Wednesday, November 25, 2015

The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs): Delivery System Reform, Medicare Payment Reform, & the MACRA

This MACRA system makes three important change to how Medicare pays those providers who give care to Medicare beneficiaries. The areas that have changed are as follows:

  • 1.      This new system ends the Sustainable Growth Rate (SGR) formula that was crucial in determining the reimbursement/payment to healthcare providers for services delivered to their Medicare beneficiaries.
  • 2.      Establishing a new framework to establish a reward system for healthcare providers that deliver better or higher quality care, not just more care over more dates of service (DOS).
  • 3.      Eliminating the fragmented quality reporting program and establishing a single system for the reporting of quality results.

The new MACRA reform works in a way that will enhance and expedite the change of the payment structure from billing for services, without the weight of quality figured in, to a system that reimburses based on value and quality of care delivered to the patient. In addition, the MACRA system streamlines and simplifies the process in which a provider can successfully take part in Medicare’s quality programs by initiating:

  • 1.      A Merit-Based Incentive Payment System (MIPS)
  • 2.      Alternative Payment Models (APM)

These two new systems will be go into effect through the upcoming years from 2015-2021 and beyond.

MIPS is a program that combines parts of the existing Physician Quality Reporting System (PQRS), the Value Modifier (VM) or otherwise known as Value-based Payment Modifier, and Medicare Electronic Health Record (EHR) incentive program into one single system that is based on:
  • ·         Quality
  • ·         Resource use
  • ·         Clinical practice improvement
  • ·         Meaningful Use for EHR

The APM model is designed to give providers new ways to get paid for the care that they give Medicare Beneficiaries. This includes lump-sum incentive payment, increased transparency for physician-focused payment models, and offering higher annual payments.

The timeline for MIPS and APM starts in 2015 and will go through 2016, and later. The payments will include for MIPS incentives of quality, resource use, clinical improvements, and meaningful use from 4% through 9% in 2016. APMs will have a 5% incentive payment and is excluded from MIPS.
For more information on MACRA you can go to:

For more information on the Medicare Access and CHIP Reauthorization Act you can to to:

Submitted by Kevin Harrington, Full Time Faculty, Health Administration, 
Saint Joseph's College.   Contact Kevin at if you would like to discuss this further.

Friday, November 13, 2015

Moving from Information to Knowledge in Challenging Times!

“The species that survives is the one most able to change.”
          Charles Darwin

The healthcare sector is a dynamic and rapidly evolving business model that has new market forces being imposed on it from a variety of directions.  Moving from the historical “fee-for-service”  (FFS)payment scheme to “bundled payments” for a defined period of time after discharge,  is intended to put providers at risk, for both the outcomes of care and the cost of the services provided.   
                In the middle of summer, the Centers for Medicare and Medicaid Innovation (CMMI) announced a mandatory bundled payment requirement for two (2) Medicare orthopedic DRG’s, or the so-called CCJR model.  This payment system is being applied in seventy-five (75) metropolitan locations across the country and is supposed to start on January 1, 2016.

                Currently, CMMI has about forty (40) demonstration projects around the country that are experimenting with numerous systems to reduce costs and enhance outcomes.   Accountable Care Organ1zations (ACO’s) in the form of “Pioneer ACO’s”, original ACO’s and Next Generation ACO’s, are all part of this evolving payment direction.  Even non-acute care organizations are moving into risk-based payment systems.  The CMMI Bundled Payment Care Initiative (BPCI) Model 3 demonstrations that saw almost 1,000 non-acute care providers (skilled nursing facilities, home care providers, and hospice organizations) accept contracts to provide services under a fixed bundle amount.

While some providers and payers have used similar models for non-governmental payers, moving the Medicare FFS to this new model will require move information about the care, costs, and outcomes to the patient by providers.  That will translate into the need for health information systems that creates a value to the organization to provide the ability to move to a knowledge-based decision process.

Darwin’s quote should certainly be considered by healthcare providers as the evolution of the care delivery system moves into the sector.  Those providers that understand the information that will be needed to thrive in this new knowledge environment will most likely be one of the survivors.  Those organizations that fail to see how information is translated into knowledge and make decisions based on the data will have difficulty competing.

Contributed by Steve Chies, MHA, Adjunct Faculty Saint Joseph's College

Friday, October 30, 2015

National Radiologic Technology Week

We celebrate the National Radiologic Technology Week 
November 8 through 14, 2015!

                In celebration of National Radiologic Technology Week, Saint Joseph’s College would like to publicly recognize all Registered Radiologic Technologists for the important work that each of you perform. The week of November 8th is set aside to thank and applaud all Radiologic Technologists for the role that you play in providing not only safe, quality exams, but also great patient care. Congratulations on behalf of Saint Joseph’s College.

                The American Society of Radiologic Technologists' (ASRT) theme this year is “Discovering the Inside Story.” 

This is two-fold: 
  • initial discovery and 
  • personal contribution.
Our founding father, Wilhelm Conrad Roentgen, discovered x-rays on November 8, 1895. This discovery allowed for the first glimpse into the human body. Since then, significant medical advances have greatly improved the way that we visualize internal organs and structures, such as bones, muscles, blood vessels, heart arteries, etc. The most recent advances in Computed Tomography (CT) Angiography, PET/CT Scans for Cancer, Digital Mammography, and Imaging Tests instead of exploratory surgery have all contributed to less invasive procedures and have enhanced the patient’s experience. These advancements have done away with surgical approaches, ultimately making it less costly, less painful, and allows for shorter hospital stays.

                There are over 324,000 Radiologic Technologists in the United States who are making a difference in the lives of their patients! This week long celebration allows each of you to stop and ponder your own personal inside story. What drew you to this profession and why do you do what you do? What contribution to the profession do you hope to make? In an attempt to keep up with the rapid pace of medical advances, what personal career goals do you aspire to? Saint Joseph’s College can help you reach your goal. Please check out the online degree programs that are available and the fast track options.

Happy Radiologic Technology Week!

Contributed by Brenda M. Rice, MHA, BSHA, RTR                                                                                
Program Manager, Radiologic Science Administration Degree, SJC

Wednesday, October 14, 2015

National Healthcare Quality Improvement Week

National Healthcare Quality Week is October 18-24, 2015.  

Any of us who are involved with healthcare should take a moment to celebrate some of the measurable achievements in healthcare quality on improved patient care outcomes. 

Each of us make a difference - Administrators, Nurses, Therapists, Social Workers, Nursing Assistants and all who contribute to a patient's healthcare experience.

I have been a health care professional and leader for the past 30 years.  In my 30 years of practice as a Nursing Home Administrator, Registered Nurse, Public Health Professional, Home Health Provider and now as an Acute Care Compliance Officer, I have never seem a time more dynamic than the past five years. "Syzergy" is a term in astrology  that means alignment of planets/celestial bodies.  I believe that we are in a time of healthcare syzergy, one where there is alignment of political, financial and consumer forces working to change the landscape of healthcare and demanding improvements in both the value and quality of U.S. healthcare.

Health Care Quality Improvement , like leadership, is part science and part art .  I believe that the Affordable Care Act (ACA) and other policy initiatives have had a significant impact on quality of care.  The increased focus on public reporting, transparency, and quality measures have sparked interest in quality outcomes and provided the catalyst for remarkable quality improvement gains in several long-term care clinical quality measures over the past several years.
On March 2, 2015 CMS released the 2015 Impact Assessment of Quality Measures Report

Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and Chief Medical Officer, stated "the 2015 Impact Report demonstrates that the nation has made clear progress in improving the healthcare delivery system to achieve the three aims of better care, smarter spending, and healthier people."

The key findings include: 
·         Quality measurement results demonstrate significant improvement. 95 percent of 119 publicly reported performance rates across seven quality reporting programs showed improvement during the study period (2006–2012). In addition, approximately 35 percent of the 119 measures were classified as high performing, meaning that performance rates exceeding 90 percent were achieved in each of the most recent three years for which data were available. 
·         Race and ethnicity disparities present in 2006 were less evident in 2012. Measure rates for Hispanics, Blacks and Asians showed the most improvement, and American Indian/Native Alaskans and Native Hawaiian/Pacific Islanders the least improvement. Transparency and monitoring of measures rates by race and ethnicity for all publicly reported measures and ensuring that disparities across programs, setting and demographic groups are eliminated, remain top priorities consistent with our CMS Quality Strategy. 
·         Provider performance on CMS measures related to heart and surgical care saved lives and averted infections. From 2006 to 2012, 7,000 to 10,000 lives were saved through improved performance on inpatient hospital heart failure process measures, and 4,000 to 7,000 infections were averted through improved performance on inpatient hospital surgical process measures. (A number of the measures are also included in the previously released patient safety results demonstrating from 2010 to 2013 a 17 percent reduction in patient harm, representing 1.3 million adverse events and infections avoided, approximately 50,000 lives saved, and an estimated $12 billion in cost savings.) 
·         CMS quality measures impact patients beyond the Medicare population. Over 40 percent of the measures used in CMS quality reporting programs include individuals whose healthcare is supported by Medicaid, and over 30 percent include individuals whose healthcare is supported by other payer sources. This demonstrates the public-private collaboration that CMS facilitates and hopes to expand. 
·         CMS quality measures support the aims of the National Quality Strategy (NQS) and CMS Quality Strategy. CMS quality measures reach a large majority of the top 20 high-impact Medicare conditions experienced by beneficiaries, with more measures directed at the six measure domains related to the NQS priorities, and better balance among those domains. Much of our data resulted from process measures; however, there is an increase in measures related to patient outcomes, patient experience of care, and cost and efficiency. CMS is moving increasingly toward these outcome measures across programs. 

The 2015 report can be found at:

I am personally very heartened by these findings and feel them in my everyday work.  This past week I attended a system collaborative meeting where the top leaders in my acute care system came together to discuss "Just Culture," national safety initiatives, strategies for involving staff in changing practices around near miss events and staff satisfaction survey results that will impact the future of quality and safety work in our organization.  This work is amazing to me and the outcomes are improving with a lot of hard work by many dedicated people. 

In closing I would like to share a quote from my healthcare quality hero, Dr. Avedis Donabedian.  In an interview with Health Affairs one month before his death he said:

"Systems awareness and systems design are important for health professionals, but they are not enough. They are enabling mechanisms only. It is the ethical dimensions of individuals that are essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system."

 Contributed by 

 Tammy Rolfe, Adjunct Professor, St. Josephs College

Monday, September 21, 2015

Predictive Modeling, a thing of the future….or is it here now?

Did you know that the Centers for Medicare and Medicaid Services (CMS) uses predictive analytics to analyze all Medicare fee-for-service (FFS) claims? This is done in part to detect claims that may be considered fraudulent.

The predictive analytics system utilizes algorithms and models that will examine claims submitted to Medicare so as to determine if the claims should be flagged for suspicious billing. Moreover, this is done in a “real time” environment. This process is being incorporated by CMS into the claims processing part of the equation.

This idea came about through the Section 4241 of the Small Business Jobs Act of 2010 (SBJS) as it mandated that CMS implement a predictive analytics system to analyze Medicare claims for areas at high risk of fraud. This is a similar process to one credit card companies are currently doing in the pre-payment arena.

As of June 30, 2011 CMS has been running all Medicare FFS claims through this predictive modeling system. This process builds profiles on providers, networks, billing patterns, and beneficiary utilization. The outcome of this process is that CMS can now create risk scores to determine the likelihood or fraud in the billing process. In addition, they can flag potentially fraudulent claims and/or billing patterns.

The risk scores will clearly and quickly identify any billing activity that is unusual and group them by providers, beneficiaries, and networks with the highest risk scores. This system, a very high-tech system, is not designed to replace the expertise or experienced analysts as the analysts still review prioritized cases and history along with identifying any innocuous billing and they will record this activity directly into the predictive analytics program and the payment is released as usual. If an analyst finds any activity that is fraudulent they will alert the CMS Center for Program Integrity, MACs, or Zone Program Integrity Contractors to enact targeted payment denials. When the alert involves egregious fraud, the billing privileges of the provider will be revoked.

The risk scores alone to not initiate any administrative action and the providers will not be able to appeal these risk scores. Currently, CMS is not denying any claims based solely on the alerts generated by this system. The predictive model is still being refined and they are developing more advanced algorithms that line up more closely to the complexities of medical treatment and billing.
With all of this said, CMS is dedicated to ensuring prompt payment to the providers as this is a statutory requirement, but in urgent circumstances CMS will leverage its authority to waive the prompt payment process and conduct a more detailed review on the provider.

Overall, by enacting a predictive modeling system, CMS is staying up with the times and doing its best to combat improper billing practices and to protect the Medicare Trust Fund.

Submitted by Kevin (Michael) Harrington, Full-Time Faculty at SJC

Friday, September 11, 2015

Happy National Assisted Living Week!

The week of September 13-19 will celebrate America’s Assisted Living communities with the theme “Nourishing Life: Mind, Body, and Spirit.” 

This theme emphasizes that in Assisted Living, the aim is to nourish the entire person, not just the body.  The philosophy of assisted living care encompasses mind, body, and spirit in order to maximize each person’s quality of life.  This goal is accomplished through spiritual care, creative outlets, enjoyable events both within and outside the community, involvement in meaningful, enriching activities, and relationships with residents, friends, family, and staff. 

Additionally, assisted living staff members find their lives enriched by interactions with residents and families.  Their lives are nourished by caring for residents, seeing them flourish, developing friendships, and putting smiles on their faces. 

Some communities will profile some of their residents who will share inspiring life stories.  Many residents have made remarkable contributions to their families, communities, and nation.  They deserve to be honored and appreciated.  Likewise, staff members often provide care and support in difficult situations; they also deserve honor and support. 

Thank you to Assisted Living staff members across the country for your dedicated service.  Thank you to Assisted Living residents for allowing us the privilege of knowing you and sharing in your lives.  Enjoy this week that is dedicated to you!

Contributed by Philip C. DuBois, CNHA, FACHCA, Program Manager, Long Term Care Administration, Saint Joseph's College

Monday, August 24, 2015

The Patient Experience

Why is it important to provide patients with the best experience we can?

The most obvious and noblest of reasons is because it is the right thing to do. We should be treating our patients, caring for them in a manner that we would want for ourselves, our families and our friends. As Michael Dowling, President and CEO of the North Shore-Long Island Jewish Health System often reminds staff, many of our patients are us, our relatives and friends. We should be treating all patients as such (Author’s attendance at Mr. Dowling’s presentations.).

A second reason focuses on the theme of choice as related to how our patients view the quality of care we provide. Deming tells us that quality is meeting or exceeding our customer’s needs and expectations. Deming also tells us that loyalty is achieved when we exceed those expectations (Aguyao, 1990; Deming, 1982). Changing how health providers view their patients as customers continues to have its detractors, but few would argue, that increasingly patients have choices, and all in health care now have multiple competitors. If our organizations are to become and continue to be facilities of choice, there is a need to be distinguished from our competitors.

            Pyzdek (2001) in his description of the Kano Model of Customer Expectations explained that meeting basic levels of quality is something that is taken for granted. Meeting them does not result in satisfaction, but not meeting them is a source of dissatisfaction. There are expectations that customers believe are important and the more they are met the more satisfied the customer. The provision of providing exciting quality occurs when the customer receives more than what was expected and this level of quality becomes increasingly important as competitive pressures for nurses present internal customer problems with dissatisfaction with peers or supervisors. Similarly, Bertel (2003) referred to events and practices that dissatisfy customers as the must-haves, which if unfilled would serve as sources of dissatisfaction. Bertel used the term delighters which would not cause dissatisfaction if not present, but when they are present serve to truly satisfy or delight the customer.

A third reason and most recent interest in the patient experience came from HCAHPS, a CMS-developed patient satisfaction questionnaire. In October 2012, HCAHPS’ (Hospital Consumer Assessment of Healthcare Providers and Systems) patient satisfaction scores were utilized by CMS in the calculation of reimbursement for patient stays HCAHPS is not only an instrument that affects reimbursement, its results are publicly reported, permitting comparisons by the public (CMS, 2015).

Creating and Managing Expectations

            Creating expectations initially derives from the informed consent process. This process should have included communication regarding diagnosis, agreed upon course of treatment following an explanation of alternatives, with risks and benefit (Bord, 2014). Patients must have an opportunity to pose questions and to have those questions answered in a manner they can understand. The process must also include an awareness that the patient understands what has been conveyed and an agreement by the patient for a course of care. The process occurs between the physician and the patient.

Once hospitalized, patients are obviously “managed” much more by other hospital staff who have a responsibility to make patients aware of what to expect during their stay. With their experience, other hospital staff have greater expertise regarding what is likely to happen to and for patients, and in what sequence, than patients could possibly have. Initial expectations also derive from past experiences with the facility, discussions with others, experiences with other facilities, and information derived from the media, “report cards,” various web sources etc.

Likewise, mindful that effective communication must be a two-way process, staff have a responsibility to seek out questions and comments from patients regarding their needs and expectations (similar to a consent process), and to appropriately respond to these, both in terms of words and actions to best meet those needs and expectations. The voice of the patient-customer regarding their expression of needs and expectations is often critical to how quality is perceived by the patient (Stroud, n.d.). Bertel, (2003) described the centrality of meeting customer needs in the Six Sigma model with: “Failure to listen to and understand the Voice of the Customer can be fatal” (p. 171). Further, Solomon (2015) stated: “If you want to stem patient dissatisfaction, stop giving off cues of indifference and uncaring.”

             Managing expectations, requires transparency of information between staff and patients on an ongoing basis. Treatment plans may have to be altered due to either patient condition, physician direction or hospital “circumstances.” Solomon (2015) provides the following additional items regarding how to improve the patient experience (Bullets rather than numbers have been utilized here):

 Get every employee thinking about purpose, not just functions… To create successful medical outcomes and hospitable human experiences for our patients’ is a purpose. 

‘Sorry’ may be the hardest word, but it’s a word that everyone on your team needs to learn.  Resolving patient issues means knowing how to apologize for service lapses…It means getting rid of the defensiveness …when confronted by a patient upset with what she perceives to be a service gaffe. Instead, take your patient’s side in these situations, immediately and with empathy, regardless of what you think the “rational” allocation of “blame” should be. And spread this approach throughout your staff through role-playing and other training devices, so it will serve you fully every time a patient hits the fan.

Teach your employees – every single one – how to handle a patient or family member’s complaint or concern.  

 If you want to improve, strive to create a blame-free environment. 

Understand that improving patient satisfaction is about systems just as much as it is about smiles.

Cultural Change toward a Customer Approach

Increasingly patients don’t want to be considered as patients; they want to be considered customers. They want to know and agree to how they will be treated, what should happen, what are the outcomes, what to expect when they leave the hospital, what to expect about their health. We cannot effectively respond to these expectations with a departmental/silo mentality. We must break down these silos, learn to work as interdepartmental, inter-professional teams, although past models of professional education did not foster this approach, and change in these educational models is needed (National Center for Healthcare Leadership, 2011).

 Contributed by Dr. Walter Markowitz, Adjunct Faculty 


Aguayo, R. (1990). Dr. Deming: The American who taught the Japanese about quality.
            New York: Simon and Schuster.

Bertel, T. (Ed.). (2003). Rath and Strong’s Six Sigma leadership handbook. Hoboken, NJ: John Wiley and Sons, Inc.

Bord, J. (2014). Informed consent. Retrieved from

CMS. (2015). HCAHPS factsheet. Retrieved from

Deming, W. E. (1982). Out of the crisis. Cambridge, MA: MIT Press.

National Center for Healthcare Leadership. (2011). Michael Dowling accepts 2011 Gail L. Warden Leadership Excellence Award. Retrieved from

Pyzdek, T. (2001). The Six Sigma handbook: A complete guide for greenbelts, blackbelts, & managers at all levels. New York: McGraw-Hill.

Solomon, M. (January 11, 2015). 8 ways to improve patient satisfaction, patient experience and (by the way) HCAHPS scores. Retrieved from

Stroud, L. (n.d.). Defining CTQ outputs: A key step in the design process.

(Note: Dr. Markowitz was the Director, Strategic Planning, North Shore-Long Island Jewish Health System.)

Tuesday, August 18, 2015

Healthcare and Schools

In the July/August issue of Health Progress magazine, an article written by Rochelle Davis, Jeffrey Levi, Ph.D. and Alexandra Mays, MHS, discusses the unique opportunity health and education systems have for partnership to serve the health challenges of elementary and secondary students.

As health care administrators, we sometimes are not aware of the important role schools have for health education programs, emergency health care services, nutrition and other health-related issues
The article titled “Ten Principles for Collaboration” outlines the opportunity hospitals have for developing and implementing programs with schools that will ultimately serve not only those in need but also invests in the future through our children.

The ten principles include:

Needs assessment and implementation strategy
Data exchange mechanisms
Project scope or targets
Community engagement
As well as several others

The full version of this article can be located at under the publications and then the Health Progress tab.

Contributed by Becky Urbanski, Ed.D., SJC instructor, Catholic Health Care Leadership and Mission Integration graduate courses

Wednesday, July 15, 2015

Thinking about the end…

According to his book cover biography, Atul Gawande is the author of three best-selling books, including Complications, Better, and The Checklist Manifesto.  I have read all three and was quite excited to read his most current publication, Being Mortal.  Mr. Gawande is a surgeon, professor, and writer.  His books cover complicated and controversial topics in a calm and uncomplicated manner.  He introduces us to real people, with real medical issues while adding a human view to the sometimes sterile medical world.

In Being Mortal, Mr. Gawande tackles end-of-life issues.  He provides a historical perspective of end-of-life care, as well as current issues facing our society.  For example, he asserts that our medical community is still confused on the best methods for providing care for patients with long-term illnesses.  He states:

               “People with serious illness have priorities besides simple prolonging their lives.  Surveys find that their top concerns include avoiding suffering, strengthening relationships with family and friends, being mentally aware, not being a burden on others, and achieving a sense that their life is complete.  Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars.”

Mr. Gawande considers how “we can build a health care system that will actually help people achieve what’s most important to them at the end of their lives”.  He states, “People die only once.  They have no experience to draw on.  We need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come – and escape a warehouse oblivion that few really want.”

Overall, Mr. Gawande uses real-life stories to teach his readers the importance of compassion and facing reality.  He asserts that encouraging patients to think about and plan for the end of their life is just as important as preventative care.  In fact, some studies have shown that simply having a conversation about advanced directives (e.g., living wills) can reduce depression and confusion at the end-of-life.

This is not an uplifting book, but it is an important one.  I encourage everyone to discuss end-of-life choices with their loved ones.  It is not an easy conversation, but it can save heartache and provide peace.  Mr. Gawande supports this notion and provides an excellent guide to help begin those difficult conversations.

Contributed by Valerie Connor, SJC instructor, law and ethics courses.

Sunday, July 12, 2015

New Continuing Qualification Requirement (CQR)

Are you prepared to meet the new CQR   directive to maintain your certification?  The American Registry of Radiologic Technologists (ARRT) has been working with multiple constituents in the profession to develop a pathway for continued education.  Certification is now time limited to 10 years. Recertification will require the completion of the new CQR process.

The first CQR deadline is set for 2021. However, this will impact those who earned their certification in 2011 (effective January 1, 2011) and subsequent years. According to the ARRT website, the compliance phase will begin in 2018, which allows three years to complete the professional profile, the self-assessment section and targeted continuing education component by 2021.  The professional profile is a reflective exercise that compares clinical experiences to others in the discipline. Next, you must complete the structured self-assessment process, which is a learning tool designed to evaluate knowledge and skills on the qualifications that are expected of those who are certified. From this, a report will be generated with the results of the assessment and whether or not standards have been met. If standards have not been met, the ARRT will identify the necessary components that will be required for completion in order to be recertified. Please visit for additional information.

Submitted by Brenda Rice, Program Manager, Radiologic Science Administration