankings CMS has developed an Overall Hospital Quality Star Rating (Star Rating) that reflects comprehensive quality information about the care provided at our nation’s hospitals. The Star Rating takes 62 existing quality measures already reported on the Hospital Compare website and summarizes them into a unified rating of one to five stars.

Here is a preview of the information CMS has released today:

Healthcare expenses expected to grow faster than GDP during the next decade

In a recent article published in Health Affairs, the authors (Office of the Actuary, Centers for Medicare and Medicaid Services (CMS)) have projected that healthcare expenditure in the United States for the period 2015 to 2025 to grow at an average annual growth rate of 5.8%, which is a full 1.3% higher than the projected GDP growth rate during the same period. The share of healthcare expenditure as a percent of GDP is expected to climb from 17.5% in 2014 to 20.1% in 2025!

As the effects of Affordable Care Act start to subside in the next two years, the key factors contributing to the growth of healthcare expenditure will be economy, growth in medical prices and aging population.

No respite to patients from increasing medical costs




Consumer Price Index (CPI) numbers from June 2016 which were released today show that prices for medical care have started to go up again after a lull for a couple of months. At 0.4% the price for medical care increased twice as much compared to all other items. Prices of hospital services increased by 4.3% compared to June of 2015 while in-patient hospital services prices jumped by 5.1%!

Prices of prescription drugs also increased quite significantly by 4.4% compared to June 2015.

Over the last 12 months, the price of medical care has increased over four times faster than the prices of all other items.

Looks like there is still no respite to patients from ever increasing medical costs.

Survey finds that EHRs many times do not catch medication errors

A recent survey report released last month by Leapfrog Group found that many EHR systems do not catch medication errors. Almost 40 percent of potentially harmful drug orders weren’t flagged as dangerous by the systems, Leapfrog found. These included medication orders for the wrong condition or in the wrong dose based on things like a patient’s size, other illnesses or likely drug interactions. Meanwhile, systems missed about 13 percent of errors that could have killed patients.

Medication errors can often times cause serious harm to patients – and even death. Many hospitals try to prevent them with the use of electronic health records (EHR) systems. But these methods are far from foolproof, according to this new report.

According to 2015 figures from the federal Agency for Healthcare Research and Quality, about 1 of every 20 patients in hospitals suffers harm because of medications. Of those, the agency estimates, half are avoidable.

Meanwhile, in a push to improve patient safety and health care quality, the federal government has been encouraging hospitals to adopt electronic health records — particularly with medication ordering systems — thanks to parts of the 2009 stimulus package and 2010 health reform. But there’s been pushback from many doctors and advocates, who say design issues can make the software difficult to use or even counterproductive.

Life expectancy in US hasn’t changed much. Where did all the health dollars go?

CDC has released the new US Life Expectancy data for the year 2014 this week. The overall life expectancy has not changed between 2013 and 2014 but in some demographics life expectancy at birth steadily receded to the level in 2009!

At the same time the healthcare expenditure, both at the consumer level and at the federal level, has increased quite substantially. So where did all the dollars go?

Here is my take on this – we are spending a lot more on our healthcare than what we used to, only to live up to the same age. By the way, US healthcare expenditure is the highest in the world but many Europeans live a lot longer than Americans. We are spending a lot of money only to find sooner that we are sick, but just because we know we are sick sooner, is not making us live any longer!

Here is an example, a patient in 2000 who was 65 years old is diagnosed with cancer with a life expectancy of five years from the date of diagnosis. The cost of that diagnosis was $1000. In the year 2016,  because there are more advanced diagnostic procedures available, another patient who is 64 years old is diagnosed with the same cancer and he has the life expectancy of 6 years from the date of diagnosis.  Since more expensive diagnostic procedures have been used on this patient he had to pay $10,000 for the diagnosis. But the interesting point to note here is that both patients died at the age of 70, but one spent $1000 and the other $10,000. It is saddeningly ironical.

All of us are running faster and faster on the treadmill only to stay in the same place.




Medical transcription is dead. Long live medical transcription!

Doctors are increasingly frustrated with the clinical documentation features in EMRs
Doctors are increasingly frustrated with the clinical documentation constraints placed on them by EMRs

Many in the EMR industry have long forecasted the demise of the medical transcription industry.  However medical transcription still continues to exist and this industry is starting to see an uptick in the dictation volumes in the past 18 months.  The EMR vendors have aggressively sold their software by convincing physicians that transcription was an old fashioned idea and that it only adds significant costs to their operations without giving any corresponding return. They also convinced them that EMR was the panacea that would cure all the ills of clinical document creation using traditional transcription services. Physicians reluctantly adopted this technology without fully realizing the consequences of what doing away with transcription service can do to their current work load. Once physicians started realizing the woes of generating the documentation themselves, they started to push back on this workflow process. The EMR industry came back with even more crisp PowerPoint presentations, colorful data sheets and cookie cutter templates which showed that incorporating speech recognition into the EMR workflow would make the clinical documentation task easier for the physician, and tried to convince them again that using a transcription service was a bad and an expensive idea.

Now the physician has to not only enter all the key strokes, spend hours learning how to correctly dictate, actually dictate and make sure that the dictated text is accurately recognized by the speech recognition program, deal with excessive alert fatigue from the EMR, switch between multiple screens to enter patient data, view multiple tabs within the screens, and within each screen focus on a sections and subsections to ensure that all data points are correctly captured to maintain revenue integrity and coding accuracy, make sure that all quality measures criteria are being addressed, all population health alerts are reviewed etc. And they have to do all these while the patient is sitting in front of them and when they should actually be focusing on the patient and listening to the patient’s story!

Physicians are increasingly getting frustrated with these tasks. No wonder that a recent article in The Wall Street Journal states that doctors are increasingly getting disillusioned with their profession. Too much work is being pushed on to the physicians and too much is being expected from them; and many of these additional tasks are less about patient care and more about coding, billing and compliance. Doctors are not trained to do this and the patients are suffering because of this. Under the pretext of reducing the cost of healthcare we cannot unfairly push the burden onto the physicians. A 2014 nationwide survey has actually shown the doctors who use EMRs spend more time on administrative work than those who use paper records. The authors who are lecturers at Harvard Medical School state “Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork,” they write, “we found the reverse is true.”

Physician appointments are generally slotted every 15 minutes and this includes the time a physician has to spend outside the exam room. A 2014 article from Kaiser News says the physicians are being asked to see a patient every 11 minutes! Physicians are under constant pressure to churn patients through the system. Research has shown that patients are allowed to speak for 12 seconds before they are interrupted and more than a quarter percent of the time physicians did not allow the patient to complete a sentence. The same research also points out that computer work interrupts the physician and patient interaction much more than all other interruptions like a knock on the door, etc.

Clinical documentation plays a very critical role in any patient’s care and the objective of creating a clinical document is for the physician to capture the patient’s story and then document each patient’s care episode in detail so that the same physician can go back and refer to the notes when the patient is back in his office again, or when the care is being shared by multiple physicians. These days providing high quality care to a patient is often complex and each episode of care involves multiple doctors across multiple care settings.  This type of involvement by multiple providers is becoming more and more important with the advent of bundled payments and value based payments. Therefore, it is going to become even more imperative that the clinical documentation be of high quality and that the document accurately captures the entire patient’s story. This cannot be achieved with point and click data capture alone. It requires physician’s narrative and documenting his or her critical insights and thinking.

Over the last few years, the role of clinical documentation has been reduced to a point where it mainly serves the purpose of capturing the required clinical terms that are needed for performing accurate coding and billing.  With this new emphasis on collecting and documenting structured data for coding and billing, the role of the narrative is highly diminished. When doctors are asked to work with such an incomplete picture of the patient story, quality of care is bound to suffer. The longitudinal care document is critical in improving the doctor – patient communication and trust.

Research has also shown that EMRs encourage defensive documentation by physicians. Defensive documentation is defined as ‘note bloat’ which means superfluous documentation that unnecessarily highlights negative findings and obscures positive results.  It also means that there are excessive brought forwards and use of copy and paste function from previous notes that oftentimes do not add any significant to value to the current document.

The pendulum has swung too far to one side in the last few years and now there is an urgent need to find an equilibrium. An equilibrium where the EMR and transcription can each play a complementary role so that the requisite information is available in a form and manner that enables the physician to improve patient care.