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The U.S. practices of medicine and surgery aren't as cost-effective as other countries. We suffer intolerable costs (poor value) and huge variation in our practices, the way we fail to coordinate care and communicate, health care reform is vital.  

Caveat: The means to a desired end –
truly integrated electronic medical record with acuity or case-mix assessment, point-of-service alerts and patient tracking (process and outcome) is necessary.

Why are we not doing the right thing?

Is it because we are rushed?  Is our practice affected by the litigious nature of our society?  it easier to test or prescribe then counsel our patients?  Are we feeling the crunch of marketplace  pressures?  Regardless, don't you find it curious that healthcare insurance reform efforts are myopic in terms of what is required to improve the quality and coordination of health care and slow the growth of spending?


Two widely discussed models for delivery-system reform are in the wings to help solve some of these problems:

  1. The 'patient-centered medical home' (PCMH) gives weight to the primary care foundation of the health care system.
  2. The 'accountable care organization' (ACO) stresses provider accountability and incentive alignment across the continuum of care.  It is noteworthy, however, that the "ACO model does not explicitly require support for primary care."  That is problematic because it will perpetuate the existing disparity of earnings— i.e., hospitals and specialists instead of primary care physicians (PCPs) garner a disproportionate share of earnings and savings.  Surely this economic driver will further contribute to a surfeit of specialists and a dearth of primary care doctors.

I recommend: "The Future of US Healthcare Part II: Care Coordination - the key to sustainable healthcare" by Barry Bittman. (It is an excellent video.)

"ACO or PCMH: Making a crucial decision for your practice." in Medical Economics, posted Feb. 4, 2015 by Jeffrey Bendix re: how to evaluate some of  the benefits and risks of these care delivery and/or payment approaches.

In terms of care coordination, there must be scalability and reducing process variability over time, across setting and providers, is critical. Furthermore, in terms of key Performance Indicators (KPI) reporting is part and parcel, vital to communication and continuous process (and quality) improvement.

Randy Williams, MD (CEO, Pharos Innovations). "How to scale care coordination successfully: integrate right out of the gates."

Note, however:

  1. Reducing expenditures is very difficult;
  2. There's not much 'low hanging fruit";
  3. This is not for managerial novices;
  4. Target small populations (panels) for compelling improvements;
  5. The "downside is intimidating."

But, according to 3M clients who manage accountable care organizations there are organizational benefits from participating in the program:

  • Increased focus on efficiency and appropriate site of service
  • Greater participation of primary care physicians for preventive care
  • Greater investment in patient-centered care and patient engagement
  • Expansion of care coordination from hospital-based discharge planning and transitions of care to include post-acute and community-based services"

Daynes K. "One more year and five lessons learned from the MSSP ACOs." Posted 3M Inside Angle Blog 9/9/16


ON THE ACO MODEL OF CARE AND PRACTICE MANAGEMENT

"You [Chief Mark McClellan] were part of a debate in the Wall Street Journal over the promise of ACOs. What is the source of the disagreement?"

"I do not think there is any disagreement about the need for disruptive innovation in health care. The question is how is to make that happen as quickly as possible. One of the reasons we have not seen more disruptive innovation is because our financing is not aligned. In most other industries you are rewarded when you develop a product that costs less or does a better job. But under traditional financing and regulatory systems in health care you are often punished. Strategies like intervening early and targeted use of interventions lead to less revenue. The promise of ACOs is making disruptive innovation pay off. ACOs align valuable innovation and health care financing systems so it is no longer the case that if you come up with an innovation in care that reduces costs while maintaining or improving quality you lose money. There are certainly other ways to align incentives for innovation and improvement, such as value-based insurance design and steps to make regulations focused more on results and value rather than on structural and process issues."

Hayward, Matthew John. "10 Questions with Former FDA and CMS Chief Mark McClellan." Healthcare JournalPosted on Nov. 8, 2014


Challenges To Implementation

 Health Care Delivery in a PCMH

An exact definition of a PCMH is evolving as is its model grows and changes over time. Nevertheless, the Joint Principles of the Patient-Centered Medical Home, endorsed by the four main primary care societies, outlines the general characteristics of a PCMH as follows:

  • Personal physician care
  • Physician-directed medical practice
  • Whole person orientation
  • Coordinated and/or integrated care
  • High quality and safety in care
  • Enhanced access to care
  • Payment that supports enhanced services

The ultimate goal of its physician-led care team in a PCMH is coordinated, safe, evidence-based medicine and high quality care, delivered consistently and reliably (i.e., accessibility is good) across a consort of providers; this is all with a decidedly person-centered focus.

Are PCMHs better than traditional care models from the perspective of patients and/or the health system at-large? The preponderance of evidence suggests "Yes" to both questions, although more study is necessary to be conclusive on that.

Patel K and Nadel J. "The Future of Patient Centered Medical Homes and Accountable Care" Brookings.edu, January 16, 2014

How Are Practitioners Judged?

Implementing patient-centered approaches such as motivational interviewing is a whole science unto itself. Clearly we practitioners suffer from having time pressures, inadequate 'sales' and patient education skills, etc. "Yet it behooves physicians to recognize that their direct effect on patient outcomes is usually limited and adjust their interactions with patients accordingly. The more effective approach is to adopt a patient-centered and collaborative style that can meaningfully help patients determine how they can best manage the myriad influences on their health."

Although .... practitioners "cannot control what patients do, .... to ignore or ineffectively address influences on patient behavior is to disregard what ultimately will determine patient outcomes and, accordingly, ratings of physician effectiveness."

Hershberger PJ, Bricker DA. " Who Determines Physician Effectiveness?JAMA. Published online October 13, 2014. doi:10.1001/jama.2014.13304

Also, it is imperative to note that the PCMH model will not succeed without payment reform and incentive alignment.  In addition, please consider two other issues that lie beyond the direct control of primary care in these and other settings:

  1. Although the model calls for primary care practices to take responsibility for providing, coordinating, and integrating care across the health care continuum, it provides no direct incentives to other providers to work collaboratively with primary care providers in achieving these goals and optimizing health outcomes.  In fact, the income disparity between primary and specialty care gives us a surfeit of specialists and a dearth of primary care.  The undersupply of primary care is already palpable and only getting worse. (Think, for instance, how it might affect a medical students' future plans.)
  2. Increasing the investment in primary care can result in savings in several areas–reducing inappropriate use of tests and procedures, emergency department care, and hospitalizations for conditions that could be treated in an out patient settings. However, most primary care practices do not have financial arrangements that allow them to share in such savings. Also, the "effect on total costs of implementing the PCMH model alone could be limited, because primary care physicians have little direct leverage over other providers in the care continuum, and under the largely fee-for-service payment system it is unlikely that other providers will respond to reductions in the number of referrals or admissions by allowing their incomes to fall."

Rittenhouse DR, Shortell SM, Fisher ES. "Primary Care and Accountable Care—Two Essential Elements of Delivery-System Reform." NEJM • October 28, 2009

"Patient costs have risen as doctors have become more entrepreneurial, protecting their turf through lobbying by medical societies and increasing revenues by offering new and more lucrative procedures."

Rosenthal, E.. "Patients’ Costs Skyrocket; Specialists’ Incomes Soar." NY Times, January 19, 2014,   [More of Elizabeth's NY TImes writngs]

Rebuttal: the article, above by Rosenthal is critical of over-testing, over-doing and over-charging; rightly so (to an extent).  For instance, she speaks to the Mohs technique–the stepwise cutting out and then microscopic examination of wound margins, hopefully verifying they are cleaned of abnormal tissue. A proven procedure, it is more effective than simple excision; undoubtedly, it has saved lives while preserving as much healthy tissue as possible for reconstruction. [See the American Academy of Dermatology's 2012 Guidelines that categorize which lesions are appropriate for Mohs— certain types of tumors; certain types of patients, growths that are very deep, in sensitive areas, on the face or ear, or are very large.]


What needs to be done can be itemized and prioritized. Please see: "The Comprehensive Primary Care Initiative and Clinically Integrated Networks," below.


The "Medicare Access and CHIP* Reauthorization Act" of 2015–MACRA

MACRA is intended to push healthcare delivery to a more coordinated and accountable level as it transforms traditional fee-for-service to fast-speed, risk-bearing payment methods that include, but are not limited to (physicians can pick one of two routes that will determine how they will be paid) a merit-based incentive payment system (MIPS) or an advanced alternative payment model (APM), under the law.

Note that these objectives are all reminiscent of "Managed Care" with the critical difference that they do not explicitly speak to efficiency, cost-effectiveness or affordability (not yet, that is). Moreover, it appears that, at least initially, "value" is talked about but "cost" is being measured.

Regardless, "Clinicians will need to consider carefully assessing their current performance in four categories: quality, resource use, clinical performance improvement activities and advancing care information" [i.e., health information technology (HIT) use....Note the "change in terminology from meaningful use of certified electronic health record technology."]

        * The Children’s Health Insurance Program (CHIP) 

CMS releases comprehensive MACRA rules: New law poised to shape payment and delivery reform in the future” by Anne Phelps and Daniel Esquibel, Deloitte & Touche LLP; posted by them, April 28, 2016.

See, also "MACRA for Busy Docs: 12 Things to Know," especially ref. 7. "Outcome Reporting Will Now Be Required."

MACRA is slated to begin in earnest January, 2017. However, "Until a September 9 reprieve that was recently announced, measurements that would be used for the MACRA program would start on January 1, 2017, and the first payment adjustments would have taken place in 2019. However, CMS has announced that it will give physicians four MACRA options for 2017 that would let them choose how quickly they'd implement MACRA, and each option would avoid a penalty in 2019.... 'Consider what performance category you need to work on to improve it, so you can have a chance to improve performance during the year.'"

Note that you will be rated[1] by various agencies and payers.  So be careful.  Do not ignore these incentive programs unless you have a very low volume of the applicable patients.  And, know that incentives will be funded by the government even as some practices are being penalized for underperforming or poor documentation.

1. Hanauer D, Jheng K, Singer D, Gebremariam A, Davis MM. Public awareness, perception, and use of online physician rating sites. JAMA. 2014;311:734-735. Abstract [Medscape.com/]

For further information, see Page, Leigh, "MIPS & Your Earning Power." Sept. 2016; pp. 14-15. Medscape.com/business

It explains that MIPS is the "Merit-based Incentive Payment System" and it is a "new" reporting system that replaces:

  1. the "Physician Quality Reporting System.  Now called Quality Performance, it is worth 50% of one's total incentive score;  
  2. the Value-based Payment Modifier is replaced by Resource Use reporting, worth 10% of your score;  
  3. The Meaningful Use program for Electronic Health Records (EHRs) continues as 3B [jgk's numbering] as Advancing Care Information (ACI); it is worth 25% of one's score.  Also, a new category of reporting called Clinical  Practice Improvement, is added and it is worth 15% of one's score.

"Making sense of MACRA: A glossary of new Medicare terms" posted https://wire.ama-assn.org by Timothy M. Smith SR Staff Writer. AMA Wire

MACRA Can Ease a Physician’s Practice in Following Ways:

  • The clinicians do not require sending any report or data for this category.
  • The physicians were earlier eligible to avail benefits through meaningful use and VM; the bonus will now increase to 5% in 2020, 7% in 2021 and around 9% after that.
  • The top performers will be eligible to claim additional bonus which can exceed up to 10% by the end of 2019.
  • Practitioners can claim additional points for reporting the data to the concerned authority. Medical practitioners.
  • The physicians were able to receive penalties when not opting for PQRS reporting and other meaningful use measures, the physicians reporting under the MIPS can expect receiving penalties if their performance does not exceed up to the national benchmarks standards.

Note: [jgk] For this to work, a truly integrated electronic medical record with acuity or case-mix assessment, point-of-service alerts and patient tracking (process and outcome) is necessary.


There is no doubt Medicare Advantage plans have grown tremendously in popularity over the past decade. MA plans also have a proven track record for cost reduction and producing better outcomes for beneficiaries, which are two components of the Triple Aim. With that said, it is curious that CMS didn’t reward the portion of Medicare offering the most innovation and desired results. Perhaps future legislation will remedy this.

Cameron C., Mills, G. "Observations from the corner of Medicare Advantage and MACRA." 3M Inside Angle, Nov. 2, 2016


Related Discussion, LinkedIn

Right now, ACOs are too tall an order! The 'devil's in the details' and that means we need better data, using episodes of care,* sharing confidential data at the point of contact, acuity rating ('apples to apples' comparisons) data analysis, and realigned incentives. Failing that, it's just another day waiting for the promise of 'Managed Care.' Given paradigm paralysis and our tolerating insurance companies in their 'shell game, I am not sanguine about the new/old development–ACOs.

 df: all care over time, regardless of setting - like Patient-Centered Episodes of Care using CRGs [3M's contribution better information flow, data analysis and electronic health record according to their own Norbert Goldfield, MD and Jon Eisenhandler, PhD; private conversation 12/15/2014])

Virtually the same conclusions were reached in a more recent P&T Journal review as follows:

Per Mark McClellan, former the head of the FDA and the Centers for Medicare & Medicaid Services (CMS), ACOs must have the following three core principles:

1) "They must embrace and incorporate a 'Medical Home' concept, which means it is provider led with primary care as its base, and it is collectively accountable for quality and total costs across a continuum of care for a population of patients";

2) "Aligned incentives where payment is tied into quality improvements that favorably affect total expenditures";

3) Measurement and Management: "Reliable and progressively advanced performance measurement that support quality and that savings are achieved through better care."

Marcoux RM, Larrat EP, Vogenberg R. "Accountable Care Organizations; An Improvement Over HMOs? Pharmacy and Therapeutics (P&T) [Section, Health Care & Law) Nov. 2012(11):629-630 and 650.

See also, Deloitte Center for Health Solutions. Accountable Care Organizations and How Could They Improve Health Care Quality? Dec. 1, 2011 [Robert Wood Johnson Foundation http://www.rwjf.org]

However, I contend these principles or objectives are no different than the modus operandi of managed care's HMOs or other similar accountability (i.e., of quality, cost and access) models.



Coordinate, Communicate, Collaborate (CCC)–The Comprehensive Primary Care Initiative and Clinically Integrated Networks

The future direction of the health environment is here, finally, with the Affordable Care Act; marketplace solutions with a grand opportunity to coordinate care and improve communication (i.e., lend mutual support in the interest of being reimbursed more when care is more effective and efficient), it brings the words, “accountable care” to a new level.  As with any paradigm-shift, the transition, the preparedness that will be required of health care professionals and their business associates will be tricky at best.  For example, a fundamental, yet most exciting challenge for any managed care professional or transformative agent in these confusing times is creating and maintaining a clinically integrated network or CIN.

A CIN is today’s version of managed care.  It takes advantage of disruptive changes in payer contracting—ones that increase revenue potential by entering into shared saving contracts that, hopefully, provide upside opportunities with minimal or only short-term risks.

As a practitioner and former physician executive, I have long felt there was/is a dearth of communication accross and throughout our health care 'systems' and, clearly, this can be a major impediment to CINs or, using today's nomenclature, Accountable Care Organizations (ACO’s). Regardless of the structure where people fail to collaborate—a fully integrated CIN, a virtual group like an “HMO without walls,’ or an independent practice association (IPA), the practitioners—primary care and specialists must act in concert in what will inevitably become a relatively closed network that that now includes a new player, the hospital.  The point is, none of the parties in these arrangements can afford to be be so fiercely independent any longer.  Rather, they have a responsibility to coordinate care, lend mutual support and communicate in real time.

In the salad days of managed care, we called the CCC strategy, an indication of failure, the fractionalization of care or the organization was said to have a 'silo mentality.'  It should come as no surprise that such "failures" led to duplication, over-testing and just plain inefficiency, if not ineffectiveness. A great reference is captured in a slide: "expectations Out of Balance," in a Joint Commission Center for Transforming Healthcare talk, "Improving Transitions of Care: Hand-off Communications," "

  1. The expectation of the Receiver is to get the critical information needed in order to safely care for the patient.
  2. The expectation of the Sender is to be able to communicate the critical information to the Receiver in a timely manner.
  3. However, there is a disconnect between the critical information the Receiver actually receives versus the critical information the Receiver actually needs to care for the patient.
  4. Receivers experienced less successful hand-offs than Senders.*

*Statistically significant, P value = .001

Fortunately, we are now seeing information technology (IT) departments stepping up to the plate to improve the translation of data into information, protect its sharing, improve documentation and communication.  The goal has been and continues to produce an integrated care product with quality improvement and utilization management (QI/UM), i.e., ‘meaningful use’ as its cornerstone.

CCC Early Adaptors: Consider the Comprehensive Primary Care initiative (CPCI).  It is a program that now involves about 500 participating practices in the following geographic areas of the United States: Southwest Ohio/N. KY, New Jersey, Arkansas, Colorado, New York, Oregon, and Oklahoma.  These practices were selected because of demonstrated willingness to participate in such programs as NCQA’s Quality Recognition or the Patient-Centered Medical Home (PCMH) certification. [Click here to read more]

It is noteworthy that CPCI money “can NOT be paid to physicians as compensation. It is to be used to improve infrastructure. This is actually pretty cool because instead of just paying doctors more and saying, ‘hey, if we pay you more, you'll do a better job, right?’ CMS is saying, ‘we will give you money to use as you see fit (within the structure of our program and its milestones) to improve patient care which should improve outcomes, decrease severe complication rates, improve patient satisfaction, and eventually decrease overall costs through an investment up front.’”

One program has “used the money to hire more staff, including Care Coordinators, an RN who can reach out to patients before, during and after appointments to …. better coordinate care. [They] try to have labs drawn before folks come for appointments, so [they] can have already reviewed the results before walking in the room. This allows for more efficient care. If someone's cholesterol is not to goal, for example, [they] can increase the dose of their cholesterol medication while sitting with them and explaining why an LDL goal of under 70 is the target. This works a lot better than a medical assistant calling someone and playing phone tag three days after their appointment to try to make sure they know that the new dose is 40 mg instead of 20. Anyway, the Care Coordinator can help reach out to people who might need help paying for meds and see what assistance programs might help someone. She can help someone who was recently in the hospital understand their new medication regimen and help set up their follow up. If someone doesn't go for the colonoscopy or mammogram that we ordered, she can call …. and find out why and/or encourage them to go (and maybe mention that preventative care is covered 100% now!). She can review their chart ahead of time and put in a reminder for the doctor that the patient is due for a pneumonia vaccine or a shingles vaccine.”

“This is all part of the team-based approach to care which is helping to improve patient outcomes. [They] also decided to hire a diabetes educator. Insurance is often squirrelly about paying for diabetes education, despite study after study clearly showing the benefits. …. This is pretty great all around. The doctors get more help, the patients get more individualized attention and care, outcomes improve, which specifically means someone didn't have a stroke. Someone didn't lose [his or her] vision because of diabetes. Someone had a precancerous colon polyp removed instead of being diagnosed with metastatic cancer a couple years later. Someone's grandmother didn't lose her foot. Oh, and all that stuff also saves money.”

Without question, we will soon see the realization of meaningful use criteria and Information Exchanges (HIEs) the monitoring of care over time, regardless of place or specialty, i.e., ‘Episodes of Care,’ and other ways of improving accountability such as Medicare’s Bundled Payment arrangements.  Determining what is meaningful use is a difficult but not impossible task. Tools for this already exist, albeit in need of the refinement that only actual use can provide. For example, Episode Treatment Groups (ETGs) have been available for some years. This tool and others like attempt isolate episodes of care from the broader context of the patient’s other interactions with the health care systems. Another approach, as mentioned above, is 3M Health Information’s Patient Focused Episodes. It foregoes that isolated episode approach by looking  at episodes in the context of the whole patient.​  

Regardless of which grouper or grouping technology is employed, however, socio-economic status (SES) and other forms of risk adjustment is necessary.  As stated by Dr. Norbert Goldfield of 3M, "As the health system moves toward value-based payment, which is directly linked to more effective population health management, the incorporation of SES factors as part of risk adjustment is critical."

CINs and/or ACOs will invest in analytic techniques as mentioned above that will give a fuller picture of what is (or is not) happening to the patient over time.  IT will, of necessity, increase its staffing, employ guidelines (as in evidence-based medicine), perform variation analysis and obtain other analytical resources that will surely be used to sift through and learn from data being provided by the payers, collected and shared claim or encounter forms, and electronic health records (EHRs).  In addition, they will hire care coordinators who will be tasked, within the limits of coverage contracts, to facilitate the care including prevention, and to ensure proper continuity in care delivery.  Hopefully, we will also see a reinvestment in social workers, mental health facilitators and case manager/field coordinators, as well.

The CIN can be an opportunity for economic improvement. Perhaps more importantly is the reality that as the marketplace changes, the CIN allows for contracting for opportunities that neither the provider group nor the hospital could successful engage alone.

With change comes new information, conceptually as well as pragmatically impacting individual practices. Practically speaking, the CIN makes sense and may help clear the path from the debris of health care reform and self-interested (let the patient be damned) financing.

For more information, see: "A little known, but potentially fantastic provision of the Affordable Care Act"


In "ACO Readiness: 6 Chief Determinants | Hospital-Physician Relationships," (beckershospitalreview.com) the authors, Eugene A. Kroch and R. Wesley Champion tell us we don’t understand—they say ACOs are not merely “HMOs on steroids.” I suggest they both are merely embodiments of managed care.

 “As more providers move towards developing ACOs (estimates suggest approximately 330 existed at the end of 2012, and another 106 have been added in 2013 through the Medicare Shared Savings Program), it's vital for them to understand the capabilities they need — and what they don't — to create and participate in an effective model that constrains healthcare costs while improving quality.”

They say three attributes that are not essential characteristics for a health system to be an ACO (Accountable Care Organization):

1) “From market share to physician employment, size does not matter.” Yes it does!

2) “Deep pockets aren't necessary.Having financial stability and adequate reserves isn’t absolutely necessary but it sure helps you sleep at night.

3) “Areas with low costs aren't further along.Look!  Either you are going to reduce the inefficiencies, coordinate the care, and improve the quality or access or you are going to cost-shift, cream skim and cost-share to make a profit.  Nothing new about the challenges here!

The authors say the chief determinants that determine ACO readiness include four broad areas or organizational design.  My comments follow their themes:

1) “Existing collaboration with other health systems or as part of a larger corporate entity.” Collaboration is good.

2) “Full or partial health plan ownership.” “Existing risk-based contracts with payors.Having skin in the game and incentive alignment is good.

3) “A sophisticated EHR and an HIE implementation strategy across the continuum of care.”  Yes, this is the digital age but the rub is translating data into information and using it to improve quality, cost and access—what I call “Measurement and Management” in real time.  (What they call “Clinical Integration.”)  I agree, therefore: “These capabilities foster seamless care coordination with sophisticated population health status measurement that will improve health status and reduce overall costs… [an] ability to foster coordination and collaboration across multiple care sites during patient episodes of care.”

4) “A patient-centered health home with employed or community providers. Health systems that redesign inpatient and outpatient scheduling, and care delivery processes to be more patient-focused are better positioned to assume accountability for the health, experience and costs of the populations they serve.” The concept of a medical home—now we’re talkin’ [but clearly we need less fractionalization and that may necessitate having more primary care practitioners and less narrowly focused specialists.

Why do we need a central authority to accomplish the aforementioned?

Suffice it to say, the reason we need a centralized authority is that we need to measure and manage.  I care not if it comes thru ACA or single payer, but we must evaluate and promote that which works and demote that which does not.  

In this context, here's what I was recently asked to summarize in terms of the role of the enlightened physician executive.  I hope it helps:

Prime Responsibilities:

  • Understand EHRs/EMRs, communication channels and failure to communicate (e.g., as in maintaining the "Problem List," incorporating meaningful use criteria, recognizing important findings or recommendations form hospitalizations, referrals, family, etc.
  • Provide inputs about the specialty(Disease/Treatment/Medicine/Workflows)
  • Provide  the partitioner's view on primary care (Medical Home) and specialty based software
  • Help in designing templates, not cook-book medicine
  • Provide general and specialty-specific practitioner and health care system support as well as drill-down and detailed support especially in facilitating the acquisition and codifying of ICD, CPT, Rx, imaging, consultant, hospital and medical home-type of data, for instance for purposes of patient care monitoring, review of processes, procedures and outcome data, measuring productivity, efficiency and effectiveness and the quality of care, unwarranted variation, the fractionalization (e.g., problems with communication, collaboration, coordination) of care and, cost-effectiveness/benefit/utility, the effectiveness of management and the reduction of unnecessary practice burden, etc.
  • Helping patients proactively do the right thing, especially in terms of prevention.  Let's take a light moment to reduce a patient's anxiety.  Here's Peter Yarrow's "Colonoscopy Song" that does just that.

Resources
See Greenway Health, LLC. including, but not limited to: "Advanced APMs and your practice: The final rule" by David Heller, which contains links to: the Quality Payment Program website; Executive Summary of the Final Rule; The Medicare Access and CHIP Reauthorization Act of 2015; Comprehensive list of APMs; Improvement Activities and APMs