Leading the Transformation of Healthcare

Letter from our Medical Director

As 2018 comes to a close, I would like to take a moment to express my gratitude to all of you in the Signature Partners family for our shared commitment to improving quality and reducing overall cost of care for our patient population. 2018 brought us many successes which are the direct result of the engagement of our network physicians working in tandem with our staff. With your contribution we have moved the needle on our quality metrics; our YTD quality scores are showing significant improvements compared to 2017.

In 2018 Signature Partners received a high performing ACO award by Premier Inc., based on our “exceptional performance” score of 90.85 out of 100 for 2017 MIPS reporting. This high score translates into a positive reimbursement adjustment of 1.39% change from 2018 in the 2019 Medicare physician fee schedule for all of the eligible clinicians who were part of our ACO in 2017. This is in addition to the 0.5% inflationary adjustment resulting in a total increase of 1.89% in Medicare reimbursements for 2019. Please note, the maximum reimbursement earned by any practice was 1.88% (i.e. a total of 2.38% including the inflationary increase).

Our quality team continues to make strides in effectively onboarding our network primary care practices during individual meetings and engaging our network primary care practices at the quarterly physician “POD” meetings. There were a total of 33 POD meetings held in 2018! We learned from these sessions and have made some adjustments to encourage all of our primary care practices to attend. If you have not had a chance to attend one this year, please plan to do so in 2019. These meetings are a great way to learn all about our payor programs, quality and cost metrics associated with our gain-share contracts, and to meet with your peers to learn best practices for performance improvement.

Our care management team developed and onboarded a Social Worker and a Pharmacist this year to solidify our multi-disciplinary team in an effort to manage the needs of our most complex patients. The team has achieved the care plan targets for the Innovation Health gain-share, and is ready to effectively manage new patient populations part of various payor contracts in 2019. The addition of our pharmacist has had a positive impact, not only in managing the patients with complex poly-pharmacy needs but also in helping guide our network providers toward more cost-effective medications, resulting in savings for patients and payors! This year we also began a pilot with our Group Purchasing Organization, Premier, Inc. and a few primary care practices to determine if the pharmacy discount program offers a greater savings for our providers than they would obtain individually. If the analysis shows favorability, we will be offering it to our entire network in 2019.

Our IT team has made advances toward establishing and validating many EHR interfaces and has achieved data integrity which has established the foundation to produce consistent, reliable and actionable reporting to our providers. This year our analytics team has been able to provide regular and timely reports identifying patient quality metrics gaps, ED utilization, and high cost prescribing by providers. All of these reports support quality and cost metrics performance improvement.

It has been a big year for network contracting with the addition of several major Value Based Contracts (VBC) – Aetna commercial, Aetna Medicare Advantage, Innovation Health Medicare Advantage and United Healthcare commercial plans. With the addition of these VBAs, our network’s attribution will increase to over 100,000 beneficiaries in 2019. Also, with the addition of 70 new providers this year, we have now grown to be a network of over 1700 ambulatory providers.

We have had a great 2018 and this has been possible due to team work and physicians collaboration. Our team is committed to continued improvement in the area of quality metrics performance, and plans to implement strategies required for achieving significant cost reduction as our Medicare ACO prepares to take risk in 2021. Our Quality Committee and the Board of Directors have been guiding us in identifying the top priorities for reducing cost and developing initiatives to be successful under various value based contracts. Based on the recent discussions during Quality and Board meetings, pharmacy and ED utilization reduction are considered to be the areas of focus next year. With your support our team is prepared to achieve success in these and other areas.

We know that our collaborative environment is working, and together we look forward to achieving new milestones in 2019 and beyond!

Thank you.


Neeta Goel, MD
Medical Director for Quality and Population Health

Physician Leaders Quarterly Meetings

We are almost done with 2nd quarter of physician leaders meetings. It has been a pleasure to work with so many of you who have joined these quarterly meetings intended to increase physicians’ engagement with Signature Partner programs and services that are designed to support physicians and their patients in multiple ways. During these meetings, physician leaders and practice administrators learn about various quality initiatives to support their patients’ care, review everyone’s quality and utilization metrics performance, and discuss/share strategies to improve performance. Coming together in small groups has provided an opportunity for shared learning with peers to improve workflows that help all of us achieve success in various value based programs. Please look for an invitation coming your way to attend the 3rd quarter meetings that will be conducted in August via Webex.

Transitional Care Management

Transitional Care Management (TCM) refers to the service provided to patients during transitions in care from a hospital or other health care facility to a community setting. Hospital setting may include Inpatient acute care hospital, Inpatient psychiatric care hospital, Long term care hospital, Skilled nursing facility, Inpatient rehab, Hospital outpatient observation or Partial hospitalization. Home setting may include Home, Domiciliary (residential facility with treatment programs for a variety of issues, such as disabled veterans), Rest home (residential institution) or Assisted living facility.

Why is this important?

When leaving the hospital:

  • Almost one in five elderly patients return to hospital for care within 30 days
  • One third can’t explain their medications (means they do not know to take medication correctly)
  • 50% patients can’t state their diagnoses
  • 75% of chronically ill patients won’t need to make a return trip to the hospital if they had a plan for follow-up care

Extra support provided during transition of care from hospital setting to home setting improves care, enhances quality of life for our patients, and reduces hospital readmission.

Required Components of Transitional Care Management:

  1. Interactive Contact with the patient or caregiver within 2 business days (Mon – Fri except holidays) following a discharge. This contact is intended to:
  • Obtain and review discharge information
  • Review need for and or follow up on pending test/treatments
  • Education of the patient, family member or caregiver
  • Establish or re-establish with community providers and services
  • Assist in scheduling follow up visits with providers and services

Contact may be made via telephone, email, or face-to-face. Attempts to communicate should continue after the first two attempts within the required two business days until a contact is successful. If two or more separate attempts are made in a timely manner, and documented in the medical record, but are unsuccessful and all other TCM criteria are met, TCM service can still be reported/billed.

  • Face-to-face visit within 7 or 14 days
  • Medication reconciliation must be performed at this visit if not already done so during earlier contact
  • Medical Decision Making of Moderate or High Complexity

Moderate Complexity – e.g.

  • Multiple number of diagnoses or management options
  • Complexity of data to be reviewed is considered moderate
  • Risk of significant complications, morbidity or mortality is considered moderate

High Complexity – e.g.

  • Extensive number of diagnoses or management options
  • Complexity of data to be reviewed is considered extensive
  • Risk of significant complications, morbidity or mortality is considered extensive

Billing for Transitional Care Management:

Use the following CPT codes to appropriately code for TCM services –

  • 99495 – Medical decision making of moderate complexity during the service period; office visit with the Provider within 14 days of discharge
  • 99496 – Medical decision making of high complexity during the service period AND office visit with the Provider within 7 days of discharge

COPD Home Education Program

The management of COPD is complex and requires collaboration among PCPs, Pulmonologists, nurses, respiratory therapists, and case managers guiding patients about appropriate therapy to prevent frequent exacerbations that can result in decreased quality of life, multiple hospital visits, and increased health care cost. In addition to the medication management, education to improve self-management skills has been shown to be the key in improving quality of life and preventing frequent hospitalizations.

Signature Partners has collaborated with Respiratory Therapist team at Fairfax hospital, working under supervision of Pulmonologist Dr. James Lamberti, Medical Director, Respiratory Care Services at Inova Fairfax Hospital, to bring disease management education to our Innovation Health and MSSP patients at their home. This program is provided as “free of cost” to patients who may be unable to visit us in the clinic or may otherwise benefit from a visit at home where they are in a more relaxed setting and may be more receptive to learning about their disease and how to manage it; family members can also facilitate learning.

Signature Partners Case Managers, supported by Tonya Kirchmyer, Director of Care Coordination, introduce the program to eligible patients and will prompt the providers for an order. Provider referrals for complicated COPD patients are welcomed.

Signature Partners