Category Archives: Value-Based Care

MACRA Care Coordination Software

By | Care Coordination, MACRA, Value-Based Care | One Comment

Last week we talked about how MACRA legislation is a game changer for how providers will be paid in the future for their Medicare patients.  This week we will focus on the value and benefits of using care coordination software solutions to maximize MACRA payments and care delivery productivity.

Specific opportunities for using care coordination software to maximize revenue include:

  • building and managing “whole person” longitudinal care plans
  • automating data collection and workflows
  • automating interactions with patients and with other professional care team members
  • automating the selection and management of community based services to help patients ‘

While some EMR software vendors will be able to support the need to capture and report quality metrics – support for care coordination – particularly for complex patients – will likely require separate care coordination software.

In selecting a care coordination software solution, we would like to point out two key considerations to keep in mind.   First, there are benefits in selecting a solution that can scale to support the more advanced MACRA alternative payment models – even if a practice begins in the basic MERIT based payment model and transitions later to a more advanced model.    Second, it is important to select a platform that can fully support the creation and management of robust longitudinal care plans as a foundation for maximizing patient outcomes that in turn should maximize MACRA payments to the practice.

Recently, Chilmark Research – an independent healthcare software evaluation company – Chilmark concluded that many software vendors where two to three years away from offering fully featured longitudinal care plan software solution.  Chilmark defined a robust longitudinal care plan as a solution that can support eight core components (see exhibit A below):

Longitudinal Care Plan Chart

Exhibit A: Eight Core Components of a Robust Longitudinal Care Plan

Source:  Longitudinal Care Plans, Chilmark Research, Dec. 2015.

Eight “core” elements of a Robust Longitudinal Care Plan:

  1. Patient demographics
  2. Members of the care team
  3. Any care management programs the patient is in
  4. Active problem list
  5. Active medication list
  6. Goals, including those for self-management
  7. All health interventions and their current status
  8. Risk factors for the patient

eTransX’s  XCare Community system fully supports all eight core components out of the box today.  The old adage of “pay me now or pay be later” applies as you evaluate and select your software application solutions for maximizing MACRA payments.   By starting now with  a robust care coordination software solution that will support your current and future MACRA deployment  options can potentially save you significant money and time in the long run.

For more information on the XCare Community system – contact Richard Taylor at 615 620 7524 or

Accountable Health Communities Software

By | Accountable Health Communities, Care Coordination, Value-Based Care | No Comments

CMS recently announced a 5-year, $157 million program to fund Accountable Health  Communities (AHC) under the CMS Innovation Center.  The purpose of this new program is to assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.   For the first time in its history, CMS is making a significant amount of money available to help communities address the social determinants of health.  CMS has referenced several key reasons for this landmark program 1:

  • Many of the largest drivers of health care costs fall outside the clinical care environment.
  • Social and economic determinants, health behaviors and the physical environment significantly drive utilization and costs.
  • There is emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and impact costs.
  • The AHC model seeks to address current gaps between health care delivery and community services.

The foundation of the AHC model is a comprehensive screening process for health-related social needs.  These needs include but are not limited to housing needs, food insecurity, utility needs (e.g., difficulty paying utility bills), interpersonal safety (e.g., problems of intimate-partner violence, elder abuse, child maltreatment). Using the data gathered through this social needs screening process, the AHC model aims to address these underlying health-related social needs through three tiers of approaches, with each tier linked to a payment method. 2   These three tiers are referenced as Tracks 1,2,and 3 in the AHC program     The primary focus of each track is shown below:

  • Track 1: Awareness – Increase beneficiary awareness of available community services through information dissemination and referral
  • Track 2: Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services
  • Track 3: Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries

While Track 2 and 3 applications were closed in May, CMS has reopened applications for Track 1 with new provisions to make it easier for communities to apply for Track 1.   Under all tracks, the AHC model will fund award recipients, called bridge organizations, to serve as “hubs”.  These bridge organizations will be responsible for coordinating AHC efforts to 2:

  • Identify and partner with clinical delivery sites
  • Conduct systematic health-related social needs screenings and make referrals
  • Coordinate and connect community-dwelling beneficiaries who screen positive for certain unmet health-related social needs to community service providers that might be able to address those needs
  • Align model partners to optimize community capacity to address health-related social needs

The eTransX XCare Community system offers an ideal software platform for any community that would like to pursue the implementation of a  Track 1, 2, or 3 AHC model.  Our flexible software as a service solution can support the social needs assessments and the ability to share information with the healthcare community and social service organizations.

As mentioned earlier,  Track 2 and Track 3 applications are now closed,  Track 1 applications are still open for interested communities until Nov 3, 2016.

CMS modified Track 1 application requirements for the new Track 1 funding opportunity. The modifications include: – reducing the annual number of beneficiaries applicants are required to screen from 75,000 to 53,000; and increasing the maximum funding amount per award recipient from $1 million to $1.17 million over 5 years.  CMS believes these two key modifications to Track 1 will make the program more accessible to a broader set of applicants. Applicants that previously applied to Track 1 of the AHC Model under the original FOA must re-apply using this FOA to be considered for the Model.  CMS anticipates announcing Track 1 cooperative agreement awards in the Summer of 2017. 4   eTransX would be glad to assist any Track 1 applicants in providing information related to software requirements for their Track 1 application.


Footnotes: 1 source; CMS AHC Track 1 Program Webinar slides, 09-14-16

2 ibid

3 ibid

4 ibid.

MACRA MIPS Software platform

By | Analytics, Care Coordination, Population Health, Value-Based Care | No Comments

MACRA is a game changer for providers.   It represents the most significant change in healthcare payments since Medicare was introduced 60 years ago.   The baseline for calculating MACRA payment adjustments starts January 1, 2017.   The purpose of MACRA is to lead healthcare providers from a fee-for-service payment model to a value-based care model where reimbursement is determined by patient outcomes that includes quality of care, utilization of care, improved patient outcomes, and improved cost control.

The MACRA payment program has to be budget neutral so there will be winners and losers.  Under MACRA, providers will have to choose to operate under a merit-based incentive program (MIPS) or transition to an Alternative Payment Model (APM).  While there are a few exceptions for providers new to Medicare and/or with low Medicare payment volume to participate in MACRA,  most providers will be impacted by MACRA.

Under the MIPS default option,  there is a potential for a maximum plus or minus 4 percent or payments in the first year (2019). A bonus payment (not to exceed 10 percent) for exceptional performance is part of this program for the first five years. An overall MIPS score will be calculated according to performance in four measures (weighted by performance, with potential changes in weight by year):  Quality =50%, Cost (Resource Use) =10%, Advancing care information (interoperability, etc.  = 25 percent, and Clinical practice improvement activities (care coordination, etc.) = 15 percent.

Under the Alternative Payment Model (APM), Medicare providers will be paid based on value of services rather than service volume. Providers meeting the criteria for this track cannot move to the MIPS track. Physicians receiving a significant portion of their payments through eligible APMs can be exempt from MIPS—and they receive a lump sum payment of 5 percent of covered services.

In regards to software requirements – some requirements can be met with a certified EMR system – while other requirements such as care coordination and interoperability will require software beyond most EMRs.   eTransX’s XCare Community system provides a solid robust software as a service platform that can be used to maximize value based payments under either MIPS or Alternative Payment Models (APM).

A robust MACRA software plaform will not only need to support capturing and reporting metrics and sharing information electronically,  it will also need to support robust team based  care coordination to maximize payments and performance bonuses.   For example, to maximize performance, patients will need to be an integral part of their care and really understand their care plans.  The care plans should be evidence based and personalized.   In addition to the physician,  the care team for the patient may include a nurse, a pharmacist, and a social worker who are all managing a group of patients with chronic conditions to make sure their needs are being met, such as arranging transportation, solving prescription problems, planning meals and exercise…this will require a robust care coordination software platform.

Providers can start generating value based payments now with the eTransX XCare Community system – through programs such as the Medicare Chronic Care Management program and/or Transitional Care Management program.   In addition, using the XCare Community system now – will help practices improve their patient outcomes and quality metrics in 2017 which will serve as the basis of future value based payments under MACRA.

Now is the time to start evaluating your software options to maximize MACRA payments.

Comprehensive Primary Care Plus Software

By | Care Coordination, Uncategorized, Value-Based Care | No Comments

If you are a primary care practice operating in one of 14 selected CPC+ regions  (see list below) you may be eligible for a unique opportunity to earn significant additional revenue from multiple payers (e.g., Medicare, Medicaid, and Commercial) by participating in the Comprehensive Primary Care Plus (CPC+) program that will start January 1, 2017 and last for five years.

Time is of the essence as interested primary care practices must submit an application to CMS by September 15, 2016.

Who is eligible?

Eligible CPC+ practitioners are those who have a primary specialty designation of family medicine, internal medicine, or geriatric medicine, and for whom primary care services accounted for at least 60 percent of billing under the Medicare Physician Fee Schedule and have a minimum of 150 attributed Medicare fee for service beneficiaries in one of the 14 CPC+ Regions (see below).

Practices owned by hospitals and health systems are eligible to apply to CPC+.

Practices within an IPA are eligible to apply to CPC+. Practices within an IPA must apply separately to participate in CPC+, as CPC+ is a practice-level transformation

Primary care practices currently participating, or considering participation in Tracks 1, 2, or 3 of the Shared Savings Program, that meet the eligibility requirements of CPC+, may participate in both initiatives. Practices participating in Shared Savings Program Accountable Care Organizations (ACOs) can participate in either track of CPC+.


Practices within ACOs participating in the ACO Investment Model (AIM), Next Generation ACO Model, or other shared savings programs may not participate in CPC+.

Also not eligible for CPC+: FQHCs, Rural Health clinics, and concierge practices, or any practice that charges patients a retainer fee as of January 1, 2017, may not participate in CPC+.

CPC+ Regions

1. Arkansas: Statewide

2. Colorado: Statewide

3. Hawaii: Statewide

4. Kansas and Missouri: Greater Kansas City Region

5. Michigan: Statewide

6. Montana: Statewide

7. New Jersey: Statewide

8. New York: North Hudson-Capital Region

9. Ohio: Statewide and Northern Kentucky: Ohio and Northern Kentucky Region

10. Oklahoma: Statewide

11. Oregon: Statewide

12. Pennsylvania: Greater Philadelphia Region

13. Rhode Island: Statewide

14. Tennessee: Statewide


Additional details for eligibility can be found at the CPC+ website:

Two CPC+ Options – Track 1 and Track 2

Practices will have two program options – Track 1 and Track 2.   Care delivery requirements for each track are:

Track 1

Existing care delivery activities must include: assigning patients to provider panel, providing 24/7 access for patients, and supporting quality improvement activities.

Track 2

Existing care delivery activities must include: assigning patients to provider panel, providing 24/7 access for patients, and supporting quality improvement activities, while also developing and recording care plans, following up with patients after emergency department (ED) or hospital discharge, and implementing a process to link patients to community based resources

CPC+ will accommodate up to 2,500 practices in each track for a total of 5,000 practices across all regions and encompass approximately 20,000 clinicians and 25 million patients

CMS expects practices that participate in CPC+ will do so for the full five years of the model. However, participation in CPC+ is voluntary and practices may withdraw from the model without penalty during the five-year program period.

Practice Additional Revenue Projections

Additional revenue can be significant for participating practices

For Track 1 and Track 2 participants – projected average payments are shown below (per beneficiary per month)

Track Care Management Fees PBPM Performance based Incentive Payments
1 $15 average $2.50 PBPM
2 $28 average $4.00 PBPM

These payments are in addition to fee-for-service payments.

Per 1,000 patients, the maximum payments for care management fees for Track 1 participants would be $210,000 and $384,000 for track 2 participants.

Technology requirements  and eTransX

Use of advanced technology will be critical for maximizing revenue in the CPC+ program – particularly for Track 2 participants.

eTransX  offers Comprehensive Primary Care Plus software and seeks to partner with practices applying to participate in the CPC+ Model Track 2 leveraging our comprehensive, modular XCare Community software system.

Our Comprehensive Primary Care Plus software offering  can act as a total solution or fill in the gaps for those products and/or services that you do  have.  Specific CPC+  Track 2 functions addressed by our XCare Community system (software-as-a-service) offering include:

  • Developing a personalized care management plan for patients with complex medical, behavioral, and psychosocial needs.
  • Managing referrals and services orders with community based service organizations to coordinate services for patients with complex needs.
  • Risk-stratifying practice site patient populations: identify and flag “patients with complex needs”
  • Capturing and tracking certified quality measures results at the practice level to support continuous feedback
  • Systematically assessing patients’ psychosocial needs and developing and maintaining an inventory of community resources and supports to meet those needs
  • Documenting and tracking patient reported outcomes
  • Developing and manage follow-up care plans for patients after discharge from emergency department (ED) or hospital stays.

Please call us today to find out more on how eTransX can help with your CPC+ initiative.

Richard Taylor 615 620 7524 –

Advanced Health Models: Healthcare’s Future?

By | Care Coordination, Population Health, Value-Based Care | No Comments

05-11-16  by Richard Taylor, Director of Business Development for eTransX Inc.


Recently,  the Advanced Health Model workgroup of the ONC’s Health IT Policy Committee issued their initial findings and recommendations*.  This workgroup, chaired by Paul Tang, MD, the chief innovation and technology officer at Sutter Health’s Palo Alto Medical Foundation, is charged with finding ways to facilitate the effective use of health IT to support and scale advanced health models.

Their findings and recommendations can be summarized as follows:

1.  Recognizing the significant impact of the social determinants of health

Providers seeking to improve individual health outcomes are increasingly acknowledging the reality that an individual’s health is shaped largely by life circumstances that fall outside the traditional health care system. An extensive body of research has shown that social, psychological, and behavioral factors, such as family support systems, stress, housing, nutrition, income, and education explain far more about an individual’s health outcomes than the results of medical care.

  1. Expanding the traditional medical “continuum of care”

The Advanced Health Platform (AHP) Workgroup recognizes that improving health will require a broad expansion of the traditional medical “continuum of care” to encompass all of the entities and individuals within a community that influence an individual’s health. The IT solutions and systems that are used to support a holistic approach across all of these entities must evolve as well to enable truly seamless services to the right individual at the right time.

  1. Defining a new  “Advanced Health Model”

The AHM workgroup has sought to describe a range of emerging, community-level interventions that strive to bring together clinical, social, psychological, and behavioral data to improve and to coordinate health across settings for individuals. In many cases, these Advanced Health Models start within the medical system but seek to bridge gaps with a wider set of relevant services. In other cases, these models may be driven by community-based organizations seeking to incorporate clinical services to meet individuals in their preferred setting, such as where the individual lives, or another community setting. Rather than prioritizing clinical outcomes dictated by the medical system, these models seek to drive sustainable health improvements by focusing on person-centered goals and priorities that matter most to the individual.

  1.  Utilizing technology to support Advanced Health Models

Selecting and implementing technology to support AHM models requires recognizing a wider  ecosystem of technology solutions beyond the traditional electronic health records system used in clinical care. In the clinical setting, these include technology applications that may exist outside the traditional EHR, such as care management modules and population health management and analytics applications,  as well as third-party services, such as those offered by health information exchange organizations. Meanwhile, organizations such as schools, food banks, and social services agencies that are focused on supports that are non-clinical in nature may have a wide range of software solutions that support case management. At the community level, technology platforms that link human-services information and deliver consumer education are also integral to improving health.

Advanced Health Models that bring together these disparate systems frequently rely on an additional layer of information management that can match, normalize and aggregate data to support individuals and inform targeted service provider decision-making.

An Ideal IT Platform for supporting Advanced Health Models

eTransX offers a robust IT Platform to support Advanced Health Models.  This platform is the XCare Community system a hosted software as a service application.   This platform was designed from the ground up to support a fully integrated care coordination solution that connects healthcare providers with community based social service providers.

For any organization seeking to implement an Advanced Health Model, the eTransX XCare Community system provides a robust IT platform that can be integrated with existing healthcare delivery systems already in place.


* Source:  Advanced Health Model Workgroup June 2, 2015 Hearing summary,  6/21/15


Is your HIT infrastructure ready for value-based healthcare?

By | Health Information Exchange, Population Health, Value-Based Care | No Comments

The CMS and Healthcare Transformation Task Force recently announced the rapid acceleration of value-based health care:

A group of the nation’s largest healthcare systems and payers, together with purchaser and patient stakeholders, have announced the creation of a new private-sector alliance dedicated to accelerating the shift to value-based business and clinical models in the U.S. healthcare system that are aligned with improving outcomes and lowering costs. Called the Healthcare Transformation Task Force,  the alliance includes six of the nation’s top 15 health systems and four of the top 25 health insurers. The Task Force has issued a challenge to providers and payers to put 75 percent of their business into value-based arrangements that emphasize better health, better care, and lower costs by 2020 1

According to new federal guidelines, the U.S. Department of Health and Human Services wants 50 percent of all ACO payments and 90 percent of all traditional Medicare payments tied to quality or value by 2018. 2

For healthcare providers, now is the time to assess their information systems infrastructure in relation to supporting value-based healthcare.

As a starting point, value-based healthcare will require core information systems functionality addressing four key areas: – data exchange interoperability, advanced population health analytics, community care coordination, and patient empowerment.

  1. Data Exchange Interoperability– the ability to support real time data exchange interoperability between multiple organizations and systems. Integrating information and workflows across EHRs, care teams, providers, community resources and health information exchanges (HIEs) with a reliable and robust master patient index system.
  2. Advanced population health analytics – the ability to support three levels of analytics: descriptive, predictive, and prescriptive for population health management and accountable care for improving population health outcomes.
  3. Community care coordination systems – the ability to support automated workflows and closed loop referrals with community partners engaged with your member/patient population. This includes the use of built-in rule engines that can trigger alerts and manage interventions, and can support the ability to systematically manage health pathways for members/patients – particularly those with multiple chronic illnesses.
  4. Patient empowerment systems – the ability to interact with members orpatients beyond simple portals, to include automated interfaces with phone apps and personal health monitoring devices. It also works to support members or patients in their self-care responsibilities, prescription drug adherence, lifestyle improvement and wellness programs.

Existing Electronic Medical Record (EMR) systems may be able to provide basic reporting on some of the value-based healthcare quality measures, but they may be inadequate at meeting the triple aim goals of improving care, enhancing patient health outcomes, and reducing per capita healthcare costs. Likewise, existing health information exchanges (HIEs) may be able to support direct messaging and transmit a continuity of care record for patients at the point of care, but may not be able to integrate or share care treatment plans, document patient interventions, support task workflows, capture non clinical social and demographic information.

In most cases, value-based healthcare delivery systems will require the adoption of new information systems and tools beyond current EMR and HIE systems.

Some healthcare providers may have purchased one, two, or even three of the four key component systems for value-based healthcare, and just need to fill the remaining gaps.  Others have yet to make any of these investments and will need to purchase all four components.

Until now, acquiring these four core value-based healthcare IT capabilities often required buying software applications from multiple vendors and then integrating those applications to work together. Today, some vendors are able to offer all four value-based healthcare IT capabilities, and eTransX is one of those vendors.

Purchasing a fully integrated value-based healthcare IT solution saves time, money, implementation efforts and shortens the learning curve. In addition, data flows more efficiently and smoothly between the four applications and security management is more manageable and secure.

eTransX welcomes the opportunity to show you a fully integrated value-based healthcare information systems infrastructure.   Contact us today for a presentation and demonstration.



1, 2/6/15

2 Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care, HHS Secretary Sylvia M. Burwell, 1/26/15 New England Journal of Medicine