Policy & Value-Based Care
New HHS Models Seek to Shift Primary Care to Value-Based Payments
The U.S. Department of Health and Human Services announced on April 22 a new set of voluntary value-based payment models for primary care physicians under the label “Primary Cares.” Adam Boehler, director of the CMS Innovation Center, called it “a clear sign that we are changing the status quo. These are sweeping models that will shift one-quarter of this country to outcomes-based payment. It is time to dismantle the old, broken fee-for-service system that we have today and replace with one that pays for outcomes and quality.”
Speaking at a press conference at the American Medical Association offices in Washington, D.C., Boehler stressed that a strong focus on primary care is essential to an effective healthcare system broadly. “Despite being only 2 to 3 percent of spend, primary care providers have an enormous influence over downstream costs,” he explained. “Our current payment systems do not recognize the central role primary care providers play. We are going to change that today.”
The newly announced effort has two prongs: The Primary Care First Initiative creates an opportunity for providers to leave behind fee for service and be paid for keeping their patients healthy and at home. The second is Direct Contracting, which allows sophisticated organizations to take full accountability for their patients at a local level.
Both paths are voluntary and they emphasize a focus on complex, high-needs patients, Boehler said. He then described the details and timelines.
The Primary Care First Initiative is made up of two model options. Both options allow physicians to move away from fee for service and potentially eliminate their revenue cycle operations, he said. “CMS will make monthly population-based payments along with a simple, flat primary care visit each time a provider sees a patient. Providers will be eligible for significant payments if their patients stay healthy and at home. There is downside risk of 10 percent, which is about the equivalent of the revenue cycle cost today, he noted. “There is an asymmetrically upside potential of 50 percent. The performance will be measured on risk-adjusted hospitalizations. For example, doctors who earn $200,000 today could earn up to $300,000 if their patients stay healthy at home,” Boehler added. “This model is scheduled to be in January 2020, and we expect to release a request for applications in the next few months.”
Direct Contracting creates multiple payment options for providers to take risks and earn rewards based on quality outcomes. “This model improves on prior efforts, including Next Generation ACOs, and they are tailored for larger organizations that have experience taking accountability,” Boehler said.
The first option is called the Professional option: This offers providers the opportunity to share in 50 percent of the savings and the losses on risk-adjusted total cost of care, Boehler said. Providers in this option will receive predictable monthly payments for enhanced primary care services. The second option is the Global option: “This will offer providers the opportunity to take full 100 percent accountability for savings and losses,” he added. “Providers will also receive predictable monthly payments for primary care services or monthly payment for all healthcare services if they chose to pay claims.”
Both Primary Care First and Direct Contracting focus on complex, chronic and seriously ill patients. They support approaches such as home-based models dedicated to serving this patient set. He said the efforts draw from hot-spotting models and from proposals form the Physician-Focused Payment Model Technical Advisory Committee (PTAC), as well as the American Academy of Hospice and Palliative Medicine, the Coalition to Transform Advanced Care, and the American Academy of Family Physicians.
“It is time that we empower providers so that they can focus on patients,” Boehler said. “This is why providers went to medical school in the first place. It is time that we put patients in the driver’s seat, so that providers can compete for their loyalty through a combination of service, price and overall experience. When you pay for quality outcomes instead of volume, you transform a healthcare system that caters to special interests into a market-based system in which providers compete for the right to take care of each patient. The patient is the empowered consumer.”
Imaging
Radiologists Creating Their Own AI Algorithms? A New Partnership Provides the Opportunity
Artificial intelligence (AI) computing company NVIDIA and the American College of Radiology (ACR) are collaborating to make an AI-based toolkit available for radiologists to build, share, locally adapt and validate AI algorithms.
Following a three-month pilot program by both parties, ACR is integrating the NVIDIA Clara AI toolkit into the newly announced ACR Data Science Institute ACR AI-LAB, which is a free software platform that will be made available to more than 38,000 ACR members and other radiology professionals to develop and authenticate AI algorithms, while also ensuring patient data stays protected at the local institution, according to officials who made the announcement at the World Medical Innovation Forum 2019 in Boston.
The pilot with the Ohio State University (OSU) and the Massachusetts General Hospital and Brigham and Women’s Hospital’s Center for Clinical Data Science (CCDS) helped NVIDIA and ACR define the assets and pathways necessary to enable facilities to work together and with industry to refine AI algorithms without sharing potentially sensitive patient data, officials stated in a press release. “Bringing an AI model to the patient data, instead of patient data to the model, can help increase diversity in algorithm training, facilitate validation of the algorithms and enable radiologists to learn the steps needed to adapt algorithms to their institutions’ clinical needs,” they said.
Specifically, using the NVIDIA Clara AI toolkit, OSU professionals were able to quickly import a pre-trained model developed by CCDS. This model was customized to local variables and successfully labeled OSU data for further testing and improvement of the algorithm, all of which took place behind their own firewall. It resulted in an accurate and enhanced cardiac computed tomography angiography model, and the shared approach reduced algorithm training, validation and testing times by days, officials noted.
“This software will offer radiologists, without computer programming experience, the ability to build and improve AI algorithms without the need to share their data,” said Keith Dreyer, D.O., Ph.D., chief data science officer at Partners HealthCare and associate professor of radiology at Harvard Medical School.
Partners HealthCare also has announced that CCDS is planning broad roll-out to the Partners system over the next 12 months, and is already offering AI capabilities and support service. “The truth is, you don’t have to be a computer scientist or data scientist to participate in the creation of AI—we are just starting to see increasing availability of tools to enable on-premises development of AI models by clinicians,” said Dreyer.
Interoperability & HIE
Long-Awaited Second Draft of TEFCA Responds to Stakeholder Concerns
After receiving more than 200 comments on the first draft of its Trusted Exchange Framework and Common Agreement (TEFCA) for connecting health information networks, the U.S. Department of Health and Human Services (HHS) has released the long-awaited second draft and a four-year funding announcement for a nonprofit Recognized Coordinating Entity (RCE) to manage the network of networks.
In a blog post on the Office of the National Coordinator for Health IT (ONC) website, Don Rucker, M.D., national coordinator for health IT, admitted that setting up the framework is not a simple undertaking. “By releasing today’s draft for a second round of public comment, we are working to get it right.”
Indeed, many of the key changes between the first and second drafts come in direct response to issues raised by health information exchange stakeholders and ONC’s own Health Information Technology Advisory Committee. Comments on the second draft are due on June 17, 2019, and then a final TEFCA rule will be written.
In brief, here are some of the key differences between Drafts 1 and 2 of TEFCA, including an alphabet soup of acronyms to remember:
• The definition of who can be a Qualified Health Information Network (QHIN) has been broadened from the first draft. “In response to comments that the definition of QHIN was too restrictive, we expanded the definition to allow for more types of stakeholders to apply,” Rucker said. In order to apply for QHIN Designation, a HIN must meet certain prerequisites, including already operating a network that provides the ability to locate and transmit EHI between multiple persons or entities electronically, with existing persons or entities exchanging EHI in a live clinical environment; and providing the RCE with a written plan of how it will achieve all of the requirements of the Common Agreement within a specified time period. “We also updated the application process to allow for a provisional period where QHINs will onboard to the Common Agreement and undergo testing and surveillance to ensure they are in compliance before actively exchanging data on the network,” Rucker wrote.
• In Draft 1, the standards were included in the Trusted Exchange Framework (TEF) itself. Draft 2 adds the Qualified Health Information Network (QHIN) Technical Framework (QTF), which details technical and functional components for exchange among QHINs. As Rucker explained in his blog post, commenters suggested specifying standards through implementation guides rather than in the Common Agreement itself. “Thus in the second draft, we included most standards requirements in the draft QHIN Technical Framework, which will be incorporated into the Common Agreement by reference, and with appropriate notice and compliance provisions for implementation of any updated technical requirements.”
• Originally, QHINs were to have 12 months to update agreements and technical requirements. That timeframe has been extended to 18 months.
What’s more, the funding announcement for the Recognized Coordinating Entity (RCE) details the role HHS envisions it playing and notes that it must take steps to avoid conflict of interest. The program will be funded for the first year at $900,000, with funding in additional years contingent upon availability of funds and satisfactory completion of milestones.
Once an applicant is awarded to be the RCE it may not be affiliated with a QHIN as long as it is the RCE. Additionally, the RCE will employ organizational policies that prevent conflicts of interest. Entities interested in applying for the RCE Cooperative Agreement must submit their application by June 17, 2019.
HIT Market
Epic, Cerner Continue to Dominate U.S. Hospital EHR Market, KLAS Finds
Electronic health record (EHR) behemoths Epic Systems and Cerner continue to corner the U.S. hospital EHR market. For the second year in a row, Cerner signed the highest number of new hospitals, but large private sector hospitals are almost exclusively choosing Epic technology, according to a new report from KLAS Research.
The report, “US Hospital EMR Market Share 2019,” from the Utah-based KLAS, noted that 2018 was the busiest of the past three years in terms of EMR purchasing. “This energy impacted every market sector, with the U.S. government finalizing contracts, three large health systems changing EMRs, and the small-hospital market continuing to see churn,” the researchers wrote.
Indeed, just like it did in 2017, Cerner signed the highest number of new hospitals but—due to customer attrition—came in second in terms of net market share gain. In 2018, Cerner cornered the market on U.S. government contracts, finalizing the deal with the Department of Veterans Affairs, giving the Kansas City-based Cerner its biggest net gain of any year KLAS has measured. The VA deal alone includes 147 acute care and 20 specialty hospitals, accounting for 76 percent of Cerner’s 2018 hospital “wins,” according to the report, which also noted that government contracts have made up 39 percent of Cerner’s hospital wins over the past five years.
But in the private sector, a different story is told. The Verona, Wis.-based Epic is continuing to dominate this segment, especially when it comes to large provider organizations. Although hospitals with 500+ beds and multihospital health systems are not making EHR purchases as much as they once did, those that do are choosing Epic. All three of the large, private organizations that made an EHR decision in 2018 went with Epic, switching from Allscripts or Cerner.
“At this point, most large organizations have invested heavily in implementing a single, go-forward solution across all of their hospitals, so future purchases in the large market will be highly contested and require a significant rip and replace,” according to the KLAS researchers. Overall, four core vendors remain in the large patient care organization space—Epic (with 163 hospitals), Cerner (77 hospitals), Allscripts (16 hospitals), and MEDITECH (12 hospitals). Of these, only Epic and Cerner have had net positive changes in market share among large hospitals (500+ beds) over the last decade, KLAS reported.
For this segment—large hospitals with more than 500 beds—Epic has a 58 percent market share with Cerner coming in second, holding 27 percent of the market. And among all acute care hospitals, Epic holds 28 percent of the market share, with Cerner right behind at 26 percent. MEDITECH ranks third with a 16 percent share, and CPSI fourth with a 9 percent share.
