Wednesday, December 27, 2017

Advance Notice of Methodological Changes for Calendar Year (CY) 2019 for the Medicare Advantage (MA) CMS-HCC Risk Adjustment Model

The Centers for Medicare & Medicaid Services (CMS) released Part I of the 2019 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part D Payment Policies (the Advance Notice), on December 27, 2017, which contains key information about proposed updates to the Part C Risk Adjustment Model and the use of encounter data.

The following HCC Categories were proposed:
  1. Drug Abuse, Uncomplicated, Except Cannabis (HCC 56)
  2. Reactive and Unspecified Psychosis (HCC 58 - the current HCC 58 will be renumbered as HCC 59)
  3. Personality Disorders (HCC 60)
  4. CKD Moderate, Stage 3 (HCC 138)

CMS also proposed the following changes to the CMS-HCC Risk Adjustment model

  1. Add selected drug and alcohol “poisoning” (overdose) codes to existing “Drug/Alcohol Dependence,” to create “Drug/Alcohol Dependence, or Abuse/Use with Complications” (HCC 55). 
  2. Add new factors to the six community and single long term institutional (LTI) segments that take into account a beneficiary’s number of conditions that are in the payment model.

Part II was released on February 1, 2018

Thursday, December 21, 2017

Give the Gift of Knowledge this Holiday Season!

    Register your team today - Orlando is SOLD OUT!

   Join Us for a Day of Risk Adjustment! 

  • Review the different risk adjustment models and their impact on medical practice management. 
  • Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims?
  • Take a deep dive into HCC Coding and clinical documentation. Review real examples to see what validates, what doesn’t, and why. Tips for engaging physicians.
  • Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments.  

     Each Attendee Will Receive:     ($130+ value)

  • Color Presentation
  • Clinical Documentation and Coding Guide
  • HCC Quick Coder
  • Laminated Coding and Documentation Tools

     Who Should Attend: 
  • Medical Coders and Billers
  • Providers, Managers and Frontline Staff
  • CDI Specialists
  • Executive Leaders
  • ACO, MSO and IPA Teams
  • Rural Health Centers
  • Health Alliance Members
  • Medicare, Medicaid and Commercial Plans

      Thursday January 25th 2018
      10:00 AM - 4:00 PM

        Symphony Presentation Center 
        2875 S Ocean Blvd, Suite 200, Palm Beach, FL 33480

      Thursday, April 5th, 2018
      10:00 AM - 4:00 PM
        Hilton Garden Inn Tampa / Riverview
        4328 Garden Vista Dr., Riverview, FL 33578


    View additional details and download the complete agenda here


Sunday, November 5, 2017

Internists encouraged by payment rules from CMS, note key areas of concern

The American College of Physicians (ACP), expressed support for some of the provisions included in the final rules for the Medicare Physician Fee Schedule and the Quality Payment Program (QPP) for 2018, and noted some areas of concern in the rules that were released by the Centers for Medicare and Medicaid Services (CMS) on Nov. 2. 
“As a practicing primary care internist, I am greatly encouraged that CMS is proposing improvements in the physician fee schedule to help me and my colleagues provide coordinated, patient-centered, high value and team-based care to our patients” said Susan Thompson Hingle, MD, MACP, chair, Board of Regents, ACP. “We look forward to providing CMS with detailed comments to support these improvements while recommending other changes to strengthen primary care.”

In the 2018 fee schedule, ACP called particular attention to improvements made in three areas:
  • Evaluation and Management (E/M) Documentation Guidelines Comment Solicitation: ACP appreciates that CMS is immediately focused on revision of the current E/M documentation guidelines in order to reduce unnecessary administrative burden. As the Agency moves forward with this process ACP will continue to provide input to CMS officials. 

  • Further Refinement of Care Management Services Codes: ACP applauds CMS for continuing to reduce the burdens associated with the care management services code set. The clarification of the CCM planning code (G0506), will allow for some or all of the care planning to be performed by the billing clinician on a subsequent day.

  • Appropriate Use Criteria for Advanced Diagnostic Imaging Services: ACP supports the additional 1-year delay in implementation of the Appropriate Use Criteria for advanced diagnostic imaging services until 2020 while physicians are still learning the evolving policies of the QPP and gaining increasing experience reporting for the program.

CMS also released the final rule for Year 2 of the Quality Payment Program, with an opportunity to provide comments on the rule to CMS by Jan. 1. Year 2 maintains many of the flexibilities from the first year of the QPP, to help physicians with the continued process of transitioning to the new payment incentive program established by the Medicare Access and CHIP Reauthorization Act of 2015.

“We will be looking at the QPP rule closely to identify positive improvements that CMS has already made and to make more detailed suggestions about changes that CMS can make to ease some of the regulatory burdens on physicians,” continued Dr. Hingle. Specifically, ACP is pleased that CMS made some positive improvements to the Quality Payment Program (QPP).

  • Extreme and Uncontrollable Circumstances: ACP strongly supports CMS’ new policy to allow clinicians who are impacted by extreme and uncontrollable circumstances to be provided relief from reporting requirements associated with QPP in 2017 and 2018. Physicians treating patients in areas impacted by the hurricanes this year will be able to focus their efforts on much needed patient care without worrying about complying with new reporting requirements under QPP.
  • MIPS Bonus for Complex Patients: ACP appreciates that CMS accepted our recommendation to increase the amount of bonus points available for treating medically complex patients. This increase will better adjust for the risk for those physicians treating more complex patients.

  • Small Practice Options: ACP thanks CMS for finalizing new policies to provide flexibilities for small practices in 2018 including the virtual groups option, small practice bonus, Advancing Care Information hardship exception, and increased low-volume threshold.

However, ACP has concerns about several of the provisions of the rule; in particular some of the provisions are inconsistent with recently announced CMS initiatives on “Patients Over Paperwork” and “Meaningful Measures.”

  • Complex Scoring: We are disappointed that Merit-Based Incentive Payment System (MIPS) scoring remains overly complex and lacks standardization across performance categories. The measures and activities should more directly align with the weight they have in the overall score. This should follow with the efforts of CMS’ new initiatives.

  • Cost Performance Category: CMS increased the weight of the Cost Performance Category for 2018 from zero percent, as proposed, to 10 percent in the final rule. Given that there are not yet adequate cost measures that have been developed, ACP opposes this increase and encourages CMS to reverse this decision.

  • Quality Data Threshold: ACP is discouraged that CMS chose to increase the data completeness threshold for quality reporting data from the proposed 50 percent of patients to 60 percent in the final rule. This adds unnecessary burden to practices at a time when CMS has acknowledged that measures need improvement and excessive burdens should be reduced.

  • Low-volume Threshold Opt-in: While we appreciate that CMS finalized an increase in the low-volume threshold to exclude those with less than or equal to $90,000 in Part B charges or 200 or fewer Part B patients from MIPS, ACP strongly encourages CMS to allow clinicians below the threshold to have the opportunity to opt-in to participate. If a practice believes that they will be able to participate successfully, they should have that option.

“We were heartened to see the announcement from CMS this week of their new initiatives designed to ease unnecessary administrative burdens on physicians; Patients Over Paperwork and Meaningful Measures,” concluded Dr. Hingle. “In light of the recent announcement we are encouraged that CMS will follow through and address our concerns.”

Read more from the ACP: American College of Physicians

Additional Links from CMS

The Physician Fee Schedule final rule (CMS-1676-F) can be downloaded from the Federal Register at:

For a fact sheet on the Physician Fee Schedule final rule, please visit:

The Quality Payment Program final rule with comment period (CMS-5522-FC and CMS-5522-IFC) can be downloaded from the Federal Register at:

For a fact sheet on the Quality Payment Program final rule with comment period, please visit:

Tuesday, October 31, 2017

ACOs Reduced Direct Medicare Spending by $836 Million in 2016


Image result for Accountable care

CMS Results Demonstrate Promise of Alternative Delivery and Payment Methods for Improving Care and Reducing Costs

Accountable Care Organizations (ACOs) reduced gross Medicare spending by $836 million in 2016, returning $70.6 million in net savings to the Medicare Trust Fund according to data on four federal ACO programs quietly released this month by the Centers for Medicare & Medicaid Services

“These results demonstrate the promise of new models of care delivery and financing for improving patient outcomes and reducing spending,” said David Lansky, chair of the Health Care Transformation Task Force, an industry consortium that brings together patients, payers, providers and purchasers who share a commitment to accelerate the pace of delivery system transformation. “This provides further evidence that we need more, not less, public and private sector investigation of alternatives to traditional fee-for-service medicine.”

The four programs and their reported results were:

  • The Medicare Shared Savings Program (MSSP). Participants in Medicare’s largest ACO program saved a total of $652 million. While CMS paid more in shared savings than it saw in net returns, 56 percent of MSSP participants reduced their expenditures, and 31 percent reduced expenditures enough to earn shared savings. MSSP has three different tracks that allow ACOs to select an arrangement that makes the most sense for their organization. Track 1, which offers upside-only financial risk, and Track 2 and 3, which both incorporate upside/downside risk and count as Advanced APMs under the Quality Payment Program (authorized by MACRA).

  • The Next Generation ACO Model (Next Gen). In the first year of the program, Next Generation ACOs saved $48M overall, with a net savings to Medicare of $63M. Eleven of 18 ACOs saved enough to earn a shared savings payment. The Next Gen model offers providers greater opportunities for shared savings in exchange for taking on greater risk. The model sets predictable financial targets, enables providers and beneficiaries greater opportunities to coordinate care, and aims to attain the highest quality standards of care.

  • The Pioneer Accountable Care Organization (ACO) Model. In the fifth and final year of the program, all 8 Pioneer ACOs produced gross savings of $61M, with 6 of 8 ACOs reducing spending enough to earn a shared saving payment. The net savings to CMS was $23M. One of the earliest Medicare ACO models, the Pioneer program was designed for health care organizations and providers that were already experienced in coordinating care for patients across care settings.

  • The Comprehensive ESRD Care (CEC) Model. The CEC model is designed to evaluate new ways to improve care for Medicare beneficiaries with End-Stage Renal Disease (ESRD), which showed promising results for future specialty ACOs with all 13 participants producing a total of $75M in savings. The net savings to CMS was $23.9M, as all but one of the 13 CEC participants earned shared savings.

Total savings are calculated by CMS based on what Medicare would have expected to spend on the beneficiaries covered by the ACO in traditional fee-for-service Medicare.  Net savings reflect the total minus shared savings payments to the ACOs for meeting spending targets, and accounting for repayments from ACOs for shared losses.

Barbara Walters, DO, Executive Vice President and Chief Population Health Officer of Task Force member Trinity Health, said, “It is important to note the performance results demonstrate that – on average – both savings and quality are improved the longer an ACO participates in the program. As organizations move down the learning curve and benefit from the substantial investments in delivery transformation, we see our performance continue to improve.”

In a recent report, the HHS Office of the Inspector General found that ACOs participating in the program longer were more likely to reduce spending, and by greater amounts. This is to be expected, as population health management is a long-term strategy. An analysis of CMS’s PY 2016 Quality and Finance Results shows that MSSP ACOs reporting in 2015 and 2016 improved average performance by over 10 percent on five key performance measures.

Task Force member organization Atrius Health, selected as one of 32 original Pioneer ACOs, showed steady improvement in savings to Medicare in each of its five years participating in the Pioneer ACO Model. For the over 25,000 Medicare beneficiaries served by Atrius Health clinicians participating in the Pioneer ACO Model in 2016, Atrius Health saved Medicare $10.4 million compared to its target, returning $6.8 million in savings to the organization. It also achieved more than a 95 percent quality score from CMS.

 “By knowing our patients well, we are able to provide the right coordinated care that keeps them healthy in the comfort of their homes,” said Richard Lopez, MD, Senior Vice President of Population Health at Atrius Health. “As we continuously strive to innovate care delivery to improve quality, access and convenience, we are delighted to see these efforts reflected in a quality score of over 95 percent. We are proud to help our patients lead happier, healthier lives and look forward to continuing this work.”

Atrius Health showed steady improvement in savings to Medicare in each of its five years participating in the Pioneer ACO Model. Offering evidence that ACOs also are reinvesting their savings to produce continuous improvement, Atrius has applied its savings to investments in care coordination, training, data analytics, information technology, and other resources serving its Medicare beneficiaries and other patients.

Cleveland Clinic ACO’s $42.2 million savings in 2016 represents a 24.5 percent increase from 2015. The ACO will receive $19.9 million back in shared savings, a 19.8 percent increase over 2015. The number of shared beneficiaries increased by more than 6,500 and the health system’s quality score was 96.3 percent.

 “The ACO helps to unify our enterprise by bringing together primary care, specialty care and independent participating physicians,” said James Gutierrez, M.D., president and medical director of Cleveland Clinic ACO. “The care model is further enabled to manage our patient populations across the whole continuum of care. This validates the work we have done in recent years to provide outstanding quality of care while being better stewards of healthcare resources.”
Task Force member Aledade, Inc. partners with primary care physicians to operate ACOs across 15 states and in partnership with more than 240,000 patients in more than 200 practices. During the 2016 performance period, Aledade’s ACOs – comprising 142 practices with over 80,000 patients in 11 states – saved Medicare more than $9.3 million.

“In every Aledade ACO – not just those that earned shared savings—avoidable emergency room visits dropped, readmissions plummeted, preventable hospitalizations from congestive heart failure, pneumonia, and pulmonary disease fell,” said Farzad Mostashari, MD, Founder & CEO at Aledade, Inc. “Collectively, our ACOs prevented more than 1,500 hospitalizations. Aledade ACO practices are giving their patients better care – and we hear it in their stories, and we see it in the data.”
Arizona Care Network, a physician-led Track 1 ACO co-administered by Task Force member Dignity Health, received an 89.9 percent score for quality of patient care and reduced the cost of Medicare spending by more than $5.78 million.

 “Our care coordination helps ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services. This level of coordination is highly effective and reduces costs,” noted David Hanekom, MD, ACN’s chief executive officer.

In addition to those mentioned above, the following Task Force member organizations successfully lowered Medicare expenditures through the Medicare Shared Savings Program:
  • Ascension
    • MissionPoint Health Partners: $1.64M
    • MissionPoint Evansville, LLC: $3.26M

  • Dignity Health
    • Arizona Care Network: $5.78M

  • Greenville Health System
    • MyHealth First Network, LLC: $21.7M

  • Trinity Health
    • Trinity Health Michigan d/b/a St. Mary Mercy Hospital: $11.4M

Task Force member Fresenius Medical Care successfully lowered Medicare expenditures by $43.3M and earned $29.7M in shared savings across six ACOs participating in the Comprehensive ESRD program:
  • ·         Fresenius Seamless Care of Philadelphia: $6.9M 
  • ·         Fresenius Seamless Care of San Diego: $10.3M
  • ·         Fresenius Seamless Care of Chicago: $11.2M
  • ·         Fresenius Seamless Care of Columbia: $4.4M
  • ·         Fresenius Seamless Care of Dallas: $8.2M
  • ·         Fresenius Seamless Care of Charlotte: $2.4M

About the Health Care Transformation Task Force
The Health Care Transformation Task Force is an industry consortium that brings together patients, payers, providers and purchasers to align private and public sector efforts to clear the way for a sweeping transformation of the U.S. health care system. Our members are committed to rapid, measurable change, both for ourselves and our country. Our members aspire to having 75 percent of our respective businesses operating under value-based payment arrangements by 2020. To learn more, visit

Read the full release here.

Saturday, October 21, 2017

Registration is Now Open for 2018 Workshops


Join Us for a Day of Risk Adjustment

·         Review the different risk adjustment models and their impact on medical practice management.

·         Discuss the impact of shifting from RAPS to EDS. What does this mean for office based claims?

·         Take a deep dive into HCC Coding and Documentation. Review real examples to see what validates, what doesn’t, and why. Tips for engaging physicians.

·         Learn how to leverage frontline staff to be successful in the world of risk adjustment and value based payments. 

Each Attendee Will Receive:     ($130+ value)

ü  Color Presentation

ü  Clinical Documentation and Coding Guide

ü  HCC Quick Coder

ü  Laminated Coding and Documentation Tools

Who Should Attend:

       Medical Coders and Billers

       Providers, Managers and Frontline Staff

       CDI Specialists

       Executive Leaders

       ACO, MSO and IPA Teams

       Rural Health Centers

       Health Alliance Members

       Medicare, Medicaid and Commercial Plans

Visit ERM to Register today!


Monday, September 18, 2017

ICD-10 to HCC Mappings for Medicare Risk Adjustment

CMS HCC and Rx HCC Mappings

(Complete ICD-10 Mappings for 2017 and 2018)

This is a must have for every coder and clinician on your team!

250 Pages (8 ½ x 11)

Includes a complete list of ICD-10 codes included in the CMS-HCC and Rx-HCC Models for FY 2017 and FY 2018.

That is 10,761 ICD-10 codes…
  • Have you ever wondered if a specific ICD-10 code had a "weight" or risk adjustment factor?
  • Have you wondered what other ICD-10 codes are risk adjusted?
If so, then you will love this book!

If your organization is looking to improve, this tool will help ensure accurate risk scores for your population.

Order one today!

Thursday, August 24, 2017

What is the impact on utilization and outcomes for adults with obstructive airway disease?

Contributions of COPD, asthma, and ten comorbid conditions to health care utilization and patient-centered outcomes among US adults with obstructive airway disease.

Background: Among persons with obstructive airway disease, the relative contributions of chronic obstructive pulmonary disease (COPD), asthma, and common comorbid conditions to health care utilization and patient-centered outcomes (PCOs) have not been previously reported.

Methods: We followed a total of 3,486 persons aged ≥40 years with COPD, asthma, or both at baseline, from the Medical Expenditure Panel Survey (MEPS) cohorts enrolled annually from 2008 through 2012 for 1 year. MEPS is a prospective observational study of US households recording self-reported COPD, asthma, and ten medical conditions: angina, arthritis, cancer, coronary heart disease, cognitive impairment, diabetes, hypertension, lung cancer, myocardial infarction, and stroke/transient ischemic attack. We studied the separate contributions of these conditions to health care utilization (all-cause and respiratory disease hospitalization, any emergency department [ED] visit, and six or more outpatient visits) and PCOs (seven or more days spent in bed due to illness, incident loss of mobility, and incident decline in self-perceived health).

Results: COPD made the largest contributions to all-cause and respiratory disease hospitalization and ED visits, while arthritis made the largest contribution to outpatient health care. Arthritis and COPD, respectively, made the greatest contributions to the PCOs.

Conclusion: COPD made the largest and second largest contributions to health care utilization and PCOs among US adults with obstructive airway disease. The twelve medical conditions collectively accounted for between 52% and 61% of the health care utilization outcomes and between 53% and 68% of the PCOs. Cognitive impairment, diabetes, hypertension, and stroke also made significant contributions.

Authors Murphy TE, McAvay GJ, Allore HG, Stamm JA, Simonelli PF
Received 19 April 2017
Accepted for publication 1 July 2017
Published 23 August 2017 Volume 2017:12 Pages 2515—2522

Read More

Humana banks on big data to boost patient health — and profits

From fewer heart attacks to stronger bones and longer functioning brains, insurer Humana hopes that a data analysis partnership with a California biotech company will help improve people’s health, lower the cost of care and increase profits.

Humana’s collaboration with Amgen will focus on the enormous amounts of health claims data that Humana collects on its roughly 9 million customers. While details about the research are still being finalized, the insurer hopes to analyze the data to detect health problems earlier and intervene before they become more serious — and costly to the patient, the hospital and the insurer.

“We believe that you lower costs by improving patient outcomes,” said Laura Happe, the company’s chief pharmacy officer.

The companies also plan to combine real-world evidence with data from wearable tech and apps or even Bluetooth-enabled drug delivery devices to target serious conditions such as cardiovascular disease, osteoporosis, neurologic disorders, inflammatory diseases and cancer.

While Humana and Amgen have worked together before, the new partnership marks the first research collaboration.

“Overall, there is a trend towards using data and learning from data to optimize care,” Happe said.
Businesses and governments hope the ability to analyze big sets of health care data will allow them to improve care and reduce waste, fraud and costs — but the sheer amount of data that is available and being collected also presents significant challenges.

In a recent report by Stanford Medicine, Dr. Lloyd Minor, dean of the Stanford School of Medicine, said the health care industry’s increasing connectivity and complexity “poses both an opportunity and a challenge.”

“By leveraging big data, we can create a vision of health care that is more preventive, predictive and precise,” he said.

California-based data analytics company MapR recently said that data analysis can help health care providers with early detection of serious health conditions, such as congestive heart failure.
CHF “accounts for the most health care spending. The earlier it is diagnosed, the better it can be treated, avoiding expensive complications, but early manifestations can be easily missed by physicians,” the company said. “A machine learning example from Georgia Tech demonstrated that machine learning algorithms could look at many more factors in patients’ charts than doctors, and by adding additional features, there was a substantial increase in the ability of the model to distinguish people who have CHF from people who don’t.”

Happe said that when CHF is undetected or uncontrolled, patients can end up with fluid retention, which can become life-threatening.

Humana and Amgen will sift through data to figure out how to detect the condition earlier and prevent bad outcomes. Healthier patients will mean fewer doctor and hospital visits, which will mean lower costs to health care providers and payers, including the patient and Humana.

Amgen, based in Thousand Oaks, Calif., conducts research and develops therapies for illnesses, primarily in six areas: cardiovascular disease, oncology, bone health, neuroscience, nephrology and inflammation. Its products include Enbrel, which treats arthritis; Neulasta, which stimulates white blood cell growth and is used often for chemotherapy patients; and Sensipar, which prevents bone disease. The company employs about 20,000 in 100 countries and last year generated revenue of about $23 billion.

Read More

Friday, August 18, 2017

While waiting for a state health-records exchange, medical society launches one

Frustrated that after 10 years of effort the state of Connecticut has yet to launch a functioning health information exchange (HIE) allowing physicians, hospitals and other health care providers to share patient medical records, the Connecticut Medical Society is offering one of its own.
Available to all clinicians in the state and called CTHealthLink, it is based on a system currently used in Kansas.

Part of the motivation was the threat that clinicians would miss out on Medicare and Medicaid incentives given for participating in a health information exchange and would instead be subject to penalties, said Matthew Katz, executive vice president and chief executive officer of the Connecticut State Medical Society (CSMS).

“The Connecticut medical society decided to go ahead and try to do it because our members are missing out on the opportunity for financial benefits,” and many have to pay penalties for not participating, Katz said.

For the 2017-18 federal fiscal year, only 800 of the eligible medical professionals and none of the eligible hospitals are expected to receive Medicaid incentive payments, according to planning documents for the state health information exchange.

In 2007, Connecticut first attempted to create a health information exchange (HIE) specifically for Medicaid with a $5 million grant, before most physicians had switched to electronic health records. It was cutting edge, but the state’s medical professionals weren’t ready for it, said Dr. Thomas Agresta, a professor and director of medical informatics in family medicine at UConn Health, who has been involved in HIE efforts since the beginning.

Between 2007 and 2016 the state tried twice more to design and implement an HIE for all providers. Neither attempt produced a functioning system despite extensive planning and $18 million in funding.

“Everybody was hyped up and interested in the potential for health, but not aware of changes that needed to occur,” Agresta said. “Most people were a little naïve in terms of complexity.”

Before deciding to join CTHealthLink, all providers — hospital systems, like Yale New Haven Health, private practices and physician groups — are facing this decision: Is it worthwhile to sign on with CTHealthLink or should they wait for a fourth attempt at a state HIE system to pan out?
A health information exchange allows any participating clinician to see the procedures, tests, lab results and medical histories ordered for their patients by other participating clinicians, preventing repetition that wastes time and money.

CTHealthLink also provides a portal that allows patients to see their own records, something providers have expressed interest in having at state-held planning discussions for attempt four.
Yale New Haven Health says it will need to make sure the CTHealthLink system would truly benefit patients and be cost-effective before signing up, said Lisa Stump, chief information officer for the hospital system.

“There are a few questions that need to be answered before I’m confident in submitting our data,” Stump said. “Is there good structure around opting in and out, so that patients get a choice” of whether to have their medical information shared?

Stump said Yale New Haven Health also would want to be sure CTHealthLink would improve care enough to make a subscription worth the cost. When the state system begins operating all hospitals will be required to join, whether they are part of CTHealthLink or not.

CTHealthLink will cost between $50 and $120 per physician per month, depending on when a facility joins, whether the physicians are CSMS members, and whether the provider is a very large practice or a hospital system, Katz said. There is also a set-up cost based on the internal records system a practice or hospital uses.

“If we do the math, even at the lowest rate of $50, for a medical practice of 1,200 physicians, it is $720,000 per year…and at $120 it’s $1.7 million,” Stump said.

For an organization the size of Yale New Haven Health, which includes five hospitals and 3,500 to 4,000 physicians, it would be two or three times more.

“The benefit of any HIE is how robust the data are in the HIE. We are a large health exchange and have good sharing within our system” and with the Veterans Administration’s Healtheway system, Stump said. “Is that cost (of CTHealthLink) going to bring us a value more than the means we already have.”
And more than the state system will in the coming years.

Incentives for participation in an HIE are available to all physicians and many other clinicians through the Medicare quality payment program (MIPS). Eligible clinicians who don’t participate in MIPS by the end of 2017 would see a 4 percent reduction in their Medicare reimbursement in 2019.
“Even though it is starting late (in the year), it is more than enough time to get the federal benefits,” Katz said.

CTHealthLink expected to sign contracts in July and to begin sharing data between medical practices beginning in August and September. But as of August 15, none of the contracts had been finalized.
According to CSMS, the process has been delayed because determining the set-up cost each hospital or practice’s electronic health record vendor is going to charge is taking longer than expected.

The goal is to include at least 80 percent of the state’s 9,600 physicians in fewer than five years, Katz said.

Connecticut Hospital Association spokeswoman Michelle Sharp said the association “is pleased that CSMS is seeking a solution for its physician practice members who may need additional support to elevate their health IT infrastructure.”

CTHealthLink is set up like a central data warehouse that allows doctors and patients to view all their patients’ health records in one place, Katz said, with only a three-minute delay from the time an electronic health record is posted.

Katz said the model is much less expensive than others in use, and wouldn’t require any state or federal funding to operate. However, the state’s health information technology officer, Allan Hackney, said there are cheaper ways to do it.

“Whenever you bring data to the center, it is automatically a more expensive undertaking, because you have to curate the data, store it, secure it, back it up, you have to have disaster recovery, all those things layered across each other,” Hackney said.

Hackney’s position was created in 2016 after a third state attempt to construct an HIE by the Department of Social Services ended without a product and the responsibility was transferred to Hackney and an advisory council.

Despite the previous work, the fourth attempt began by working to understand what providers really needed, with $10 million in combined federal and state money.

The state knew from experience that if it were going to succeed this time, it needed the input of individuals who would be using the system as well as technology that wouldn’t become outdated before the project was complete.

At the same time, DSS requested more than $14 million in grant money — 90 percent percent from the federal government and 10 percent from the state — to implement a Medicaid-specific health information system that eventually would tie into the larger state system, if both are successful. 
According to the office of the lieutenant governor, DSS needs to construct its own system as quickly as possible because of specific Medicaid reporting requirements.

But efforts to implement a strategy to make reporting for Medicaid easier have always been a central part of the state HIE efforts, whether they were led by DSS or not, and that is no different with the fourth attempt, planning documents show. But it is not clear when the universal statewide system would implement the needed Medicaid features.

The system is scheduled to be functioning by the beginning of 2018, but various features and access to different kinds of data will be added incrementally, based on priorities identified by the system’s users.

Unlike the CTHealthLink model, the state is working on a system that allows data to be pulled directly from its source instead of being gathered all in one location, a lower-cost and lower-risk option, Hackney said.

The state system will be built to connect all clinicians, from physicians to pharmacists to behavioral health workers, even if they are participating in CTHealthLink or any other, smaller exchanges already, Hackney said.

Eventually, the system will allow all medical information, including veterans’ information from the Department of Defense as well as prescriptions and immunization records, to be accessed by all participating medical professionals.

The order of the first few features to be created will be decided by September, according to the office of the lieutenant governor.

Despite the potential for a more user-friendly product, according to Hackney, this will take time, and Dr. Jeff Gordon, CSMS president, who works in a private practice owned by Hartford Healthcare, said the state already has lost the faith of many health professionals because of its many failed attempts. 

“CSMS have a model that they’re using that’s been proven to be financially sustainable,” Gordon said. “Hospitals and physician groups have a good relationship with us; they don’t have a good relationship with the state.”

Despite the previous failures, Agresta said he has more faith in the state’s latest attempt because the technology is finally ready for it.

“Unlike the first few attempts, when we tried to do this in the past, and very few people understood what exchanges could do, there is more understanding of data,” Agresta said. “During the 2010-2012 time frame, we were still trying to get physicians to adopt EHRs. Basically we were asking them to learn to crawl, to walk and to run all at the same time.”

Although CTHealthLink hopes the Kansas model will work just as well in Connecticut, Hackney is not as confident.

The difference in Connecticut, Hackney said, is that healthcare providers already have invested millions in their own internal systems, and the major providers of those systems have connections to allow record exchanges between clinicians that use the same vendor. Hartford Healthcare, Yale New Haven and Trinity New England, parent of St. Francis and St. Mary’s hospitals, all use the same vendor, Epic, and UConn Health is in the process of switching over to it, Agresta said.

Other hospitals, physician groups, behavioral health facilities and small practices have yet to be linked in such a way. They are still waiting for a system like CTHealthLink or the state system to connect them with their patients’ other providers.

Hackney said he doesn’t want Connecticut to fall into the same trap that many other states have, where systems are developed and then not adopted by many providers, or the systems become obsolete after only a short time as technology progresses.

“My view on this is that the only way state efforts will win is if it is collaborative and focused on value,” Hackney said. “If we focus on value, you know you’re going to hit people with a difference in the way they deliver health care.”