Disrupting the Clinical Laboratory Market

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This interview is part of a new collaborative series made possible by Business of Healthcare (BOH) and the North Carolina Medical Group Management Association (NCMGMA). These interviews further our mission to provide high-level continuing education content for our members while highlighting key players and issues in North Carolina’s healthcare industry.

In this interview:
Disrupting the Clinical Laboratory Market

price240bChad Price
Founder and CEO
Mako Medical Laboratories

Mako Medical Laboratories provides clinical laboratory services primarily in partnership with independent physicians, 50,000 of whom they report use their high-service, mission-oriented value proposition. Founders Chad Price and Josh Arant began with no healthcare industry experience. Price, who is Chief Executive Officer for privately-held Mako Medical, shared his vision with host Matthew Hanis as part of the North Carolina Medical Group Management Association’s BOH series.

Follow this link to view the interview video

Continuing Education Credit

By reading, watching or listening to the full interview, you may self-report to earn 0.5 hours Continuing Education Credits for Certified Medical Practice Executive (CMPE) or Fellow of the American College of Medical Practice Executives (FACMPE) credentials.

NCMGMA and BOH thank Mako Medical Laboratories
for helping to make this interview series possible.
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About the Business of Healthcare

BOH was founded as a forum and information exchange for the 40,000 decision-makers leading hospitals and health systems, physician practices, pharma, device, and senior living as well as government and commercial payers. These leaders, and innovators serving them, join Business of Healthcare interviews to solve the complex issues they face together.

Hosted by Matthew Hanis, each interview balances Margin & Mission: making good healthcare accessible to all. New subscribers come to BOH through your referrals. Please share our content with your colleagues and invite them to join our expert community.

BOH-NCMGMA Interviews

Interviews published in the Business of Healthcare (BOH) and North Carolina Medical Group Management Association (NCMGMA) interview series contains the expressed opinions and experiences of the interview subjects and do not necessarily represent the position of NCMGMA.

Upcoming Interview
Next month’s interview will feature Jeff James, Chief Executive Officer of Wilmington Health.

Interested in Participating?
If you are interested in being interviewed or have a tip on someone who would be a great interview candidate, please contact Melissa Klingberg in the NCMGMA offices at melissa@ncmgm.org.

Nominations are Open for Administrator of the Year and Practice of the Year

Annually, the North Carolina Medical Group Management Association (NCMGMA) recognizes outstanding performance by an individual and a medical practice with our Administrator of the Year Award and our Practice of the Year Award. For 2019, both awards will be presented at our Annual Meeting, to be held May 8-10 in Wilmington, NC. Nominations for both awards are now open.

NCMGMA-Medical Mutual Administrator of the Year Award

medical-mutual-medEach year, NCMGMA and Medical Mutual recognize a healthcare administrator, affiliated with the NCMGMA, who has exhibited exceptional leadership management proficiency and enhanced the effectiveness of healthcare delivery in his/her practice and community through recent, noteworthy achievements.

If you wish to learn more about this award and/or nominate a colleague, follow this link to fill out a complete form or email our offices at info@ncmgm.org to nominate an administrator. The deadline for nominations is March 8, 2019.

NCMGMA-First Citizens Bank Practice of the Year Award

First-Citizens-HorizontalThe North Carolina Medical Group Management Association (NCMGMA) is proud to partner with First Citizens Bank to present the 7th Annual Practice of the Year Award. This award recognizes a medical group practice that has made a significant contribution to their community, patients and/or staff through volunteer work, indigent clinics, fundraisers, staff wellness programs, community clean ups, community screenings and education (internal & external), etc.

Follow this link to learn more about the award or to begin the nomination process. The deadline for submissions is March 8, 2019.

Questions

If you have any questions, please contact the NCMGMA offices at info@ncmgm.org or 800-753-MGMA (6462).

Medical Practice Issues to Watch in 2019

Originally published in the January 9, 2019 issue of MGMA’s Washington Connection
Reprinted with permission from MGMA

Medical Practice Issues to Watch in 2019

2019 promises to be another busy year in healthcare. The 2018 midterm elections shifted the balance of power in Washington as Democrats now hold the gavel in the U.S. House of Representatives, creating a divided Congress with the Republican-held Senate. MGMA has identified the following legislative and regulatory issues critical for medical practices in the coming year. We will keep members apprised of key developments in these areas and their impact on medical practices and will continue to advocate for policies that enable practices to thrive in their mission to furnish high-quality, cost-effective patient care.

1. HHS doubles down on risk

Despite an anemic pipeline of new voluntary Medicare alternative payment models (APMs) trickling out of the Department of Health and Human Services (HHS), Secretary Alex Azar is planning a new approach to accelerate participation in risk-based APMs. Forgoing incremental implementation, the Secretary is expected to unveil new mandatory models in 2019 and to emphasize performance-based risk as a necessary component of any new APM.

MGMA strongly supports voluntary participation in APMs when it makes financial sense for individual practices and disagrees with the Secretary that the way to expedite the move to value-based care is to mandate participation. We will continue to advocate for new opportunities for practices to participate in voluntary APMs and for development of more physician-led models.

2. Regulatory relief from government burdens

It is expected that Congress and the Administration will continue to work toward reducing the regulatory burden on medical practices participating in government healthcare programs. The Centers for Medicare & Medicaid Services’ (CMS’) “Patients Over Paperwork” initiative is one such example. However, this has translated into only modest relief for practices thus far, as 88% of MGMA members polled reported an increase in overall regulatory burden last year. MGMA will continue to make regulatory relief a top advocacy priority in 2019. Keep up with our efforts at mgma.com/regrelief.

3. Kicking back the Stark Law

As part of the effort to accelerate payment innovation, HHS leaders pledge to revisit antiquated fraud and abuse rules such as the Stark Law and Anti-Kickback Statute. In 2019, watch for proposed rules that expand exceptions and safe harbors to protect value-based arrangements and benefit providers willing to take on performance-based risk.
While a push to simplify Medicare compliance rules is welcomed, it is likely that congressional intervention will be necessary to achieve meaningful reform. It remains to be seen if Congress will also prioritize this issue in 2019.

4. Surprise! Here is a medical bill you didn’t expect

Medical practices can expect to see a push to curb surprise medical bills, including efforts to empower patients and consumers through improved access to healthcare cost information. The sticker shock of surprise hospital bills continues to make headlines and draw bipartisan attention in Congress, making this issue ripe for legislative action in 2019.

5. A spoonful of new regulations to help drug prices go down

With a new Congress and support from the Administration, reducing Medicare drug prices is on the action list for 2019. For physician-administered drugs, one proposal seeks to curb the price of drugs in Part B by tying prices to a new International Price Index, create new private-sector vendors to supply practices with drugs, and set drug administration cost as a flat fee. CMS is also looking to give Part D drug plans greater flexibility to negotiate drug prices in protected classes.

6. The stakes are higher in MIPS

Implementation of the Merit-based Incentive Payment System (MIPS) continues to ramp up. In 2019, MIPS performance will determine whether clinicians receive a positive or negative payment adjustment of up to 7% on 2021 Medicare reimbursement. Medicare is accelerating cost accountability for MIPS clinicians by increasing the cost component to 15% of the overall MIPS score and introducing episode-based measures. The performance threshold required to avoid a payment penalty also doubles from 15 to 30 points in 2019. With more on the line this year, it is critical that MGMA members prepare their practices for success. Visit mgma.com/macra for helpful resources.

7. Data interoperability a priority for feds

The Office of the National Coordinator for Health Information Technology (ONC) is expected to release regulations to meet requirements of the 21st Century Cures Act and facilitate improved data sharing between healthcare entities. ONC will define and seek to discourage “information blocking,” develop a framework to facilitate data movement between heath information exchange entities, and release specifications for the use of apps to foster data exchange between different providers and between providers and patients. The goal of using apps, a component of MIPS and Stage 3 Meaningful Use, is to permit practices to efficiently and securely move administrative and clinical data via their EHR.

8. Cybersecurity continues to be a top practice concern

Medical practices can be a prime target for phishing and other cybersecurity attacks because they possess valuable information assets (patient clinical and financial data) and often have inadequate cybersecurity protections. HHS’ HIPAA enforcement arm is expected to ramp up audits and fines in 2019. Medical practices should protect both their data and business continuity by completing a comprehensive risk assessment, identifying vulnerable areas of the organization, and taking the steps necessary to mitigate risk. Check out MGMA security resources to prepare your practice this year.

9. Site-of-service payment differentials remain a target

Policymakers will continue the trend toward site-neutral payments with the goal of equalizing Medicare payments for the same services across clinical sites. Medicare expanded this policy through 2018 rulemaking by phasing-in payment reductions for clinic visits at hospital outpatient departments (HOPDs), including HOPDs excepted from previous site-neutral payment rules. In addition to saving money for patients and the government, site-neutral payments are viewed as a policy lever for increasing market competition, eliminating the incentive for hospitals to purchase freestanding clinics and leveling the playing field.

10. “Repeal and replace” is out, “Medicare for all” is in

This shift in power within Congress will recast the role the federal government plays in healthcare in 2019. With “Medicare for all” a key platform for many progressives during the 2018 primaries, the politicized debate over a single-payer health system shows no signs of slowing down and will likely gain steam ahead of 2020 elections.
Passage of any major health reform bill is highly unlikely anytime soon. However, as presidential contenders begin campaigning for the 2020 primaries, universal healthcare will almost certainly become a point of debate.

Welcome New Members

Our membership continues to grow! Take a look at the list of healthcare professionals and students who have recently joined NCMGMA (November 30, 2018 through January 4, 2019):

Active

  • Allen Habif, UNC Pediatrics, Chapel Hill, NC

Affiliate

  • Mary Gage, Hire Scene, Inc., Raleigh, NC
  • Hunter Houck, MARSH & McLennan Agency, Wilmington, NC

Corporate Active

  • Teri Armstrong, Rex Heart Failure Clinic, Raleigh, NC
  • Caitlyn Grow, Charlotte Eye Ear Nose & Throat Associates, P.A., Charlotte, NC
  • Rashanda Joe, UNC Physician Network, Morrisville, NC
  • Teresa Medlin, Charlotte Eye Ear Nose & Throat Associates, P.A., Charlotte, NC

Corporate Affiliate

  • Philip Pickard, MSOC Health, Chapel Hill, NC
  • Emerald Smith, MSOC Health, Cary, NC

Student

  • Pamela Hammond, East Carolina University, Morehead City, NC

Clinical Decision Support Mechanisms (CDSM)

You know that can you’ve been kicking down the road?
Well, don’t look now but it’s starting to roll back!

by John Lillie, Senior Strategic Accounts Manager, CMS Imaging, Inc.

And it’s more like a 55-gallon drum that is slowly picking up speed.

Clinical Decision Support Mechanisms (CDSM) utilize Centers for Medicare and Medicaid Services (CMS) approved Appropriate Use Criteria (AUC). These CDSMs must be consulted prior to completing an order for either CT, MRI, Nuclear Medicine, or PET studies for Medicare outpatients in any non-inpatient place of service. CMS has targeted reporting for eight clinical areas to identify outlier physicians:

  • Coronary artery disease (suspected or diagnosed)
  • Suspect pulmonary embolism
  • Headache (traumatic or non-traumatic)
  • Hip Pain
  • Low Back Pain
  • Shoulder Pain (to include suspect rotator cuff injury)
  • Cancer of the Lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

Ordering providers don’t have to abide by what was shown to be the best imaging modality; they must only demonstrate that they consulted AUC through an approved mechanism. Failure to consult an approved AUC will cause the professional and technical component reimbursement to be denied – as in zero-dollar reimbursement. That should get your attention.

The goal is admirable: reduce the number of inappropriate exams, which would improve the quality of healthcare by reducing dose where applicable. Good for the provider and good for the patient. However, as always, the devil was, and still is, in the details.

Originally slated to go in effect on January 1, 2016, this initiative has been delayed time and time again, and thankfully so. Neither CMS, nor the providers, nor the industry was prepared to implement these standards. Like peeling away the layers of an onion, the deeper reasonable interests investigated the topic, the more challenges became apparent. Available space to devote to the resultant coding is an issue, for example.

Moreover, what about those providers who still use the fax machine or paper orders? How are we going to get all providers, regardless of their specialty or size, to do this? These are real-world challenges.

A more significant challenge is that not everyone knows enough about the AUC consultation requirement, the approved mechanisms, and all of the other details, and are nowhere close to implementing a workable solution. Plus, there is no funding mechanism provided externally to help you to comply with the mandate. Assuming you have addressed this, I am quite sure that this was a pleasant conversation for radiology managers to have with their CFO’s (I sincerely hope you’ve had these conversations, right?). Apparently, many have not.

In a recent survey conducted by the Association for Medical Imaging Management (AHRA), among the 291 total responses who responded to the question “Have you implemented or begun implementing Clinical Decision Support (CDS)?”, 35% responded Yes, 61% responded No, and 3% were not sure what CDS is (Source: Regulatory Affairs: Clinical Decision Support (CDS) 05/2018 Survey, released on July 5,2018).

The good news is that since the passing of PAMA 2014, healthcare entities have far more choices available today as to which CDSM they would like to consider. The list of qualified Provider-led Entities (qPLE) who have been approved to “develop, modify, or endorse” Appropriate Use Criteria (AUC) are growing as well (see the list at the end of this blog posting). Newly approved qPLE’s are announced each June. The industry around Clinical Decision Support for Medical Imaging is growing. More choices allow for more informed decisions. More options will enable the marketplace to reward those who succeed and punish those whose products don’t pass muster.

What is a more significant concern, now that the mandate has been pushed back to January 1, 2020, is will the industry still be ready? The first year will, in effect, be an educational and operations testing period, but full compliance will be the standard for the second year. It is my concern that this reality has not become real. According to Sheila M. Sferrella, MAS, RT(R), CRA, FAHRA, Chair of the AHRA Regulatory Affairs Committee and President of Regents Health Resources, “It typically takes 12-18 months to implement a program like AUC in a hospital setting. Budgeting, funding, IT interfaces, RFP or vendor selection, and then implementation. This regulation is the most challenging one we have had to implement on the hospital side because we have to make sure we capture the AUC code from the referring physician so that the hospital gets paid and then somehow transfer that information to the radiologist’s professional group for payment. It includes hospital bling forms and physician billing forms where codes do not necessarily populate in the same place. The AHRA (The Association for Medical Imaging Management) is working with a group of industry leaders to find a solution that is electronic and not manual. We are trying to help our members prepare for implementation.”

The AHRA has been at the forefront of working with the CMS and their members to find a solution. I count myself as a member of this organization, and I applaud their actions on this front.

It is vitally important that the radiology industry examine, explore, and make their voices heard on the selection of the best CDSM for their facility. They should lead the charge on selection because it is their world that bears the responsibility for it to work. Moreover, they will be the ones penalized if they do not implement the change.

The can that was kicked is now rolling back. According to Ms. Sferrella, the likelihood that this initiative will be again kicked down the road is “almost none.” While some may have hoped this would happen, or the initiative will die and go away, that is not going to happen.

In summary, it is always a better outcome to plan and prepare before a crisis hits. Acting at the last minute, deciding and implementing a CDSM to make the deadline, usually results in panic buying and a whole lot of stress. There is still time, but it is running out faster than you think.  January 1, 2020, is now just 12 months away.

Approved qPLE’s as of this writing:

  • American College of Cardiology Foundation
  • American College of Radiology
  • Banner University Medical Group-Tucson University of Arizona
  • CDI Quality Institute
  • Cedars-Sinai Health System
  • Intermountain Healthcare
  • Massachusetts General Hospital, Department of Radiology
  • Medical Guidelines Institute
  • Memorial Sloan Kettering Cancer Center
  • National Comprehensive Cancer Network
  • Sage Evidence-based Medicine & Practice Institute
  • Society for Nuclear Medicine and Molecular Imaging
  • University of California Medical Campuses
  • University of Utah Health
  • University of Washington School of Medicine
  • Virginia Mason Medical Center
  • Weill Cornell Medicine Physicians Organization

2018 Alliance sponsor article provided courtesy of CMS Imaging, Inc.  For more information, please contact John Lillie of CMS Imaging, Inc. – jlillie@cmsimaging.com.

Healthcare Lessons from Beyond our Borders

By Kirsten Meisinger, M.D. | June 5, 2018

2018 Alliance sponsor article courtesy of athenahealth

Why does the rest of the world spend less on healthcare than the U.S. and have better health outcomes? Because other countries have done what we in the United States have repeatedly declined to do: Align the public health sector with the healthcare delivery system.

I work on a project in Nepal to reduce maternal and infant mortality. We knew that mothers and babies were dying because midwives in remote mountain areas lacked necessary medical supplies: Antiseptic for babies and misoprostol to prevent hemorrhage in mothers. The government gives these supplies away for free because its data show that mortality rates go down when they do.

But keeping those supplies on hand was a challenge. So we gave all the midwives in our project cell phones and had them text central supply when their stock levels ran low. Within three months, all the rural health posts were fully stocked, and maternal and infant mortality decreased dramatically.

This kind of rapid response is only possible in a decentralized healthcare system in which public health data directs and informs healthcare delivery.

In the U.S., we created a centralized, hospital-based system, believing better outcomes would result. We were wrong. We do emergency and tertiary care very well, but the rest of the world has shown that for primary care, a decentralized delivery system is far more effective.

The key to decentralized systems is health promotion via community health workers, trained laypeople who know their communities and can translate medical recommendations in a way that patients – their neighbors – understand and follow. And that leads to better outcomes.

In centralized systems, normal events like pregnancy and pediatric care tend to be medicalized. We moved all our pediatric care into medical offices, for example, and our vaccination rates plummeted. The reason? It’s really hard for parents to take off work, particularly for an appointment where their child is measured and someone says, “Good job, Mom and Dad.”

In France, Australia, and over much of the rest of the world, children often go to the doctor only when sick. Their vaccinations and well-child care are largely managed by a nurse, often one who works at their school, because that is more efficient and, therefore, more effective.

The resource-poor world has developed efficiencies in care delivery through necessity. And most rely on community health workers. In Brazil, community health workers reduce the risk of falling among elderly by teaching patients exercises to do while holding on to a chair. Driven by necessity, their decentralized, community-based strategy yields results any health system in the U.S. would be proud of, and shows precisely why harnessing the power of community to get widespread results is an area of such intense interest right now.

In Rwanda, the Ministry of Health provides most of its citizens access to primary care consultations via a telehealth app on their mobile phones. These are incredibly efficient and effective interventions. Our health system is rich enough that we don’t demand these kinds of simple efficiencies, and then we blame patients when our inefficient systems don’t meet their needs. Rwanda shows us a perfect example of how to make crisis an opportunity by investing in a technology solution that empowers patients to direct their care.

Consumers in the U.S. are using similar technology for everything other than healthcare. Now is the time for us to learn from our neighbors and make the leap.

To achieve efficiency in healthcare delivery, we need to trust our patients to a much higher degree and give them recommendations they can easily follow. The resources we need are already in our communities, our patients, and our public health data. It is our job, our mission, to connect them. And we can learn to do so from our global neighbors and colleagues.

Kirsten Meisinger, M.D., is president of the medical staff at Cambridge Health Alliance.

January 15th HR Updates Webinar is Next Week

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January Lunch & Learn Webinar: HR Updates

January 15, 2019 | 12:00 PM – 1:00 PM
Sponsored by Medical Mutual

Program

Dee Brown, HR Advisor for Medical Mutual’s HR|Experts program, can help you with any human resources issue, from wage and hour situations to leadership development. Join us on January 15th as Dee discusses the essential points of operating successful medical practice personnel management. Plenty of time will also be devoted to answering your various HR questions.

Speaker

DeeBrown162aDee Brown
Human Resources Advisor
HR|Experts
Dee Brown is the HR Advisor for the Medical Mutual HR|Experts’ program. With significant HR experience, Dee is a dedicated, on-call resource for all Medical Mutual members. HR|Experts is a benefit of membership in Medical Mutual, provided at no additional cost.

Dee has been an HR professional and consultant for more than 30 years, with business experience in both the private and public sectors. She spent the last decade running her own HR consulting firm, Brown Human Resources Consulting. Over the course of her career, Dee has worked with small, mid-size, and large global companies, such as MCI, ReEnergy Holdings, Glaxo, CCME, and BASF.

Dee provides sound advice and guidance through email, phone calls, and live chat. She monitors trends and current events and provides resource guides, compliance e-alerts, quarterly newsletters, and monthly webinars to provide practical advice on HR topics related to the business of running a medical practice. She is based in Raleigh but serves all Medical Mutual members.

Registration

This webinar is complimentary for NCMGMA members and $50 for non-members. Space is limited so make sure to register early! After you register, you will receive an emailed confirmation with webinar and phone-in instructions.

Continuing education credit may be granted through your professional organization (MGMA, PAHCOM, AHIMA, etc.). Please self-submit for these organizations.

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Questions

For questions or more information please contact the NCMGMA offices at info@ncmgm.org.