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Understanding CMS’s New Medicare Advanced Primary Care Management (APCM) Program: A Pathway to Better Patient Outcomes and Value-Based Care

The Centers for Medicare and Medicaid Services (CMS) continues to advance healthcare reforms through new programs aimed at strengthening primary care and improving patient outcomes, with a particular focus on chronic disease management. Recently, CMS introduced the Medicare Advanced Primary Care Management (APCM) program, an initiative designed to empower primary care providers with enhanced tools, resources, and reimbursements to manage the needs of Medicare beneficiaries, especially those with chronic conditions.

In this blog, we’ll explore the APCM program’s goals, its significance for the U.S. healthcare landscape, and how HealthViewX can support care practices in effectively implementing APCM at scale to improve clinical efficiency, patient outcomes, and profitability.

The Growing Need for Advanced Primary Care Models in the United States

Chronic disease is one of the most significant challenges facing the U.S. healthcare system. According to the Centers for Disease Control and Prevention (CDC):

6 in 10 U.S. adults have at least one chronic disease, while 4 in 10 have two or more chronic conditions.
The annual cost of managing chronic diseases in the U.S. is estimated at $3.8 trillion in direct healthcare costs.

For Medicare beneficiaries, the prevalence of chronic disease is even more pronounced. Nearly 80% of Medicare beneficiaries have at least one chronic condition, and 68% have two or more. With an aging population and the rising costs of healthcare, the need for proactive, well-coordinated chronic care management is more critical than ever.

CMS’s APCM Program: An Overview

The APCM program was introduced to address these pressing challenges by promoting a proactive and comprehensive approach to primary care. Through APCM, CMS seeks to foster a healthcare environment that is both patient-centered and preventive. The program has several key objectives:

Enhancing care coordination by supporting primary care practices in managing patients with complex and chronic conditions.
Promoting preventive care to reduce the onset and escalation of chronic diseases.
Encouraging data-driven decision-making to improve the quality of care.
Boosting value-based reimbursements by linking payments to the quality of care provided rather than the volume of services.

By providing additional funding, resources, and technical support, APCM enables primary care providers to invest in the staff, technology, and processes required to deliver more efficient and effective patient care.

Key Components of the APCM Program

The APCM program incorporates various components to help primary care practices succeed in value-based care, particularly for managing chronic conditions. Some of these elements include:

Risk-Stratified Care Management
APCM encourages providers to stratify patients based on risk levels and tailor their care management approach accordingly. This strategy ensures that patients with the highest needs receive more intensive care management and support, which can prevent hospitalizations and emergency visits.
Care Coordination and Integration
The program emphasizes the importance of seamless communication and data sharing among healthcare providers. By facilitating integrated care across multiple specialties, APCM ensures that patients receive coordinated treatment, reducing fragmentation and duplication of services.
Patient Engagement and Self-Management
To improve health outcomes, APCM prioritizes patient education and self-management support. Patients are encouraged to play an active role in their health, which has been shown to improve adherence to care plans, reduce symptoms, and enhance overall well-being.
Enhanced Reimbursements for Chronic Care Management (CCM)
Primary care providers participating in the APCM program can benefit from enhanced reimbursements for managing chronic conditions, allowing them to invest more in care delivery infrastructure, including staffing, technology, and training.
Data-Driven Quality Measurement
APCM requires providers to collect and analyze data to measure the quality and effectiveness of care. Through regular reporting, CMS aims to improve accountability and foster a continuous cycle of improvement in primary care delivery.

Industry Statistics: The Need for APCM in Medicare and Chronic Disease Management

With an increasing Medicare population and a rising burden of chronic disease, APCM comes at a crucial time for U.S. healthcare:

Medicare beneficiaries currently total over 64 million people in the U.S., with a growing segment aged 65 and older.
Nearly two-thirds of Medicare spending is attributed to patients with multiple chronic conditions.
By 2030, Medicare enrollment is projected to reach nearly 80 million, further straining the healthcare system’s ability to provide quality care without coordinated preventive programs like APCM.

As healthcare providers work to address the demands of this population, CMS’s APCM program serves as a valuable framework for optimizing chronic care delivery while improving patient outcomes and reducing costs.

Benefits of APCM for Healthcare Providers and Patients

The APCM program offers numerous advantages for providers and patients alike. Here are some of the primary benefits:

Improved Patient Outcomes: By focusing on proactive care and preventive strategies, APCM helps reduce disease progression and improve long-term outcomes for patients with chronic conditions.
Enhanced Patient Satisfaction: APCM’s patient-centered approach promotes engagement and ensures that patients feel supported in managing their health, leading to higher satisfaction rates.
Increased Efficiency: With streamlined care coordination and a focus on integrated care, providers can deliver more efficient and effective services, reducing redundancies and optimizing resource allocation.
Boosted Reimbursements: The APCM program’s enhanced reimbursements for chronic care management encourage providers to invest in high-quality care and technology, ultimately boosting profitability within value-based care models.
Reduced Healthcare Costs: By focusing on prevention and early intervention, APCM can help reduce avoidable hospitalizations and emergency room visits, leading to significant savings for both providers and the healthcare system.

How HealthViewX Supports APCM Implementation at Scale

To effectively deliver APCM services, healthcare providers need an integrated, data-driven approach to care management. HealthViewX’s digital health platform is uniquely positioned to support providers in scaling APCM services and maximizing the benefits of this value-based program.

1. Comprehensive Care Coordination and Workflow Automation

HealthViewX enables seamless care coordination across the care continuum, allowing primary care providers to manage all aspects of patient care, whether for chronic disease management, preventive screenings, or follow-up appointments. The platform’s automated workflows ensure that all care team members are informed and aligned, reducing the chances of errors or missed follow-ups.

2. Risk Stratification and Patient Segmentation

HealthViewX’s data analytics capabilities allow providers to categorize patients by risk levels, ensuring that those with higher needs receive more intensive and targeted interventions. The platform’s patient segmentation tools enable efficient allocation of resources to where they are most needed, improving outcomes for high-risk patients and ensuring efficient use of staff time.

3. Enhanced Patient Engagement and Self-Management Tools

Through its patient portal and mobile app, HealthViewX provides tools for patient engagement, including education materials, reminders, and self-management resources. By empowering patients to take an active role in their care, HealthViewX fosters better adherence to treatment plans and promotes healthier lifestyle choices that are crucial for managing chronic diseases effectively.

4. Real-Time Data Analytics and Reporting

HealthViewX’s robust analytics platform provides real-time insights into care quality and patient outcomes, helping providers comply with APCM’s reporting requirements and make data-driven improvements. With comprehensive data on patient progress, adherence, and outcomes, providers can continuously optimize their care strategies to ensure the highest quality of care.

5. Increased Value-Based Reimbursements and Profitability

With HealthViewX’s support for APCM services, providers can maximize their value-based reimbursements by delivering high-quality care and meeting CMS’s program requirements. The platform’s focus on efficiency, patient outcomes, and real-time data analytics helps providers increase profitability and achieve sustainable success within value-based care frameworks.

Conclusion

The Medicare APCM program represents a significant shift toward advanced, patient-centered primary care, particularly for Medicare beneficiaries with chronic conditions. With an aging population and increasing rates of chronic disease, APCM’s focus on coordinated, preventive, and data-driven care is timely and essential.

Implementing APCM services at scale requires robust support, and HealthViewX is well-equipped to empower healthcare providers in this transformation. HealthViewX enables providers to enhance clinical outcomes, optimize operational efficiency, and maximize value-based reimbursements by facilitating seamless care coordination, risk stratification, patient engagement, and real-time data analytics.

The future of primary care is advanced, integrated, and patient-centered, and HealthViewX is here to help providers deliver better care to Medicare patients across the United States.

Contact us to learn how HealthViewX can support your practice in implementing APCM and achieving improved clinical experiences, patient outcomes, and value-based profitability.

Learn how the COVID-19 pandemic is transforming healthcare with technology

The COVID-19 pandemic and its global sweep is scaling exponentially across the globe. We are witnessing that health systems across some of the COVID-19 affected countries are stretching beyond their ability to handle this pandemic. The affected countries have geared up and are urgently scaling-up aggressive measures to tackle the disease and combat COVID-19.

Unfortunately, even some large health systems in developed countries are designed to handle regular patient loads and not pandemics. The international community has asked for US$675 million to help protect states with weaker health systems as part of its Strategic Preparedness and Response Plan. Right from mid-March till the first week of April, the number of cases of COVID-19 outside China has increased 13-fold, and the number of affected countries has tripled. Patients with an extreme disease from COVID-19 need average respiratory support of approximately 13 days and the number of new patients that can be accommodated during this prolonged outbreak is really low.

The rapid growth of cases can alter a public health emergency into an operational crisis if containment flops. Proper planning and response will require multidisciplinary effort from physicians, healthcare professionals, nurses, respiratory specialists, supply chain, pharmacists, etc.

Here’s how technology is helping through its virtual care potential and other advancements

Healthcare workers on the front lines are overwhelmed due to the COVID-19 outbreak. The number of calls they receive from patients who want to talk to their respective physicians about COVID 19 symptoms is unimaginably high. As a result, health systems are suggesting their patients to use self-triaging tools to check for the COVID-19 symptoms before putting them through to their doctors. Chatbot’s have also been reconfigured with FAQ’s and assessment related to Coronavirus symptoms.

The current COVID 19 outbreak scenario is terrifying and the major concern for many of us throughout the world. Due to the sudden spike, patients triaged for COVID-19 should wait long in a virtual queue. During this long wait patients get frustrated and impatient, and also puts many patients in a state of panic and anxiety. In one of the articles it is stated that the number of virtual visits have gone 10-15 times more after the COVID-19 outbreak.

This insists on the need for health systems to standardize and streamline processes eventually to handle intake volumes and have the technology in place to manage such pandemics efficiently. It is said since the COVID-19 outbreak Telehealth visits/usage has increased by approximately 500% in the last few weeks. While some of the health systems have already successfully adapted to new healthcare technologies there are still plenty out there who have not thought about it yet.

It is time for health systems to realize, the power and potential of Telehealth, bring it into the mainstream and take it at one stroke to transform care delivery. Likewise, remote patient monitoring is also equally important to monitor chronic conditions patients and patients who are at high risk or suspected of contracting the virus during such pandemics.

The COVID-19 pandemic may be a turning point as we look at the future of healthcare across time horizons, how we live and work, and perhaps the planet’s future. During such situations, a certain degree of reprioritization is needed to speed-up the digital transformation of healthcare delivery.

Mainstreaming of Telehealth

Telehealth is on the rise during the COVID-19 pandemic. The HealthViewX platform supports patient-to-provider, provider-to-provider and multi-party collaboration from the onset of a condition. The platform supports both audio and video calling, and live-chats along with document transfer. Allows patients to join from any device like mobile, laptop, tabs, etc. It enables healthcare organizations to customize Telehealth experience for providers and patients, thereby enhancing the quality of patient care, raising patient engagement and improving patient experience and health outcomes.

For further customization, the platform engine helps build digital tools and platforms on-the-fly with no-code or low-code to orchestrate care journeys and facilitates transitioning to value-based care. The current system definitely needs to adapt to modern healthcare technology.

Talk to us to understand more about healthcare technology advancements.

It’s time to stop faxing referrals – Why are we still faxing patient referrals?

One out of every three patients is referred to a specialist each year. These referrals are sent to specialists, imaging centers, etc., through multiple channels like phone calls, fax, emails, website forms, etc., and fax is the most commonly used channel. Despite the array of digital patient referral management software available in the market, health systems are still following the old school model of referring patients through fax machines and paper-based letters. Ironically, there could be multiple barriers like the reasons listed below for not using the electronic referral communication software

Traditional workplace culture
Not having the right technology in place
Not understanding the software usage
Peers not using eReferrals

Healthcare professionals need to understand the usability, security, and interoperability of the solutions available in the health IT market. Health systems need to adapt to more secure means to send and receive referrals. With that being said, Referral Management Solution is progressively vital for better patient experience and care coordination. Today, in most health systems referral workflows are poorly documented, insecurely sent and are not effective in providing quality care for patients.

Knowing the security consequences of maintaining paper-based systems and physical paper letters is critical – as they could be easily misplaced and accessed by unauthorized people. Some health systems still depend on their EMR to manage their referral process but they need to understand that EMR’s are not equipped enough to handle the end-to-end referral process. Health systems should understand the need of having a good patient referral solution.

Why do health systems need a good patient referral solution?

The healthcare industry is constantly scrutinized for inefficiencies in processes, systems, operations, etc. As a result, health systems are under more pressure to do more with fewer amenities. Inefficient referral processes lead to long lead times and are inconvenient to both patients and providers. A referral solution can streamline communication between the referring provider, receiving provider, patient and other healthcare providers, save time, enhance care quality and a lot more for both patients and providers.

Revenue lost due to patient leakage in hospitals and health systems

The last few years have been a tumultuous time for hospitals and health systems due to the high patient leakage rate. Even today, patient leakage is a key concern and remains an unsolved challenge in many of the health systems. Health systems are losing more than 20% revenue due to inefficient organizational referral processes, as a result, patients are opting to different care providers for their care needs. Identifying the gaps or latitude to go out of the system, and sealing this, is the basic step that health systems need to take in solving patient leakage challenge.

What are the main causes of patient leakage?

Here are some reasons why patient leakage happens

– Referring physicians refer patients to out-of-network providers

– Patients move out of the care network due to poor care coordination

– Unavailability of a specialist within the care network

Patient Leakage and its consequences

Though in most hospitals patient leakage is contributing to significant revenue loss, this loss is ignored, and not given much importance. Health systems and hospitals need to consider this leakage extremely important. Non-coordinated or fragmented care is one of the main reasons for patient leakage. The point is to emphasize on some damaging consequences patient leakage can bring on care quality and patient health outcomes.

Understanding the actual causes of this leakage and taking tangible steps to address this challenge is vital. It is the responsibility of the health system to track and manage patient referrals in a better way with a solution for tracking leakages and referrals. Otherwise, it can damage the health system’s reputation, undermine its brand value, and even jeopardize its competitive edge.

Challenges in processes that cause patient leakage

Streamlining different processes for different aspects is required for better overall operational efficiency. One such process that needs attention to arrest leakage is the patient referral process. Health systems need to adapt to solutions that will help seal this leakage. HealthViewX helps referral coordinators in health systems to manage patient referral efficiently and improve care, performance, compliance, and reduce leakage.

The current referral process lacks certain mechanisms to make this process effective. Hospitals and health systems need a referral solution in addition to an EMR to solve their referral challenges especially referral leakage.

An ideal referral solution for hospitals should have the following features

Multi-channel referral consolidation

Health systems have multiple access points for patients and chances are that health systems may miss following-up with some referrals. The solution needs to consolidate referrals from multiple sources like fax, email, phone calls, online forms, etc. It should integrate well to bring all of these referrals into one single queue and ensure not a single referral is missed.

Secure exchange of information

A HIPAA compliant solution that supports the secure exchange of sensitive patient information among the care providers involved in patient care is a must. The provider should be able to attach documents securely at any time for one another’s reference.

Patient referral history

Both the referring physician and the receiving provider should have access to the entire referral history. All required information right from the time a referral is initiated and consequent diagnosis reports, referral status, etc. should be available at any point of care.

Scheduler Integration

Patient convenience is one of the most important factors in providing care. Scheduling appointments as per patient convenience and automated reminders for both patient and provider about the appointment is mandatory.

Dashboard and referral insights

The solution has to give complete data of the referrals flowing into the health system. The number of referrals processed, number missed and many more as per the requirement of the health system. These data analytics should give the practice a clear picture of how referrals are handled and where the leakage is happening.

Speak to HealthViewX solution experts to understand more about HealthViewX Referral Solution features that will help solve some of the challenges in the patient referral process and increase revenue through effective tracking. Schedule a demo today!

Advantages FQHCs Gain From A Patient Referral Management Solution

Community health centers or federally qualified health centers provide critical primary care services to tens of millions of people every year. Their role in healthcare makes them necessary access points for patients coming into the vaster healthcare system. Let us see how these organizations use patient referral management systems to leverage their role as a crucial source of patient referrals and enhance the care they can provide for their populations.

1. Making a more combined provider network:

Right from small to large, FQHCs are moving towards providing value-based care for their patients. Many FQHCs have discovered that requests for better care coordination with specialists go unheard until there is a change in the current referral process. FQHCs have realized that technology can provide them with the ability to differentiate from their competitors while helping them deliver quality care to their patients and closing referral loops. An efficient referral management solution will help them organize, quantify, and ultimately shape their referral stream and improve care coordination.

2. Improved patient support and access to care:

Insurance prior authorization is one of the major challenges in the patient referral process. Finding the right specialist, insurance prior authorization, ensuring the patient visits the specialist, getting the information back, and updating the information back to the EMR is all crucial inpatient care. A referral management solution helps FQHCs to automate end-to-end referral process and helps them close referral loops with ease. This improves patient experience and increases their access to quality care.

3. Improved referral workflows:

Many FQHCs lack care coordination in their current referral process. Manual processes are both time-consuming and tedious. Simplifying the referral workflow will not only help referral coordinators and patients but will also help the FQHC performance as a whole.

4. Better care coordination and patient outcomes:

In an efficient referral process, patients get the care they need. This involves referring the patient to the right provider, ensuring insurance pre-authorization, scheduling appointments, sending reminders, and updating the patient information back into the EHR. All these steps contribute to better care coordination and patient outcomes.

5. Increased referral loop closures and MU Credits:

Receiving a report from the provider to whom the patient was referred to and updating that information back into the EHR is critical for FQHCs. Referral loop closure is essential for better care coordination and will help FQHCs improve patient experience and outcomes. A referral solution that is MU stage 3 certified can help the practice with MU credits, as referral transferred using the platform can be counted for MU credits.

Talk to our solution experts to know more about Patient Referral Management Solution.

Why do hospitals need a patient referral management solution?

Today, hospitals face numerous challenges in their day-to-day operations. One of the biggest challenges is managing their high-volume inbound and outbound patient referrals. Right from receiving patient referrals through multiple channels like email, fax, phone, etc., this method is often information-intensive and document-driven, requiring greater control and visibility of the entire process.

Patients have difficulty navigating through the referral process, and this experience directly impacts the quality of care. Poor referral management negatively impacts hospitals, and hence clinical staff needs to be careful in processing every referral. An inefficient referral process leads to patient dissatisfaction, patient leakage, loss of revenue, missed appointments/no-show rates, overall operational inefficiencies, etc.

Successful clinical practice depends on effective collaboration and communication among the parties involved in patient care. A solution such as patient referral management for large hospitals has the power to enhance communication beyond the four walls of a healthcare facility. It extends communication to all parties involved in patient care, including the patient. Such solutions can have enormous sway on enhancing the patient experience while driving overall operational efficiency.

Top reasons why hospitals need a patient referral management solution

1. Doesn’t let you miss any referral

Hospitals send and receive high-volume patient referrals through multiple-channels like emails, fax, website form fills, direct messaging, etc. It becomes difficult to track every referral, and there are high chances of missing out on them. An end-to-end patient referral solution will bring all referrals in one single queue and eliminates referral leakage. Referrals from physicians are a key source of revenue for hospitals and they would not want to miss out on them.

2. Engages patients throughout the referral process

Hospitals need to involve patients’ in the referral process. Engaging patients will not only increase process visibility for patients’ but also gives them a clear expectation and visibility into their care transition. Involving patients in the referral process directly impacts the standard of care patients’ receive from the hospital. Overall, engaging patients’ will help reduce referral leakages, improve patient satisfaction, and increase revenue.

3. Referral patterns and metrics/analytics

Referral solutions help hospitals understand their referral patterns and appointment conversion rates. Customized reports and analytics on referrals will help hospitals gain better insight into their business, using analytics such as the metrics dashboard, referral volume, referral patterns leakage rate, wait times, etc. help them with informed decision making.

4. Involves and engages key players for better results

To drive results and for better outcomes, it is crucial to include all the key players’ involved in patient care. Patient referral management solution helps people in different designation achieve their goals at the same time helps provide quality care for their patients. Persona-based reports help each of them in informed decision making.

HealthViewX Patient Referral Management solution helps practices in managing their referral network and increasing their revenue. Are you referral inbound & outbound-heavy practice looking to track all your referrals very effectively? To know about HealthViewX Patient Referral Management System in detail schedule a demo with our team.