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Overview of HPHC Reporting Connecticut Medical Directors Meeting Martha Hoefer, Manager, Provider Analytics Wednesday, September 30, 2015 Agenda Purpose of orientation – orient you to HPHC’s commitment to Medical Informatics – demonstrate the array of reports, downloads, and dashboards available to provider groups Reporting Framework – Content areas: What? – Delivery mechanisms: Where? Resources 2 © 2011 Harvard Pilgrim Health Care Challenges in CT Reporting – No PCP selection HPHC’s product in CT is Open Access HMO (OAH) – No PCP selection is required PPO Attribution Methodology enables assignment of patient to a PCP – 24 months of claims history for professional services – Most CT members have not yet amassed sufficient claims history Current Attribution Logic (modifications in 2016) Step 0 1 2 3 4 5 9 3 Specialty Criteria Primary Care (PC) Primary Care (PC) OBGYN Primary Specialist dual (PS) Eligible Specialist Not Attributed © 2011 Harvard Pilgrim Health Care Visit Well Visit Any Visit Any Visit Any Visit Any 2 Visits Other Member Selection (Mass GIC only) Reporting Overview – Content Domains (what) & Access (where) Secure Server HPHConnect LCU Reporting (static pdf) Provider Performance Reporting Tools Data Extracts (interactive; Microstrategy) Financial / Cost & Utilization Financial Capitation Lab Steerage CSU Dashboard [PAID]** PCMH Dashboard ** Provider Util Reports by Physician Group [PASS] SFTP1 (by contract model) Hosp & Med Claims * Membership Capitation Pharmacy Claims Clinical IP Discharge [IP-DC] ** IP Census [IP-C]** Authorization /Notification Report [ANR]** CMDM Participation [CMDM]** Gaps in Care Metrics [EBIM/QMR]** SFTP2 Quality Mgmt Rpts * Gaps in Care Registries** Pharmacy Overview/Prescriber Profile Therapeutic Class Top Drugs Tier 1 (raw) Therapeutic Class Reports (target 2015Q2) ** contains PHI 4 © 2011 Harvard Pilgrim Health Care v111414 Access to HPHC Reporting Physician Group must have Privacy and Security Agreement in place (Contracting) HPHConnect Secure Server sftp User must have signed HPHConnect User Agreement (contains PHI) Requestor must complete User Access Request available at www.HarvardPilgrim.org/LCUReporting Submit form to: [email protected] Provider eBusiness provides account code; user sets password MicroStrategy: • HPHC Helpdesk provides Htrio Account with MSTR Web Report License • Provider Analytics establishes Htrio account and associated CSUs in access security table in EDW 5 © 2011 Harvard Pilgrim Health Care User must complete form HPHC Provider Reporting Support sends out SSH Tectia client software Contracting establishes type of Claims Downloads, per contract model and updates user access table NMM/Contracting establishes access to Quality Management Reports (HEDIS) Domain 1: Financial/Cost & Utilization Reporting HPHConnect LCU Reporting (static pdf) Secure Server Provider Performance Reporting Tools Data Extracts (interactive; Microstrategy) Financial / Cost & Utilization Financial Capitation Physician Group Provider Roster Member Months (Matrix) Mo. Cap Summary Capitation Rosters Hosp/Med Expense Detail Commercial 1 Pool Commercial 2 Pool Profit & Loss Commercial 1 Pool Commercial 2 Pool CSU Dashboard [PAID] $ PMPM & Util trends Vital Statistics High Cost Claimants Expense Type Detail Service Category Detail IP DRG Detail OP Service Detail ReAdm & ReER** Amb .Sensitive Cond Adm & ER SFTP1 (by contract model) Fully Insured Claims: Pool 1 & 2 Medical ASO Claims Membership: Weekly Chg Membership File snapshot a/o 1st of month Capitation Roster File Packages Options – with and without financials Flash & Excel Output Monthly Updates * *contains PHI 6 © 2011 Harvard Pilgrim Health Care Monthly Updates Monthly Updates (overwrites last month) Focus on: PAID Dashboard • • • • • • • • • 7 © 2011 Harvard Pilgrim Health Care 3 years of data trend Compared to Physician Group Linear regression Compared to top 25th percentile in network Can look at all CSUs combined or individually Can look at subpopulations by product, funding, and age Vital stats on membership and leakage High Cost claimants drillable to patient ID and cost over 100K threshold Readmissions/ReER shows cases seen within 30 days (all cause) drillable to patient level . Ambulatory Sensitive Conditions (ASC) shows cases with IP and ER activity that are best managed in ambulatory setting Focus on: PAID Dashboard • • • • Expense Type detail provides deeper view Heat map shows PMPM (size of box) and change from prior year (color) Can narrow time slider Can drill down for IP DRG information, OP Services (including ancillary), and Rx Report (class/drug/ prescriber, patient) Exportable: • Button to export dashboard to interactive Flash format, which retains all the interactivity off-line, so can be sent as attachment (Flash will not support data drilldowns of PHI , as you must be on live system and pass security checks • Excel icon in upper right produces tabbed excel file with all data points used in dashboard • Drill down outputs on live system can be exported to Excel output for further analysis/work flow management. 8 © 2011 Harvard Pilgrim Health Care Domain 2 Clinical Reporting Secure Server HPHConnect Provider Performance Reporting Tools LCU Reporting (static pdf) Data Extracts (interactive; Microstrategy) Clinical Daily updates Authorization & Notification [ANR] IP Discharge * IP Census* Authorizations Report* Monthly updates Care Management [CMDM] CMDM Participation* Quality Measures [EBIM/QMR] - Retrospective 12 months - Prospective: 1/1- this month * contains PHI 9 ** in development © 2011 Harvard Pilgrim Health Care Monthly updates SFTP2 Quality Mgmt Rpts * Gaps in Care Registries** Focus on: Authorization & Notifications (ANR) • • • • • • • • 10 © 2011 Harvard Pilgrim Health Care Data from HPHC Care Management System, updated daily by CMs Discharges within user defined time window IP Census of any cases IP during user defined time window Authorizations in system, past or upcoming Similar data on each report (hospital, attending, begin/end dates, diagnoses, procedures while IP, etc.) All hospitals where HPHC has been notified Exportable to Excel Frequent downloading of report enables detection of frequent flyers Focus on: Quality Measures Reporting (QMR) • • • • • • • 11 © 2011 Harvard Pilgrim Health Care Data sourced from Optum Impact Pro tool’s EMB suite Flat file, exportable to Excel RETROSPECTIVE VIEW (rolling 12 months, to enable overall practice performance; 28 measures) PROSPECTIVE (Cal YTD to find defects before year end; 17 measures) HMO/POS and PPO (Attributed) Adding more over time (e.g., Choosing Wisely) Metrics compares Physician Group performance to Prior Year HEDIS, HPHC Plan wide average, Regional 75th an d 90th Percentiles, National Focus on: Quality Measures Reporting (QMR) Member Detail Report • PCP information • Member Contact Information • Compliance Flag (1=Compliant) • Excel Format output 12 © 2011 Harvard Pilgrim Health Care Domain 3: Pharmacy HPHConnect Secure Server Provider Performance Reporting Tools LCU Reporting (static pdf) Data Extracts (interactive; Microstrategy) Pharmacy Tier 1 (raw) PAID Drilldown: Rx ** - Drug Class - Drug - Prescriber - Patient * contains PHI 13 ** in development © 2011 Harvard Pilgrim Health Care Pharmacy Claims (SFTP1) Multiple Prescriber Reports Secure Server/sftp SSH Tectia Client Claims Download files Harvard Pilgrim Health Care Integrated Product Download Program User Documentation Caritas currently receives this information - No Financials & No NPI File Pool 01 Claims File Pool 02 Claims Medasompxx.txt* When it’s available The 15thof the month. The 15th of the month. The 15th of the month. Medasoypxx.txt* Weekly Changes File Membership File Capitation Roster File Every Thursday The 2nd working day of the month. Around the 21st of the month. What it contains Partial Pool 1 Claims, which were paid in the previous month. i.e. In February, the claims file will contain claims paid in the month of January. Pended and payable claims are not included. The Medmy1XX.TXT will contain Year to Date claims data. Partial pool 2 Claims, which were paid in the previous month. i.e. In February, the claims file will contain claims paid in the month of January. Pended and payable claims are not included. The Medmy2pXX.TXT will contain Year to Pool Date claims data. Self insured claims, which were paid in the previous month. i.e. In February, the claims file will contain claims paid in the month of January. Pended and payable claims are not included. The MedasoypXX.TXT will contain Year to Date claims data. A download of the members who had a change since the last run of the change file. A snapshot of current eligible members as of the 1st of the month. The aca096xx.txt download file that contains the member level detail of your capitation payment. It includes one record per member for each month capitated. This file will save lots of paper and allow providers the ability to create reports by age/sex, drug eligibles, employer group, etc. The aca098xx.txt will contain Year to date claims data. Name of file on the bulletin board Medcmmp1xx. Medcmyp1xx. Medcmmp2xx. Medcmyp2xx. Medasompxx.txt Medasoypxx.txt ACA033XX.txt ACA005XX.txt ACA096XX.txt ACA098xx.txt *XX represents the Care Sub Unit Number of your file. Each sub care unit will have its o own file created. 14 Download files can Pilgrim be accessed on the HPHC SFTP Server defined for each user. Consult HPHC for © 2011 Harvard Health Care username, password, and directory information. www.harvardpilgrim.org/LCUReporting Live Link:Triage point for questions/issues Within Network Medical Management web page 15 © 2011 Harvard Pilgrim Health Care