Download ACO Made Simple

Frederick Integrated
Healthcare Network
All Provider Meeting
February 4, 2015
FIHN Board of Managers
• 13 Member Board (75% MSSP participants = 10)
– 1 Medicare Beneficiary
– 2 Health System Representatives (included in
“participating MSSP provider” count)
– 10 Physicians (at least 8 of whom are MSSP
participating)
– Physician composition:
• 3 specialists:
• 7 PCPs:
2 independent, 1 Monocacy Health Partners
6 independent, 1 Monocacy Health Partners
– At least 8 providers are non hospital affiliated,
independent practitioners
2
Frederick Integrated Healthcare Network
Board of Managers
Chair: Richard Gough
Credentials Committee
1.
2.
3.
4.
5.
6.
7.
8.
Johnson Koilpillai
Neil Waravdekar
Kevin Hohl
Wayne Crowder
Sibte Kazmi
Gaffar Syed
Neil Waravdekar - Chair
Wayne Crowder
Manny Casiano
Gaffar Syed
Leonard Kinland
Michael Costello
Johnson Koilpillai
Jennifer Teeter
Governance and Membership
Committee
1.
2.
3.
4.
Johnson Koilpillai - Chair
Sibte Kazmi
Vincent DiFabio
Jennifer Teeter
Lakhvinder Wadhwa
Saeed Zaidi
Mark Soberman
Michelle Mahan
Jennifer Teeter
Richard Holz
Clinical Integration and IT
Committee
1. Richard Gough - Chair
2. Dawei Yang
3. Lakhvinder Wadhwa
4. Johnson Koilpillai
5. Andrew Donelson
6. Gerard Delgrippo
7. Paul Feinberg
8. Mark Chilton
9. Jim Trumble
10.Manny Casiano
11.David Quirke/Phil Stiff
12.Heather Kirby
13.Jennifer Teeter
Finance Committee
1.
2.
3.
4.
5.
6.
7.
8.
Saeed Zaidi – Chair
Mark Soberman
Kevin Hohl
Amy Jones
Dave Bromberg
Richard Gough
Michelle Mahan
Jennifer Teeter
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Network Participation
PCPs
Specialists Total
84 (83% of 160
244
available)
Non par
Future provider contracting strategy –
Preferred SNFs, HH Agencies, Radiology,
Urgent Care, Lab
4
Contracts for 2015
2016 and beyond
Commercial
Payors:
AETNA,
United, CIGNA
Frederick Integrated
Healthcare Network
(FIHN)
Does not interrupt
fee for service
contracts and billing
shared savings
contracting
CY 2015
FMH
Employee
Health Plan
Medicare
Shared
Savings/ACO
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Medicare ACO participant practices for 2015
Sajjad Aziz
Anusha Belani
Cardiovascular Specialists of Frederick
Centers for Advanced Orthopedics – MMI
Jeff Cowen
Mark Coyne
Frederick Medical and Pulmonary
Frederick Gastroenterology Associates
Frederick Kidney Care, Drs. Nahar and
Rengen
Frederick Oncology Hematology Associates
Syed Haque
Irfan Hassen
Internal Medicine Specialists, Tyra Kane
William Johnson, MD, PA
Sibte Kazmi
David Kossoff
Julio Menocal
Middletown Valley Family Medicine
Cynthia Moorman
Hitesh Patel
Banislav Romanic
Jalal Saied
Gaffar Syed
Saeed Zaidi
MONOCACY HEALTH PARTNERS AND FMH
Center for Chest Disease
Center for Breast Care
Frederick Urology Specialists
Mononcacy Health Partners Immediate Care
Monocacy Health Partners Pain and Palliative Care
Monocacy Health Partners Wound and Hyperbaric Specialists
Monocacy Health Partners Behavioral Health Services
Monocacy Health Partners Endocrine and Thyroid
Orthopaedic Specialists of Frederick
Oncology Care Consultants
Parkview Medical Group
Surgical Specialists
Union Bridge Family Practice
Frederick Memorial Hospital
FMH Home Health Services
Hospice of Frederick County
FMH Rose Hill, Mt. Airy, Urbana and Crestwood locations for
lab, radiology and rehabilitation services
FMH Diabetes Center
Practices can be added to ACOs during the year, but PQRS reporting is not done through the ACO
unless a practice was participating prior to the start of the calendar year for ACO reporting.
What is an ACO?
• Providers working together under a payor contract to
improve the quality of care and reduce avoidable costs
for a defined population
• Medicare calls these organizations “accountable care
organizations” (ACOs).
• Frederick Integrated Healthcare Network is an ACO
(organization under contract with MC)
• There are approximately 424 ACOs under contract with
Medicare nationwide
• 15 in Maryland: AAMC, GBMC, Meritus, Carroll, Shah,
Universal American (3), Adventist, Hopkins, Lifebridge
How are Medicare beneficiaries
“attributed” to an ACO?
• Medicare reviews 1 year of claim data to see which beneficiaries
received plurality of primary care services (E&M services) from ACO
providers:
– Primary Attribution – PCP visits (FP, IM, GP, Geriatrics)
– Secondary, if no PCP – Specialist providing E&M visits
• If the tax ID/physician practice is part of an ACO, the ACO is attributed
that practice’s beneficiaries
• 5,000 attributed beneficiary threshold requirement
• FIHN achieved 10,061 attributed Medicare beneficiaries
• The attributed provider may be accountable to report quality
measures
• Providers in the ACO report PQRS through the ACO quality measures
• If the practice leaves the ACO, the beneficiaries leave as well over
time
How is success measured?
– Quality measures/metrics – quality can not be
sacrificed for cost savings
•
•
•
•
Care of chronic conditions
US Preventive Health Services Task Force Measures
Customer service
Quality measures reported through EHR integration,
CG-CAHPS surveys and Claim data
– Cost efficiency measures/metrics
• Comparison of historical overall costs/patient
MSSP ACO Quality measures
Updated
MSSP Quality measures
Updated (continued)
MSSP Quality measures
Updated (continued)
•8 customer service measures reported via CG-CAHPS surveys
•7 measures reported via claim data from ACO providers
•18 measures reported via practice EHR data collected by ACO and reported via
PQRS Group Practice Reporting Option (GPRO)
•If the ACO does not successfully report, the practices within the ACO do not
successfully achieve PQRS reporting
Quality Measure Reporting
• ACOs integrate Electronic Medical Record data
from practices to report on quality measures
• EMR surveys by ACO IT staff are necessary to facilitate
extraction from EMR fields
• Medicare shares claim data on attributed lives
• Data mined by ACO to see gaps in quality and report
opportunities to ACO providers for action
Medicare wants physicians to join
ACOS and participate in CMS
Innovation Center Pilots like MSSP
Medicare incentives…
CMS Value Based
Purchasing
Value Based Modifier Program – 2016, adds efficiency
measures to PQRS
– Cost - per capita spend for patients with 4 chronic conditions:
COPD, HF, CAD and Diabetes
– Quality 6 domains – harm, patient experience, coordination of
care, prevention, best practice, affordability of care
•
•
•
•
2012 pilot reports given to physicians in select states
2015 – modifier for groups 100+ physicians (-1%)
2016 – modifier groups 10+ physicians(-2%)
2017 all physicians (-2%)
PQRS negative adjustments not applicable for providers in an ACO 20152017 so as not to disturb physician investment in initiatives that work
toward similar triple aim goals, ACO reports PQRS measures
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CMS Value Based
Purchasing continued
• 2018 Merit Incentive Payment System (MIPS) currently
“proposed” next step for CMS Value Based Payment - likely to
pass. Replaces “pay to report” with “pay to perform” on quality
measures.
• Permanently eliminates physician fee schedule sustainable growth
rate reductions (26.5% threatened) and Provides a (.5%) physician
fee increase 2015 through 2018
• Combines PQRS, Value Based Purchasing and Meaningful Use
• Creates national objective for interoperability of EHRs by 2017
• ACO providers receive
1% fee schedule increase instead of .5% for all other physicians
5% bonus for alternative payment methodology participation
• MIPS supported by AMA, AAFP and American College of Physicians
and likely to pass
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Medicare Regulations
• Poster in PCP offices explaining ACO participation
• Beneficiary Notification - right to opt-out of CMS
sharing historical claim data
• Notification via 2 methods
• Face to Face physician office visit, record in EMR
• Beneficiary mailing by ACO, ACO tracks
• Beneficiary can use Form to opt out or call Medicare
directly to declare opt-out choice
• Medicare will send ACO claim data on any attributed
beneficiary who does not opt out of data sharing
• ACOs benefit from data to develop actionable plans to
meet goals
What is different for patients, why
agree to data sharing?
Patient experience is improved through ACO
investments
– Support outside of physician office visits –
• Care Managers, social workers, navigators
• Pharmacists – medication reconciliation, fewer adverse drug
interactions
• Home monitoring, catch problems before they happen
– Shared medical record data – improved communication
between providers, reveals gaps in care, reduces
duplication and out of pocket cost
Proactive outreach reduces acute episodes and out of
pocket cost for patients, better care over time
Priorities for Success
Population Health Management Priorities
• Engage contracted lives – Beneficiaries, FMH Employees,
encourage data sharing
• Select Analytics Platform
• Establish ACO communications plan - physicians &
patients
• Identify high risk/utilizers and strategy
• Capture Quality Measures – CMS 33 and Employee HP
• PCMH strategy - improve access and patient support
• Implement Care Management Plan
• Identify Leakage opportunities to grow market share
• Assess Post acute provider quality/cost, use best in class
• Develop shared savings distribution methodology
Strategy underway
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ACO Reduction of Avoidable
Utilization/Cost Where to start?
• MSSP Goal: 3.5% cost reduction, $3.8M estimated
• Equivalents: $400 per beneficiary, 379 admissions
• Data from CMS
• FMH Employee Health Plan: Up to 13% savings will be
shared, $840,000
• Equivalents: $455 per member, 84 admissions
• Data from TPA/UMR reports underway
• MSSP/ACOs experience data delays due to –
– Beneficiary mailing opt out notice timing
– CMS delays in sending claim data
– Challenges of incorporating CMS data into analytic tool
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High Utilizer Reports –
Let’s get started!
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Data Solutions –
Behind the scenes work in progress
• MD Hospitals have access to new HSCRC/CRISP data:
Potentially Avoidable Utilization:
• Readmissions: Inpt, Observation & ER revisits
• Admissions for “preventable” acute exacerbation of chronic
conditions that should be managed outpatient
• Plan: Review Medicare high level data – Top 25
• Distribute patient level data by PCP accompanied by resource list to
begin matching high utilizer patients to solutions
• PCP Revenue Opportunities – Transitions and Complex Care
Management (2015 CMS physician fee schedule)
• Medicare Wellness visit - capture 33 measures and identify rising
risk patients
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Physician Report Overview
• Data Source:
– HSCRC Potentially Avoidable Utilization Report
– Case level, Inpatient data only
• Data Period:
– Calendar Year 2014 YTD data through September
• Included Cases
– Medicare FFS patients only
• Comparison groups:
(1) Primary Care Physician (MC FFS)
(2) FIHN MSSP Providers (MC FFS)
(3) All FRHS MC FFS
24
Admission Statistics
• IP Admissions = Count of Inpatient cases for physician
• Average LOS (Length of Stay) = Sum of total Inpatient days / IP
Admissions
• Average SOI (Severity of Illness) = Sum of total SOI (severity level assigned to
each Inpatient case) / IP Admissions
– SOI ranges from 1 (least severe) to 4 (most severe)
• Unique Patients = Count of distinct patients
• High Utilizer Patients = Count of distinct “High Utilizer” patients, with:
(1) >= 2 Inpatient stays, and
(2) >= $50,000 total charges
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Readmissions and Revisits
• Readmissions
– Inpatient Readmissions = Inpatient cases that occur within 30 days of an
initial Inpatient stay
– Cases Eligible for readmission = All Inpatient cases, excluding:
(1) Deaths
(2) Transfers to another acute hospital
– Readmission Rate (%) = Inpatient Readmissions / Cases Eligible for Readmission
– Expected Readmissions
• Target line on Readmission Rate graph
• Expected calculation = Physician cases by DRG severity of illness x State average
readmissions by DRG severity of illness
• Revisits
– Emergency Department or Observation visits that occur within 30 days
of an initial Inpatient stay. The Initial visit must be Inpatient.
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Potentially Avoidable Utilization (PAU)
• PAU is volume that can be potentially avoided though
improved ambulatory care PAU includes:
– Prevention Quality Indicators (PQIs) as defined by AHRQ –
13 diagnosis
– Inpatient (IP) 30-day readmissions (intra and inter-hospital)
– Outpatient (OP) 30-day revisits to ER/Observation (after an
IP stay)
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Hospital Potentially Avoidable Utilization
Preventable Admissions – Prevention Quality Indicators -
diagnosis for which strong primary care would reduce rates
of hospitalization. National Quality Foundation endorsed
measures used by state agencies.
Lower extremity amputation in patients with diabetes
Uncontrolled Diabetes, Long Term Diabetes, Short Term
Diabetes
Adult Asthma
Angina
Urinary Tract Infection
Bacterial Pneumonia
Dehydration
COPD
Hypertension
CHF
Perforated Appendix
Sample Report – Dr. Gough
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Patient names
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Names
31
Further data forthcoming
• Emergency Room High Utilizers
• Imaging Utilization – FMH off site location
use appropriateness compared to best
practice
• Data on FMH Employee Health Plan
Utilization
• ACO claim data from Medicare – April
timeframe
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Planned Population Management Interventions
Activity
Expected Outcome
Expected Timeframe
Transitions of Care
Reduce Readmissions
3 months
Discharge Planning
Reduce inpatient days and
readmissions
3 months
Case Management for targeted High
Risk Populations
Reduce Admissions, cost of
outpatient services
3-6 months
Case Management for other
populations
Reduce Admissions, cost of
outpatient services
6-12 months
Pharmacy Management
Increase generic use and mail
order
6-12 months
Nursing Home Management
Reduce Readmissions and
Admissions
12-18 months
More efficient specialists and
ancillary providers
Decreased cost per episode of
care
12-18 months
SHORT TERM
MID TERM
Source: Geisinger
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Planned Population Management Interventions
(cont’d)
Activity
Expected Outcome
Expected Timeframe
High Cost Imagining
Reduce unnecessary testing
12-18 months
Reduced ED Visits
Reduced ED visits for all
insurance products
6-12 months
Interventions for low risk chronic
disease populations
Improved disease control and
prevention of complications
2+ years
Preventive care, screening, wellness
Earlier identification and
treatment; decrease disease
incidence
2-5+ years
Increased Use of Advance Directives
Improve quality of life; free up
acute care beds; increased
patient engagement
2-5 + years
MID TERM
LONG TERM
Source: Geisinger
34
Population health interventions by time to ROI and impact on quality
Large
Utilization –
end of life
care
Post-hospital transition
management
Post acute care
management
Disease
management
Patient access
Case management
Impact on
quality
Utilization - pharmacy
Utilization – discretionary
procedures
Leakage - inpatient
Utilization - imaging
Small
Leakage – OP
procedural
Leakage – OP
non-procedural
Leakage - imaging
Long
Time to Return on Investment
ROI – Return on Investment, OP - outpatient
Quick
Toolbox of resources
1. Care Managers - help manage high risk patients, develop care plans,
education, navigation, access and affordability for services and resources
2. Dietitians – educate patients about linkage between diet and disease
management
3. Pharmacists – Medication reconciliation, access and affordability of the most
efficacious medication plan, and Medication Therapy Management
4. Social Workers – social needs assessment, connection to community
resources, coaching (housing, medications, meals, transportation, in-home
support, etc).
5. Home tele-Monitoring – identification of early warning signs/triggers for early
home/office based intervention to avoid unnecessary emergency room or
acute episodes
6. Lay Navigator - training and patient support of nonclinical individuals to
increase patient self-care/management and to facilitate/navigate available
supportive resources
7. Behavioral Health resources
8. Home Health capabilities listing and resources
9. SNF capabilities listing
10. Emergency Room Case Management
11. Disease Specific intensive education for patients with COPD, CHF, Diabetes
12. Interpreter
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Other resources
1. Telemedicine
2. Beneficiary communication (newsletters, web site, lectures) regarding
disease process management, resources
3. Patient portal for communication with FIHN providers, access to
records, adding information about health history
4. IT resources for integration of EMR data to improve communication
and reporting
5. Primary Care Redesign resources to help practices transform to
highly accessible practices that make use of evidence based
medicine and EMR resources to measure and improve patient health
6. Clinic services for coordinated disease management education,
support, navigation, social services, and various other supportive
services to improve overall health status.
7. CME Training for providers on up-to-date evidence based care for
specific diseases
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What we should do now –
Focus on High Risk/High Cost –
• PCPs Review High Utilizer Report – review for patients who
could be helped through care management
Manage Transitions – whether or not you bill for TCM codes,
contact patient within 72 hours of discharge, use CRISP data to
learn of transitions
Access to Care – is the practice open evenings/weekends? Consider
options to improve access and reduce ER use
Get patients in for their MC Wellness Visit – collect Quality
measures in your EMR, engage with FIHN IT in data integration
Specialists – more to come when we have CMS data
• Encourage patients to have a PCP (quality measures)
• Review Choosing Wisely recommendations from your specialty
• Consider use of Generic Prescriptions
All – Advanced Directives, end of life care
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MSSP/ACO PCPs taking new
Medicare patients
Middletown Valley Family Medicine
Parkview Medical Group
Dr. Aziz
Dr. Zaidi *** double check
Dr. Kazmi
Dr. Syed
Union Bridge Family Practice
Dr. Menocal
X’cel Primary Care – Jalal Saied
Internal Medicine Specialists – Tyra Kane
Transitions in Care
Contact within 72 hours with patients who are
transitioning from one level of care to another
is a key factor in reducing readmissions
CRISP can send notifications to the practice
when your patients are discharged
FMH care management reaches out to any
discharged patient who through screening is
determined to be at high risk of readmission
to help schedule follow-up appointments
Create capacity to see these patients
Chesapeake Regional Information
System for Patients (CRISP)
• Maryland statewide information exchange
• Currently houses: lab, x-ray, hospitalization and ER use
data
• Physician alerted when a patient is hospitalized or
visits the ER, view medical record. Direct encrypted email to your practice.
• Supports meaningful use and PCMH
• RxHub shows medication fill information
• Free to physicians affiliated with a MD hospital
• 1-877-952-7477 or [email protected]
CMS Transparency Requirements
• Web site – approved by CMS www.fihn.org
– ACO Name, Address, Primary Contact
– Composition – Partnership or Joint Venture
between hospitals and ACO Providers
– Participants (Practice names)
– Governing Body Names
– Committee names and Chairs
– Shared Savings Methodology (high level)
– Results of any Savings reconciliations to date
– Quality Performance Results
42
Next Steps
Implementation of 1st FIHN Payor contracts – 1/1/2015
• FMH Employee Health Plan
• Medicare Shared Savings
All Provider Meetings – education and implementation
sessions: care management, patient notices, reporting
Mailing to Medicare Beneficiaries – data sharing opt-out
Selection of Population Health IT software solution –
Integration of practice EHR data on quality measures
Deployment of medical management strategy using
available data on high risk patients
Medicare Patient Visits / Wellness visit – collect quality
measures!
Contract CG-CAHPS vendor – customer service survey
43
FMH Employee Health Plan
FIHN
Shared Savings Agreement
Timing
• Concept work with TPA and FIHN: April – June
• Legal review and contract development: August,
ERISA issues evaluated by special council: Sept.
• Fair Market Value Assessment: October
• FMH Fiduciary/Board Approval: October
• FIHN Board Approval: October
• Opt-out mailing to FIHN Network: November, 0
opt-out
• Final 2014 baseline numbers from TPA: January
• Implementation: January 1, 2015
• Hurdle with TPA – HIPAA concerns over patient
identifiable data, aggregate reports for now
Quality Measure Considerations
• Areas where health plan scores poorly
compared to UMR book of business and
Healthy People 2020 goals
• Measures that can be reported via claims
data in lieu of having EMR access
established
• Measures crossing prevention, utilization
and quality domains
• Measures that cross over into other shared
savings programs, continuity of effort
Measures selected with FMH Human
Resources and FIHN Medical Directors
PCP Practice Survey
• Purpose – to obtain a network baseline
– Accessibility to Primary Care services
– Interest in PCMH
– Practice capabilities care management,
tracking and reporting referrals
– Health Plan Participation
• Different than IT Survey for EMR quality
measures
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Next Steps both contracts
Physicians –
• High Utilizers- Strategy development and deployment – care management
or other tools & patient access
• Transitions in Care Management – 72 hour appointment
• Patient visits – collect and report quality measures – identify rising risk
• Participate in EHR Integration with FIHN IT
• Specialists – Choosing Wisely and ensure patients have a PCP
• End of Life/Advanced Directives
FIHN –
•
•
•
•
•
•
•
•
•
•
Credentialing of network providers
Web site development – beneficiary and FIHN physicians
Beneficiary Mailing – find addresses, opt out tracking
Claim reports – quality, cost; network and provider level report cards
Financial Management – Progress on savings goals
CG-CAHPS vendor contracting
Use integrated EMR data to report on quality measures – report cards
Future provider contracting strategy –Preferred SNF partners, lab, xray
Participation Fee – FMV assessment, paid from savings
Payor contracting – future Agreements
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