Thursday, March 30, 2017

Modern Death?

I picked up a copy of Haider Warraich’s book Modern Death as soon as I saw it advertised.  This is a topic that I find fascinating and Mr. Warraich’s book was billed as the “follow-up” to Atul Gawande’s Being Mortal, so I didn’t think twice about the impulse purchase.  While reading the first few chapters, I was a little disappointed.  Mr. Warraich wasn’t presenting anything that I hadn’t already read or taught about as a professor of health law and ethics.  I didn’t make my first earmark until page 91, but shortly after had to be careful not to earmark every other page.   I quickly decided that Mr. Warraich had written a text that should be read by everyone – not just people fascinated with the legal and ethical issues surrounding end of life.

Modern Death begins with an overview of issues surrounding death, including the legal definition of “death” and methods of sustaining life.  Landmark cases are explained and a detailed history of the development of CPR is included.  After building a firm foundation, Mr. Warraich delves into the issues he sees most often as a physician.  That first earmark on page 91?  It was for this quote: “The reason people increasingly don’t want CPR is not that they are afraid it will fail but that they are afraid it will only partially work.  Patients are afraid that if CPR makes their heart start beating again their brain will have to pay a huge cost.”  In a society that values independence and self-reliance, this is so very true.  Most people would rather not continuing living if they have to live in a vegetative or severally impaired condition.  What is life in today’s world if you cannot continue to do the daily activities that you love?

After an excellent ethical analysis of death and resuscitation efforts, Mr. Warraich considers deeply the role of religion in the dying process.  He states: “Physicians very frequently find themselves in difficult situations with patients who have a strong faith, but rarely do they talk about religion and spirituality.”  One study estimates that only 10% of physicians broach this difficult but important subject.  This number is extremely low considering a study of cancer patients showing that patients provided with “spiritual care had a better quality of life prior to their deaths, were more likely to pass in hospice, and were less likely to receive aggressive and unnecessary care close to death” when compared to patients not provided spiritual intervention.

Modern Death also examines the role of physicians assisting care-givers and surrogate decision makers.   He proffers that physicians are usually at the center of the decision-making process and they are often required to buffer the various opinions of family members and caregivers.  In addition, he states that the burden placed on surrogate decision makers (aka health care proxies) is seriously overlooked.

The topics of euthanasia and physician assisted suicide are also touched on in Modern Death.  Mr. Warraich offers his own personal perspective and thoughts regarding this controversial topic.  He provides a unique perspective regarding the shift in opinion over centuries, not just decades.

I have added this book to my list of texts that every healthcare professional should consider reading.  Additionally, I will be giving it to my parents.  Per Mr. Warraich’s suggestion, I will instigate the talk that everyone avoids, but everyone should have before it is too late and we simply have to guess.
Submitted by Valerie J Connor, MA CCC-SLP; MS CHES

Thursday, March 23, 2017

How does the Quality Payment Program work? (Part 2 of 2)

Merit-based Incentive Payment System (MIPS) rewards exceptional performers by giving them a positive adjustment in their payment from Medicare. If the practice is a low performer then they will receive a lower payment, or a penalty. For exceptional performance a practice can receive additional payments from 4% in 2019 to 9% in 2022 and forward. For a poor performing practice they can be penalized anywhere from 4% in 2019 to 9% in 2022 and forward. Each practice can choose how much they wish to participate. They can go from a “Test Pace” where they submit some data after January 1, 2017 and receive a neutral adjustment to a small pay adjustment. They can choose a “Partial Year” option where they can report for a 90 day period after January 1, 2017 and before October 2, 2017 and they can receive a small positive payment adjustment. 

Keep in mind that whenever a practice chooses to start, they will need to send in their performance data by March 31, 2018. Lastly, they can choose a “Full Year” option where they can fully participate starting January 1, 2017 and receive a modest positive payment adjustment. The best way for a practice to realize the positive impact from the Full Participation option is to submit data on all the MIPS performance categories.

Now to avoid any downward payment adjustment a practice can submit a minimum amount of data in 2017 to Medicare that can be one quality measure or one improvement activity, and they can avoid any downward payment adjustment. A key factor for positive adjustments is that these are based on the performance data on the performance information submitted, and not the total amount of information submitted or the length of time that the practice is reporting on during the year.

The Bonus Payments and Reporting Periods are as follows. To receive the MIPS payment adjustment it will be based on the data submitted. 

The best way to get the most out of the program is to participate for a full year. This type of participation gives the practice the most measures to pick from. CMS is encouraging clinicians to pick the option that best fits their practice needs and abilities. The categories are Quality, Cost, Improvement Activities, and Advancing Care Information. The default weights for each category are Quality (60%), Cost (0%), Improvement Activities (15%), and Advancing Information (25%). These default weights can be adjusted in certain circumstances. Quality has approximately 300 different quality measures and the practice needs only to select about 6. For Advancing Care Information there are 2 measure sets for EHR. 

The nice thing here is that if a clinician faces a significant hardship and are unable to report on the Advancing Care Information measures, they can apply to have their performance category reduced to a weight of 0%. If this category is not applicable to the clinician, then the 25% weight will be added to a different category. 
Submitted by Michael "Kevin" Harrington, MSHA, RHIA, CHP, Faculty, Saint Joseph's College

Wednesday, March 08, 2017

Medicare and the Quality Payment Program- What is it and who can participate. (Part 1 of 2)

Many physicians and their staff ask what a Quality Payment Program is and who can or should participate. Currently the Centers for Medicare and Medicaid Services (CMS) is looking to move to a more beneficial Quality Payment Program (QPP), but knowing the past would be helpful. Way back physicians were reimbursed in a Fee-for-Service (FFS) model where it was volume, not quality that drove the payment. As this payment model was slowly getting out of hand, Congress passed temporary fixes called “doc fixes” to avoid cuts in reimbursement. If they did not do this it would have resulted in a 21% cut in Medicare payments to clinicians.

In comes a great idea, a Quality Payment Program (QPP) that can help to reform Medicare Part B payments for more than 600,000 clinicians across the country. This is a huge step in the direction of improving care and controlling costs across an entire healthcare delivery system. There are two tracks that a clinician can choose from which are Advanced Alternative Payment Models (APMs) that require the clinician to participate in an innovative payment model. 

The second option is the Merit-based Incentive Payment System (MIPS) which works with clinicians that choose to remain in a more traditional Medicare payment model and possibly earn a performance-based payment adjustment.
Now the question is who can participate? The Quality Payment Program is available to all Medicare Part B clinicians billing more than $30,000 a year to Medicare and providing care for more than 100 Medicare patients per year. The clinicians include Physicians, Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, and Certified Registered Nurse Anesthetists. 

Those clinicians who are excluded from the QPP are ones that enroll in Medicare for the first time during a performance period as they are exempt from reporting on any measures and activities for MIPS until the next performance year. Also, clinicians that are below the low-volume threshold of $30,000 per year in billing to Medicare or they see less than 100 Medicare patients per year. In addition, clinicians significantly participating in Advance Payment Models (APMs) are excluded.

Overall, this program is designed for small practices to be able to successfully participate in the Quality Payment Program by reducing the time and cost to participate, allowing the small practices to “Pick Your Pace,” increasing the opportunities to participate in an APM, including a practice-based option for participation in an Advanced APM as an alternative to total cost-based, and by conducting support and outreach to small practices through various programs such as Transforming Clinical Practice Initiative.  

For the Rural and Health Professional Shortage Areas (HPSAs) they can have less than or equal to $30,000 in Medicare Part B allowed charges or less than or equal to 100 Medicare patients served. They only need to report on one high-weighted activity or two medium-weighted activities. These are all designed to have ease of access to the program, regardless of the size of the practice or the location that they serve Medicare patients.
Written by Michael "Kevin" Harrington, MSHA, RHIA, CHP  Faculty, Saint Joseph's College