Medicare announces a new program to pay primary care practices for managing their own patients

On April 11, 2016 CMS announced Comprehensive Primary Care Plus (CPC+), a significant advancement of an earlier program known as CPC that was launched in 2012.

The new initiative is open to primary care practices that do not participate in other types of comprehensive care programs such as ACOs, including MSSPs.

A unique feature of CPC+ is that CMS wants to include other types of health insurance plans, in addition to Medicare, to participate so that the majority of a practice’s patients are covered.  This will reduce the complexity for participating practices and will create enough of a critical mass to make participation viable.

The CPC+ design is intended to provide partial up-front funding, added to FFS payments, and backward looking quality performance rewards to practices who actively manage the health of a panel of patients.  Many details have yet to be explained, but the Medicare component will contain two Tracks.  Track 1 is intended for practices who want to develop comprehensive care capabilities.  It is less demanding than Track 2, but also comes with lower $PMPM and performance rewards.  The prospective $PMPM will be risk stratified under both Tracks, with the methodology still to-be-determined.  As an example, under Track 1, a primary care practice with an average risk score will receive:

  • Full FFS reimbursement, billed as usual
  • Plus, a $15 PMPM, paid in advance
  • Plus, up to $2.50 PMPM based on quality performance

For a practice with 300 Medicare beneficiaries, the $PMPM payments could amount to $63,000 per year on top of any FFS dollars received.

Track 2 is designed for PCPs who are already advanced in their PHM efforts.  Compensation under Track 2 follows a similar structure, but the amounts have been increased to reflect the additional effort and resources needed.

Commercial and other health plans will need to develop their own parallel programs and coordinate with CMS so that practices can achieve economy of scale by including most, if not all, of their patients.

The next step for the CPC+ program is for CMS to receive applications for participation from insurance in order to define the participating regions.  The regions will be announced in June.  At that time practices who are in a participating region can submit their applications.   Participating practices will be announced in October.

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Physician Revenue Cycle: A Key to Successful Integration

By Kelvin Drawdy, Director, JHD Healthcare Partners

As hospitals and health systems take steps to develop sustainable relationships with physicians, they are increasing physician practice acquisition and physician employment.  Effectively integrating the revenue cycle should be a top priority because it not only affects the financial performance of the health system, but may also affect the physicians’ compensation, and their satisfaction.

The Healthcare Financial Management Association defines revenue cycle as: “All administrative and clinical functions that contribute to the capture, management, and collection of patient revenue.” In other words, from the point of first patient contact to final payment and settlement of the claim. Each of the following functions must be performed for the revenue cycle to be effective – and must be prioritized as part of the integration of new physicians and practices.

  • Pre-Visit/Pre-Service Processes
  • Front-End Process at Time of Service
  • Encounter – Patient Services
  • Billing
  • Third Party Claims
  • Payment Processing
  • Patient Collections

There are challenges to successfully integrating the revenue cycle functions of the newly acquired practice into the health system and gaining the trust of the physician that the revenue cycle is working.   Efficiencies can be achieved working in a large health system, but if not executed well there is a risk of losing the physician’s trust and lowering the patient’s satisfaction.

If the physician revenue cycle isn’t meeting expectations, this could be an indicator the health system has issues integrating the physician revenue cycle or that it is not effectively prioritized or managed as part of the overall system.  Timely recognition and resolution of these issues will keep physicians and patients happy, and improve the health system’s financial results.

Let’s discuss how your health system is managing the challenges of your physician revenue cycle.

Kelvin Drawdy is a director with JHD Healthcare Partners.  For a complimentary assessment, please visit

Yes, PHM Can Get You Paid

Stethoscope and cash sm

Skip Leavitt, PA, MBA, FACMPE

The case for effective population health management couldn’t be clearer. But still there is great reticence on the side of providers and health systems, many of whom believe that adding PHM activities will threaten fee-for-service revenue. They want to be able to increase quality and lower costs for their patients, but there are some commonly held concerns that don’t have to be true:

  • Myth 1. If they are successful with their PHM, then their fee-for-service revenue will drop, and it will drop faster than value-based revenue increases.
  • Myth 2. The tech cost will be very high and they think they have to pay for the technology up-front.

Here is what organizations that have been successful at a transition to PHM have figured out: There are activities documenting a track record of increasing quality that are also reimbursable under the current fee-for-service system.

Let’s take, for example, Chronic Care Management (CCM), which Medicare has just put in place.

If a provider has a Medicare patient who meets CCM criteria, they can get paid $42 per month per person for care coordination, which can be done by non-physician staff, such as an office nurse.  For a typical internist, who has 500 Medicare patients, that’s $21,000/month for doing care coordination. And that’s just one example.

By appropriately documenting the care coordination done for those patients, providers can build their record.  Also, it’s been shown practices doing chronic care management experience a higher rate of Medicare patients coming in for annual medical evaluation — which increases the compliance with the wellness evaluation.

Many practices would like to do care coordination, but are overwhelmed by the day-to-day issues of running the practice. Becoming part of a clinically integrated network can provide the needed expertise and resources at minimal cost.

Another example to show how PHM can get you paid is closing care gaps. We know most patients don’t get the preventive care they need; typically, less than half of the patients get the recommended preventive care measures. Simply identifying those patients, bringing them into the office, and arranging for preventive care increases FFS volumes and also increases the documented improved quality of care.

PHM can be game-changing for your practice, if you’re willing to make a few changes. Don’t let the misconceptions about transitioning to value-based care hold your practice back.  Not only can you set your practice up for success in this new healthcare landscape — but also increase your revenue during the change-over.

Skip Leavitt, PA, MBA, FACMPE, has more than 25 years of healthcare management experience, including clinical and executive positions in both the provider and payor sectors. On the leadership team of JHD Healthcare Partners, Mr. Leavitt puts that expertise to work helping physicians, hospitals and health systems succeed.

Cowboys and Pit Crews: Change is Here

by John H. (Hank) Duffy, founder, JHD Healthcare Partners

shutterstock_240686083.jpg pit crewA few years ago, New Yorker magazine published a commencement address from Atul Gawande, a surgeon, writer, and public health researcher, who spoke to students at Harvard Medical School. Dr. Gawande made the very insightful remark that today’s medicine doesn’t need “cowboys,” the lone rangers who do everything themselves. Rather, in today’s medical environment, you want the patient to be surrounded by a “pit crew” — several medical professionals collaborating on how best to care for one person. Never before has the industry experienced such a dramatic shift in ideology, and culture change it requires.

The public’s experience is that while we have amazing technology and highly trained clinicians, there is little consistency with doctors and technology coming together to provide an actual system of care, from start to finish. We train, hire, and pay doctors to be cowboys. But it’s pit crews people need.

The solution to rallying the front lines around this new methodology is aligning incentives — creating frameworks for success where the physicians are incented to team, to look at clinical quality, to manage clinical costs, and to be patient-focused.

With the healthcare landscape shifting from a pay-for-service model to one based on accountable care and qualitative patient outcomes, the way physicians are incentivized and compensated needs to change in step with what the market is dictating. Physician compensation is a major issue in this transition. At one extreme, physicians are suspicious about changes in their income. At the other extreme are legal regulatory issues related to compensation.

The reality is that no matter how you configure it, any successful physician compensation plan needs to be built around 5 pillars:

  1. It (still) needs to be volume- or productivity-related. Within this are two components that must be artfully balanced: panel-sized — how many patients the physician is responsible for; and how many encounters (wRVUs) — how busy is the physician?
  2. It needs to require demonstrated clinical quality. This can be broken down into two parts. First, are the patients being given the right protocols (pap smears, vaccines for children, and best-practice processes for illnesses)? Secondly, are they staying out of the hospital and living longer?
  3. It should include clinical cost management. There is a saying that the most expensive item in healthcare today is a pen: the pen that writes multiple MRI screens, multiple pharmaceutical scripts, multiple X-rays, and more. It’s the physician’s ability to quell his or her use of the pen (or mouse) that will be the greatest impact on clinical cost. More often than not, it’s because the physicians are practicing what we call “defensive medicine”: prescribe the Z-pak, do the CT scan just to be “safe” – rather than focus on rational clinical need.
  4. It must focus on the patient experience. Enhancing the patient experience starts with opening up the schedules to get the patients cared for on a timely and convenient basis. The patient experience is knowing your patient when they come in the door, knowing what’s going on with them. It’s the antithesis of having all the patients re-do their paperwork every time they come in the door, rather than greeting them and asking if anything has changed.
  5. It has to include citizenship. It’s more than showing up at work. Citizenship is teaming with your colleagues, being a part of the group, helping to find solutions and sharing in both successes and opportunities for improvement. Being a part of the health system not only of your patients, but also your provider organization, is important in this new healthcare landscape.

There are several things that have to happen to get us from being cowboys to being well-oiled pit crews, starting with a significantly different communication process. This is not about management trying to hustle down the cost of the physician cohort; it’s about moving from fee-for-service to fee-for-value. Here’s what your communication plan needs:

  1. Education on all sides. All sides need to understand the other. You have to have an involved physician cohort in the development of your organization’s methodology; you can’t take two or three accountants and have them go in a room and develop the methodology. It’s a process that is going to take time, and you can’t do it in 3 weeks. We just completed one successfully and it took 10 months.
  2. Explain the positives. Show physicians the upside to this alignment,….how it will be good for the patients. Explain what there is to be gained and how the entire organization is going to be aligned. Otherwise, assumptions will be made that they are the ones bearing the brunt of this change. Show them the upside, which lies in tangibly demonstrating clinical quality.
  3. Data. It’s easier to say than to deliver on, but you have to give physicians data on their panel size/demographics, clinical outcomes, to the extent you can get clinical costs, and more. Also, get them comparative data, which should be blinded initially to ensure the data is correct, and then once you have enough built up to be meaningful, make it transparent to all providers. It’s the way to get us all in the same boat, and the way for us to start to feel like we’re reliant on each other, and focus more on the patient.

The reality is that change is inevitable. CMS has said it wants 70 percent of its payments under a value-based stream of contracts by 2018. Whether this happens for your organization in late 2017 or late 2018 doesn’t matter; it’s inevitable. There are going to be winners and losers, and the winners are going to be the ones who learn how to do this sooner.

Teaming — like a good pit crew.

For more information on how JHD Healthcare Partners can help your organization through this transition, please contact us at For a copy of the “Cowboys and Pit Crew” commencement address, please visit


Report Says Physician Engagement is Greatest Challenge for Healthcare Executives

by Skip Leavitt and Kimberly Buser, JHD Healthcare Partners

HealthLeaders recently published an insightful report on physician alignment, centering on strategies that require both risk and clinical integration. The article notes that physician engagement is the greatest need, and also the greatest challenge, for health system executives: it’s highest on the list of objectives, at 66 percent, and is most frequently cited as being the most difficult.
Some other key findings from the report include:
• The survey showed 66 percent of respondents engage physicians in quality initiatives. And, 24 percent say engagement is the most difficult part of aligning physicians. Physicians know that the goal is delivering higher-quality, lower-cost healthcare, but they are often resistant to change. A proactive change management plan is needed to help the physicians achieve their goals.
• Clinical integration is often cited as a mechanism for health systems to gain physician alignment. For employed physicians, 55 percent of health systems use clinical integration, and for independents, 52 percent, according to the HealthLeaders report. This movement can be an important way to align with physicians on common ground, but it cannot succeed in isolation.
• Executives are expecting a 48 percent growth in clinically integrated medical staff over the next three years – the same staff that are expected to provide a high level of coordination of care, but only if they are properly engaged.
The successful organizations we work with realize that to really engage physicians in the alignment effort, the entire health system needs a philosophical shift to a culture of inclusion. They also have a detailed action plan to guide the change process on all levels. We recommend that clients provide a flexible range of alignment options including employment, participation in clinically integrated networks, or through a “fabric” of supporting physician practice services.
Creating a plan for successful alignment often includes these practices:
• Implement a robust physician engagement and communication program that is bi-directional, inclusive and transparent
• Provide a robust clinical and non-clinical education program
• Establish physician support capabilities as good, or better than, what is available in the market elsewhere for them.
Lots of people talk about physician alignment. But let’s discuss how it can be one of your organization’s main strategies for success. Give JHD Healthcare Partners a call today at 972-220-0474.
To download your free copy of the HealthLeaders article, click here.

“More Care is Better Care” is Dangerous Mythology

by James Couch, MD, JD


At least since the beginning of third party payment of health services, the myth has grown that “more care is better care.” The default position has always been that it is better to be safe than sorry when it came to ordering tests, procedures or consultations. The “more care is better care” mythology has also been driven by “defensive medicine” where providers of care seek to protect themselves by obtaining as many tests as possible, even those of marginal value In the name of providing better care, many physicians did not consider enough the extra time, hassle, medical risk (from invasive procedures and false positive test results), uncertainty and anxiety that those extra interventions may have caused patients and their families.

No matter how good the sensitivity, specificity and positive predictive value of diagnostic tests and procedures, there is always an irreducible possibility of false positives. These faulty findings may send patients and their families off into yet additional blind alleys of hassle, time wasted, anxiety and distractions away from their activities of daily living and quality of life. Plus, with the rapid growth of high deductibles and other cost shifting health plan features, patients and their families will have to absorb a steadily increasing proportion of those costs.

As the drumbeat to convert from a volume to a value-based system has grown louder, the medical establishment has begun to move the profession in anticipation of this inevitable transformation.   The American Board of Internal Medicine (ABIM) Foundation has served as the convener for the “Choosing Wisely” campaign. This campaign has also been supported strongly by the leading medical journal JAMA Internal Medicine and its Editor-in-Chief, Rita Redberg, M.D., M.S., professor of medicine and director of Women’s Cardiovascular Medicine for the University of California San Francisco School of Medicine.

A total of 60 medical and surgical specialty and sub-specialty societies have each identified the five most commonly overused and abused tests and procedures in each of their specialties and pledged to find ways to reduce the use of them.

More on the “Choosing Wisely” campaign can be found at its website:

In his new book, Achieving the Quadruple Aim in a Technology-Driven Transformed Health System: Better Care, Improved Health, Lower Costs and Decreased Medical Liability, James Couch, MD, JD, explores the questions in America’s medical liability system and how they relate to the current effort to transform the health care system.

Why Only Three? Should We Have a “Quadruple Aim”?

healthcare focus aimThe “Triple Aim” concept, first articulated by Don Berwick, MD, has become the guiding principle for the nation and for many individual providers as they seek to address the chaos in the American healthcare system.  As Dr. Berwick notes, he believes that improving the health care system in the U.S. is dependent upon the simultaneous pursuit of three goals:

  •  improving the care experience,
  • improving the health of populations and
  • reducing per-capita costs associated with health care.

But is there a fourth component to this?

In his new book, Achieving the Quadruple Aim in a Technology-Driven Transformed Health System: Better Care, Improved Health, Lower Costs and Decreased Medical Liability, James Couch, MD, JD, explores the questions in America’s medical liability system and how they relate to the current effort to transform the health care system.

Unless we also address the medical liability system, Dr. Couch argues, our ability to realize the Triple Aim is in jeopardy.

Is that the final piece of this healthcare puzzle?  Stay tuned as we feature a series of posts around the Quadruple Aim and Dr. Couch’s insights.

Does PHM Stand for Patients?

Drew Nietert, CPHIMS, PCMH CEC, CHPSE, JHD Group

If you know your “ABCs” of healthcare, you’ve undoubtedly heard the term “PHM.”  You may know that it stands for population health management.  But you may also be like many out there, struggling to understand what this term, and this notion, really means.

population healthcareThe confusion is understandable. Terms such as population health management (PHM) and accountable care organization (ACO) are often interchanged.  In practice, PHM is not accountable care, but without PHM, accountable care is unlikely to be successful.  The term is also widely defined: PHM has come to be defined mostly by vendors selling PHM solutions, and has adopted a variety of meanings depending on the various systems’ capabilities.

The definition of “population health,” as noted by Kindig and Stoddart in an article they co-authored in 2003, is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”  Population health management is how that gets done or, in other words, the methodology and tools for managing the health outcomes of a defined group of people and ensuring the effective distribution of those outcomes across the group.  Key steps in PHM methodologies include, but are not limited to:

  • sharing data
  • aligning and partnering with all aspects of the care continuum
  • changing the mindset and work at the point of care
  • incorporating other modalities of care
  • understanding which patients are costing the system the most
  • proactively reaching out to patients with specific health indicator
  • creating solutions for patient engagement
  • and others

The tools are the data analytics, the EHRs, the engagement DME and patient portals.  PHM must affect the entire continuum of care and be tied into it — otherwise, even small gaps in patient health management will cause great cavernous pit holes of quality and cost.

As you can see, the method is complex and requires a lot of change. In addition excellent and integrated tool sets are needed to drive almost all of the changes.  So how does a healthcare entity create a strategy for success that employs and fully utilizes the best of PHM?

First, a group should define its goals around ACOs and PHM.  For example, does the group want to become an ACO, become part of an ACO, or simply try its hand at managing a portion of its patient population? Second, based on those goals, a group will need to determine what tools it needs to manage its population.  Needless to say, there are dozens available — and choosing the right solution can be time-intensive and mind-boggling.

The JHD Group has developed a comprehensive RFP that helps identify more than 400 software features, as well as how the software and implementation is designed to work with patient engagement, point of care changes, cross continuum workflows, etc.  If you are just starting on this journey or are stuck in the middle of it, call the JHD Group and we will help guide you through a strategy, selection and implementation as needed.  Simply put, we know the ABCs to PHM success, and we’re happy to spell that for you.

Give JHD Group a call today or send me an email to learn more about this new RFP tool.



Is Healthcare on Repeat?

Drew Nietert, CPHIMS, PCMH CEC, CHPSE, JHD Group

Sure the “repeat” function on your music player is good when it comes to your favorite song — but will it work with healthcare reform?

healthcareIt’s hard to miss the similarities between today’s Accountable Care Organizations’ (ACOs) efforts and those of the 1990s when HMOs and capitation ruled.  Yet, while many liken these ACOs to those HMOs, there is some significant evolution of those programs — but, unfortunately, not quite a revolution.  Is it the same old song? Not quite.  But the melody might sound similar.

As a quick refresher, Health Management Organizations (HMOs) capitated payments to providers. Capitation is a set fee per month per member, and members could see in-network providers as often as needed. The impetus was on the providers to reduce duplicative costs, be efficient and attempt to proactively manage care to reduce patient visits. The difficulties of HMOs were many, from gate keepers to prior authorizations.  A major obstacle for a provider was the inability to see into their own patient population quickly and comprehensively across the care continuum. This visibility is part of what Population Health Management will do for today’s ACOs.

If the ACO is an evolutionary step of the HMO, how is this tune different?  First, it’s a paradigm shift to value, rather than volume.  With HMOs, it made sense for providers to proactively manage care.  In reality, the tools and agreements were not there and the systems rarely supported providers’ efforts.  In the ACO model, the entire continuum of care is responsible, not just the provider.  The whole system — hospitals, PCPs, specialists, LTACs, etc. — becomes a team and will either share in the losses or the savings.  It is this shared accountability that will offer alignment and a better chance for success.

Secondly, for an ACO to work, the system must understand its patients, from diagnosis to frequency of visits to cost to the system, along with dozens of other analytical variables.  In the 1990s, the systems didn’t really exist to mind such data in a single office, let alone along the entire continuum of care.  Yes, there are still gaps to be filled in regards to technology and data, especially around the quality of data, but the healthcare industry is light years ahead of where it was two decades ago.  The breadth and depth of available systems and data are akin to adding an entirely new symphony of sound to this song.

Third, there is a confluence of factors such as health networks’ integration, physician alignment and even ownership, regulatory requirements and incentives, and payors looking to find reductions in cost, among other things, that are pushing healthcare to change its tune. Forcing a system to change from being paid for activity to being rewarded for quality outcomes is music to everyone’s ears.  It’s a song that has not been heard with such fervor yet, making it entirely different from the healthcare reform drumbeat of decades past.

How does population health management play into this mix?  Stay tuned for my next post on PHM. If you had to give healthcare one song title, what would you call it?

From the Mouth of an M.D.

“They make these empty promises.”

Hearing directly from physicians on their work life is always so impactful to me. With the JHD Group, I enjoy helping physician groups and health systems learn how to work together in mutually beneficial relationships that benefit patients. I was at the AMGA Conference this spring when I heard something so disheartening, spoken by a respected physician, about his experience with administration:

“People come out and talk to me and say, ‘We’re going to fix this’ — and then they never come back.  They make these empty promises and they act like they’re listening to me, but they don’t.”

This intelligent, talented, busy physician with whom I was talking about physician communication was recounting his experiences to me. Promises — empty promises — seemed to be his experience with administration. Besides not fostering an ongoing exchange of ideas, unfulfilled promises like these this physician experienced actually breed distrust and discontent.

No hospital wants that.



Many health systems intellectually understand that physician communication is important.  At this very conference, I heard it preached over and over again: “Communication, communication, communication.” Everyone will nod in approval, think to themselves how important that is — and then go back to their busy day jobs and not do the work it takes on an ongoing basis to create and foster a culture of physician engagement.

I say “culture” because it’s not about an “initiative” to inspire trust among physicians. It’s not one event, one newsletter, one meeting. Rather, it’s about an approach to how you do business and ultimately recognizing the value that physicians bring to a system with their unique perspective and needs, and how their satisfaction can greatly influence your business, especially in the new landscape of healthcare. To create a culture of engagement, it requires involvement from your entire senior leadership team (e.g., no one single person in charge of physician engagement).  Do something daily to communicate with them, and keep it short and simple.

Here are a few ideas:

  • Visit physicians regularly, in-person and via telephone
  • Host a physician-only internal website where news can be posted for transparency, CME opportunities and promotions can be announced, and other robust content and industry news can be shared with physicians
  • Consider creating a closed Facebook group for physicians and administration
  • Pass along articles you find insightful
  • Host a webinar on a topic physicians will find useful, educational or interesting
  • Conduct physician mixers, where you also invite the physician’s right-hand person, their office manager

Understanding their communication needs and style also shows them that you care. E-mail is not always effective with physicians because of their limited availability of time.  Bullet points are best if you’re going to communicate with them in written form so that they can skim it.  Don’t overwhelm them with needless content; respect their time, intelligence and experience. Find that happy medium.

Most of all, it’s important that administrators listen. When physicians give you feedback, take it seriously. Respond to them promptly. If you don’t know an answer, tell them you will find out and then get back to them.

I asked this physician what his hospital administration should do to allow him to feel more engaged.  His insightful thoughts:

“Come to my office, talk to me, see what’s going on in my practice. Have a way to listen to me.”

From birth to grave, physicians take care of our patients.  Engage these important clinicians with a culture of communication that integrates their voice with that of hospital administration.  Your business will thank you.