On the Right Path: A Move from Volume to Value · Measurement and Value-Based Incentives Group...
Transcript of On the Right Path: A Move from Volume to Value · Measurement and Value-Based Incentives Group...
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On the Right Path: A Move from Volume to Value
February 29, 2016 Robert Anthony, Deputy Director, Quality
Measurement and Value-Based Incentives Group (QMVIG)
Center for Clinical Standards and Quality (CCSQ) Centers for Medicare & Medicaid Services (CMS)
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Conflict of Interest Robert Anthony Has no real or apparent conflicts of interest to report.
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Learning Objectives • Describe 2016 CMS Quality Strategy • Discuss HHS Secretary Burwell’s Delivery System Reform Goals, including
MIPS and APMs • Explain how MIPS is a streamlined approach using facets of existing CMS
quality programs
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Working Toward Value and Quality The CMS Quality Strategy guides the activities of all agency components working together toward health care transformation. The Strategy: Builds on the foundation of the CMS Strategy and the HHS
National Quality Strategy (NQS). Prioritizes six goals for success. Illustrates continued collaboration through a participatory,
transparent and collaborative process with a wide array of stakeholders.
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The 2016 CMS Quality Strategy Mission
Optimize health outcomes by
leading clinical quality
improvement and health system
transformation.
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CMS Quality Strategy Aims and Goals
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CMS Quality Strategy Goals and Foundational Principles
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Administration’s Goals for Payment Reform
Goal #1 • 30% of Medicare payments are tied to quality or
value through alternative payment models by the end of 2016, and 50% by the end of 2018
Goal #2 • 85% of all Medicare FFS payments are tied to
quality or value by the end of 2016, and 90% by the end of 2018
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The Future: Merit-Based Incentive Payment System (MIPS) Shifting Medicare Reimbursements from Volume to Value
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In January 2015, the Department of Health and Human Services announced new goals for value-based payments and APMs in Medicare:
MACRA is part of a broader push towards value and quality
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2016 2018 New HHS Goals:
30%
85%
50%
90%
The new Merit-based Incentive Payment System helps to link fee-for-service
payments to quality and value.
The law also provides incentives for participation in Alternative Payment Models
in general and bonus payments to those in the most
highly advanced APMs
0%
All Medicare fee-for-service (FFS) payments (Categories 1-4)
Medicare FFS payments linked to quality and value (Categories 2-4)
Medicare payments linked to quality and value via APMs (Categories 3-4)
Medicare Payments to those in the most highly advanced APMs under MACRA
MACRA moves us closer to meeting these goals…
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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a bipartisan legislation signed into law on April 16, 2015.
What does Title I of MACRA do?
• Repeals the Sustainable Growth Rate (SGR) Formula • Changes the way that Medicare rewards clinicians for value
over volume • Streamlines multiple quality programs under the new Merit-
Based Incentive Payments System (MIPS) • Provides bonus payments for participation in eligible
alternative payment models (APMs)
What is “MACRA”?
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Through MACRA, HHS aims to:
• Offer multiple pathways with varying levels of risk and reward for providers to tie more of their payments to value.
• Over time, expand the opportunities for a broad range of providers to participate in APMs.
• Minimize additional reporting burdens for APM participants.
• Promote understanding of each physician’s or practitioner’s status with respect to MIPS and/or APMs.
• Support multi-payer initiatives and the development of APMs in Medicaid, Medicare Advantage, and other payer arrangements.
MACRA Goals
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MACRA streamlines those programs into MIPS:
There are currently multiple individual quality and value programs for Medicare physicians and practitioners:
MIPS changes how Medicare links performance to payment
Physician Quality Reporting Program
(PQRS)
Value-Based Payment Modifier
Medicare EHR Incentive Program
Merit-Based Incentive Payment System (MIPS)
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A single MIPS composite performance score will factor in performance in 4 weighted performance categories:
MIPS Composite
Performance Score
Quality Resource use
Clinical practice
improvement activities
Meaningful use of
certified EHR technology
How Will Physicians and Practitioners Be Scored Under MIPS?
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Weighted Performance Categories
Quality MeasuresResource UseClinical Practice Improvement ActivitiesMeaningful Use of EHRs
25% 30%
30% 15%
MIPS Performance Categories
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The Secretary is required to specify clinical practice improvement activities. Subcategories of activities are also specified in the statute, some of which are:
MIPS: Clinical Practice Improvement Activities
• Secretary shall solicit suggestions from stakeholders to identify activities. • Secretary shall give consideration to practices <15 EPs, rural practices, and EPs
in underserved areas.
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• Performance assessment in four categories using weights established in the statute
• Weights may be adjusted if there are not sufficient measures and activities applicable for each type of EP, including assigning a scoring weight of 0 for a performance category.
• EHR weighting can be decreased and shifted to other categories if Secretary estimates the proportion of physicians who are meaningful EHR users is 75% or greater (statutory floor for EHR weight is 15%)
• Performance threshold will be established based on the mean or median of the composite performance scores during a prior period
• The composite performance score will range from 0 – 100 • The score will assess achievement & improvement (when data
available)
MIPS Composite Performance Score:
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• Based on the MIPS composite performance score, physicians and practitioners will receive positive, negative, or neutral adjustments up to the percentages below.
• MIPS adjustments are budget neutral. A scaling factor may be applied to upward adjustments to make total upward and downward adjustments equal.
MAXIMUM Adjustments
Adjustment to provider’s base rate of
Medicare Part B
payment
Merit-Based Incentive Payment System (MIPS)
*4% *5% *7% *9%
2019 2020 2021 2022 onward
-4% -5% -7%
-9%
*MACRA allows potential 3x upward adjustment BUT unlikely
How much can MIPS adjust payments?
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• Make available timely (“such as quarterly”) confidential feedback reports to each MIPS EP starting July 1, 2017.
• Provide information about items and services furnished to the EP’s patients by other providers and suppliers for which payment is made under Medicare to each MIPS EP, beginning July 1, 2018.
• Make information about the performance of MIPS EPs available on Physician Compare.
To implement MIPS, CMS will:
More on MIPS
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There are 3 groups of physicians and practitioners who will NOT be subject to MIPS:
1
FIRST year of Medicare participation
Participants in eligible Alternative Payment
Models who qualify for the bonus payment
Below low volume threshold
Note: MIPS does not apply to hospitals or facilities
Are there any exceptions to MIPS adjustments?
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MIPS adjustments
MIPS only
APM-specific rewards
+ MIPS
adjustments
APMs
eligible APM-
specific rewards
+ 5% lump
sum bonus
eligible APMs
• APMs—and eligible APMs in particular—offer greater potential risks and rewards than MIPS.
• In addition to those potential rewards, MACRA provides a bonus payment to providers committed to operating under the most advanced APMs.
Potential value-based financial rewards
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What should I do to prepare for MACRA? Look for future educational activities
Look for a proposed rule in spring 2016 and provide
comments on the proposals. Final rule targeted for early fall 2016.
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Questions ?
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Join CMS Sessions at HIMSS16 Title Session Time & Location
Tuesday, March 1 CMS EHR Incentive Programs in 2015 through 2017
Overview 26 10:00 a.m. – 11:00 a.m.
Palazzo B
CMS Listening Session: EHR Incentive Programs in 2018 & Beyond
56 1:00 p.m. – 2:00 p.m. Palazzo B
A Special Session with ONC and CMS (Presentation by Dr. Karen DeSalvo and Andy Slavitt)
N/A 5:30 p.m. – 6:30 p.m. Rock of Ages Theatre
Wednesday, March 2 CMS Listening Session: Merit-Based Incentive
Payment System (MIPS) 101 8:30 a.m. – 9:30 a.m.
Palazzo B
CMS Electronic Clinical Quality Measurement (eCQM) Development and Reporting
131 11:30 a.m. – 12:30 p.m. Palazzo B
Thursday, March 3
Interoperability Showcase: eCQM Submissions N/A 10:00 a.m. – 11:00 a.m. Booth #11954
CMS Person and Family Engagement: Incentivizing Advances that Matter to Consumers
234 1:00 p.m. – 2:00 p.m. Palazzo B
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Visit CMS Office Hours at Booth 10309
Office Hours Topic Time Tuesday, March 1
Merit-Based Incentive Payment System (MIPS) 11:30 a.m. – 12:30 p.m.
Booth #10309
Quality Measurement Development and Reporting 12:30 p.m. – 1:30 p.m.
Booth #10309
EHR Incentive Programs 2:30 p.m. – 3:30 p.m.
Booth #10309
Wednesday, March 2 Merit-Based Incentive Payment System (MIPS)
10:00 a.m. – 11:00 a.m. Booth #10309
EHR Incentive Programs 11:00 a.m. – 12:00 p.m.
Booth #10309
Quality Measurement Development and Reporting 2:00 p.m. – 3:00 p.m.
Booth #10309
Thursday, March 3 Merit-Based Incentive Payment System (MIPS)
9:30 a.m. – 10:30 a.m. Booth #10309
EHR Incentive Programs 11:00 a.m. – 12:00 p.m.
Booth #10309
Quality Measurement Development and Reporting 1:00 p.m. – 2:00 p.m.
Booth #10309
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On the Right Path: A Move From Volume to Value February 29th, 2016
Shawn Griffin, MD, CQIO, Memorial Hermann
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Conflict of Interest Shawn Griffin, MD has no real or apparent conflicts of interest to report.
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Agenda • New Data, New Systems, New Partners (Technology
and otherwise) • High Reliability Hospitals / Developing Aligned
Physicians • Aligning Primary Care Networks • Powering Population Management • Improving Population Health • Evolving Provider Incentives
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Learning Objectives • Discuss the implications of health information technology in
moving from volume to value (i.e., changes in sources of data, how we connect to other systems and partners, etc.)
• Identify the need for interoperability and data analytics to guide care in value-based care models
• Share Examples of Inpatient Interventions to Decrease SSE’s • Share Successful Methods to Engage Ambulatory Providers
in Population Management Using Reporting, Analytics, and Office Support
• Evaluate the Impact on Improved Population Health and Savings
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STEPS Value in this Presentation • This presentation will discuss programmatic areas related to the
following STEPS Values • T – Treatment / Clinical • E – Electronic Secure Data • P – Patient Engagement Population Management • S – Savings
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Memorial Hermann Health System • Largest Not-for-Profit Health System in Southeast Texas • 13 hospitals -- ~2,800 licensed beds • MH-TMC – one of busiest Level 1 Trauma centers in US • 24,000 Employees, 5,500 Affiliated Physicians • $4.5B Annual Revenue • $438M Annual Community Benefit • Most Successful Medicare Shared Savings Programs ACO
with >$110M in savings in first two performance years • MSSP ACO with ~1800 participating physicians, but only
~10% employed • Over 300 different EMR databases among participating
providers in ACO
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Evolutions at Memorial Hermann • Hospital Centered Thinking and Contracting to
Population Management • Staff Physicians to IPA to Clinically Integrated
Network to ACO • Relationship of Antagonism between MHHS and
Physicians to Written Compact to Culture of Alignment
• Physician Participation to Contract Incentives to Strategic Incentives
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Memorial Hermann Health System
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We Started Many Years Ago…
5 Key Strategic Inflection Points Clinical Programs Committees (CPCs) (2000) Clinical Integration (2005) The Physician Compact (2008) The Patient-Centered Medical Home (PCMH)
(2011) The Accountable Care Organization (ACO) and Single Signature Contracting (2012)
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CREATING HIGH RELIABILITY HOSPITALS
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Authority of the CPCs
Delegation from the health system
Protocols (creating and measuring EBM practices and order set templates) Performance (setting and monitoring progress against established quality
standards and protocols) Products (drives the standardization of vendors, formularies, supply chain
decisions) Payment (Pay for performance goals, co-management agreements, ACO
project metrics, PCMH elements) Projects (ED to ED transfer policy, CT scanning in pediatric head trauma,
standardized order sets in Observation units, service line, credentialing and privileging standards) Program Rationalization (Consolidation and concentration of clinical service
delivery – i.e. open heart and joint programs)
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MHMD Clinical Programs Committee & Subcommittees
MHMD Board of Directors
Clinical Programs Committee
H&V
Cardiology
CV Surgery
Neuro
Neurology
Neurosurgery
Woman/Child
Neonatal
OB/Gyn
Surgery
Anesthesia
Bariatrics
Orthopedics
ENT
Allergy
Medicine
Critical Care
Emergency
Ad hoc
Hospital Medicine
Post Acute
Oncology
Oncology
Contract
Imaging
Pathology
Primary Care
Adult PCP
Peds
Peer Review
Clinical Ethics & Palliative Care
Order Set Editorial Board
Informatics
Acute Surgery
510 Evidence-Based Practice Recommendations made by CPCs in 2014
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Selected MEC-Approved CPC & SQC Safety & Quality Guidelines
• Real-Time Ultrasound for Central Line Insertion
• Real-Time Ultrasound for Cath Lab Central Punctures
• OB Safety Training
• Prevention of Retained Foreign Bodies Policy
• DVT/PE Prophylaxis
• Bariatrics Privileging and Leveling
• Moderate and Deep Sedation Privileging
• Peer Review for Physician-Related SSEs
• Clinical Escalation Policy
• Postoperative Pulse Oximetry Monitoring
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Safety & Quality Guideline MEC Approval
Clinical Programs Committee
Critical Care Surgery Medicine
MHMD Board of Directors
Hospital MECs (11)
System Board Quality Committee
“Up and Over”
CPC Subcommittee(s):
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Med Exec Up or Down Vote
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This document is privileged and confidential Quality Committee or Peer Review work product under Hospital Committee Privilege contained in the Texas Health and Safety Code §161.031 & §161.032, or Medical Peer Review under the Medical Practice Act, Texas Occupations Code, §151.001 et. seq.; and the Medical Peer Review immunity provided by federal law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq.
Acute Hemolytic Transfusion Reactions
Hospital Acquired Conditions “Never Events”
Transfusion Events Jan 2007 - June 2015
2,139,000 Adjusted Admissions
11,601,000 Adjusted Pt Days
1,061,000 Transfusions
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This document is privileged and confidential Quality Committee or Peer Review work product under Hospital Committee Privilege contained in the Texas Health and Safety Code §161.031 & §161.032, or Medical Peer Review under the Medical Practice Act, Texas Occupations Code, §151.001 et. seq.; and the Medical Peer Review immunity provided by federal law, the Health Care Quality Improvement Act, 42. U.S.C. 11101, et. seq.
Acute Hemolytic Transfusion Reactions
Hospital Acquired Conditions “Never Events”
Transfusion Events Jan 2007 - June 2015
2,139,000 Adjusted Admissions
11,601,000 Adjusted Pt Days
1,061,000 Transfusions
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Zero
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46
HAI Hospital Scorecards
Number of HAIs in one month
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HAI Hospital Scorecards
Number of HAIs in one month
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Central Line Associated Bloodstream Infections Ventilator Associated Pneumonias
Surgical Site Infections Retained Foreign Bodies Iatrogenic Pneumothorax
Accidental Punctures and Lacerations Pressure Ulcers Stages III & IV
Hospital Associated Injuries Deep Vein Thrombosis and/or Pulmonary Embolism
Deaths Among Surgical Inpatients with Serious Treatable Complications
Birth Traumas Serious Safety Events
Hospital Acquired Infections, Conditions and Patient Safety Indicators
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Central Line Associated Bloodstream Infections Ventilator Associated Pneumonias
Surgical Site Infections Retained Foreign Bodies Iatrogenic Pneumothorax
Accidental Punctures and Lacerations Pressure Ulcers Stages III & IV
Hospital Associated Injuries Deep Vein Thrombosis and/or Pulmonary Embolism
Deaths Among Surgical Inpatients with Serious Treatable Complications
Birth Traumas Serious Safety Events
Hospital Acquired Infections, Conditions and Patient Safety Indicators
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Central Line Associated Bloodstream Infections Ventilator Associated Pneumonias
Surgical Site Infections Retained Foreign Bodies Iatrogenic Pneumothorax
Accidental Punctures and Lacerations Pressure Ulcers Stages III & IV
Hospital Associated Injuries Deep Vein Thrombosis and/or Pulmonary Embolism
Deaths Among Surgical Inpatients with Serious Treatable Complications
Birth Traumas Serious Safety Events
Hospital Acquired Infections, Conditions and Patient Safety Indicators
50
Central Line Associated Bloodstream Infections Ventilator Associated Pneumonias
Surgical Site Infections Retained Foreign Bodies Iatrogenic Pneumothorax
Accidental Punctures and Lacerations Pressure Ulcers Stages III & IV
Hospital Associated Injuries Deep Vein Thrombosis and/or Pulmonary Embolism
Deaths Among Surgical Inpatients with Serious Treatable Complications
Birth Traumas Serious Safety Events
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MH Southeast Hospital Iatrogenic Pneumothorax
MH Southeast Hospital MH Southeast Hospital MH Southeast Hospital
22 Months Zero Iatrogenic Pneumothorax
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MH Southeast Hospital Real Time Ultrasound Guidance
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1st Memorial Hermann Hospital >90% Ultrasound Compliance ICU Safe Practice Guideline:
Real-time ultrasound guidance will be used for placement of all central venous catheters,
whenever possible.
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High Reliability Certified Zero Award
1. Zero Events
2. 12 Consecutive Months
3. Certified Zero Category 54
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High Reliability Certified Zero Awards 2011-2015
ICU Central Line Associated Bloodstream Infections (15) ICU Catheter Associated Urinary Tract Infections (5)
Hospital-Wide Central Line Associated Bloodstream Infections (5) Ventilator Associated Pneumonias (23)
Surgical Site Infections Retained Foreign Bodies (40) Iatrogenic Pneumothorax (18)
Accidental Punctures and Lacerations (3) Pressure Ulcers Stages III & IV (28)
Hospital Associated Injuries (5) Deep Vein Thrombosis and/or Pulmonary Embolism (1)
Deaths Among Surgical Inpatients with Serious Treatable Complications
Birth Traumas (12) Obstetric Trauma in Vaginal Deliveries with Instrumentation (2)
Serious Safety Events 1&2 (13) Serious Safety Events 1 & 2 for 1000 Days (2)
All Serious Safety Events (1) Early Elective Deliveries (4)
Manifestations of Poor Glycemic Control (15) 55
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MH Northwest: Zero Retained Foreign Bodies
Zero Retained Foreign Bodies x 60 Months
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MD/Nursing OR Count Policy
Mandatory RFID Scanning
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MH Children’s: Zero Ventilator Associated Pneumonias
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Zero Ventilator Associated Pneumonias x 48 Months
Ventilator Bundle Compliance
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MH Katy: Zero Central Line Blood Stream Infections Hospital-Wide
Zero CLABSIs Hospital-Wide x 17 Months
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Central Line Bundle Compliance
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MH Sugar Land: Zero ICU Catheter Associated UTIs
Zero ICU CAUTIs x 24 Months
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CAUTI Bundle Compliance
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MH Woodlands: Zero Hospital Acquired Injuries
Zero Hospital Injuries x 21 Months
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CLINICAL INTEGRATION
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Clinical Integration (2005) Participating physicians must participate
• Selecting quality measures • Reporting performance • Determining performance targets (setting realistic
goals) • Participate in committee work, performance
feedback, and quality improvement activities • Time, effort and IT infrastructure all required
Those who do not participate even after remediation, must be removed!
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The MHMD Compact (2008)
MHMD agrees to: Maintain primary loyalty to physicians Negotiate well to align incentives Include physicians in work and decision making Provide clear and timely information
• Membership Criteria, Quality Measure Scoring • Accountability / Improvement Process • Contract, Financial Performance
Provide physicians with information, services, and education to ensure high quality and ease practice burdens Seek feedback from its physicians Maintain confidentiality Communicate, communicate, communicate Make meetings worthwhile and engaging Create leadership training programs
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The MHMD Compact
Physicians agree to: Practice evidence-based medicine Uphold regulatory, quality, and safety goals Report quality data Meet CI criteria Come to meetings and performance feedback sessions Pay attention to information from MHMD Accept decisions by physicians in MHMD committee settings Be flexible, share ideas Collaborate with colleagues and hospitals Behave as professionals
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WHAT ELSE IS NEEDED TO MANAGE POPULATIONS? WHAT ABOUT OUTPATIENT?
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Discounts Liability Ins Group Purchasing
Single Signature Contracts
Clinical Integration | Accountable Care Organization
Physician Training HCC
Documentation ICD-10 CMEs
MU University Physician University
Practice Transformation EMR
Point of Care NCQA
Practice Assessment
Patient Access
Patient Portal
Pt Engagement Patient Education
Gap Reports At Risk/High Risk
Physician Report Cards
Supp Medicine Post Acute
Ambulatory ICU
UC/AH Retail Clinics
Care Mgmt Disease Mgmt
Health Coaches Preventive Care
The Patient-Centered Medical Home (2011)
Informed Physician Better Care Great Experience
Quality Innovation
GNE Program
Data Claims Files
EMR data Lab Rx
Technology
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Selecting Practices for Advanced Primary Care Practices (APCP’s) • Nominations from aligned PCP’s • Visits by practice facilitators • Grading of each office capabilities
– Employment, Compatible EMR, On CPC’s, reported PQRS for CI, etc.
• Goal to have 100 in “first wave” - 200 expressed interest
• Specific incentive plan built – funded by system
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Program Benefits to APCP’s • Help with NCQA Certifications, Bridges to
Excellence, and Disease Program qualification • Brings in PMPM moneys and greater bonus
opportunities • Relieves offices of some care management duties • Network control necessary for risk management
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Patient Centered Medical Home Growth
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113
124 188
210 279
Jan 2012 Mar 2012 Mar 2013 Jun 2013 Sep 2013
47 NCQA
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Primary Care Network >350 Adult & Pedi Medical Home Physicians
West Region 73 APCPs
Region Leaders – Dr. Ankur Doshi & Dr. David Reininger
SW Region 82 APCPs
Region Leader – Dr. John Vanderzyl
North Region 62 APCPs
Region Leader – Dr. John Walker
Northeast Region 26 APCPs
Region Leader – Dr. Tejas Mehta
Central Region 55 APCPs
Region Leader – Dr. Kevin Giglio
Southeast Region 52 APCPs
Region Leaders – Dr. Maqsood Javed & Dr. Adnan Rafiq
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STRATEGIC REPORTING
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Population Health Data
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Claims Based Reporting
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MHMD Summary Report by POD Population PCP and Averages Jan-Mar 2013
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Regional Performance Reporting
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MHMD CI-APCP Report by (A) POD by Population
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Individual Physician Score Card
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ED Visits Per 1K By (A) POD By (X) Population of PCPs Jan-Mar 2013
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Report on CI-PCPs with Patients who have incurred overall cost of over $50K
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High Cost Patient Report
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Advanced Analytics SMART Registry
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Quality and Contract Metric Registries (Rolling Out Now)
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INCENTIVE EVOLUTION
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Incentive Strategy
• Incentives begin to satisfy requirements or drive early adoption of strategic behaviors
• Start simple and clearly measurable • Educate regarding drivers of earning incentives and align to payer strategic goals
• As analytics improves, sharpen measures • Unearned incentives physicians roll into carryover funds – Money doesn’t go away
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Evolution of Incentives
Start - Drive Adoption of Strategic Behaviors
Middle -Transition to Drive Behaviors of Value to Program
End - Sunset Program When Behavior Ingrained
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Transparent Measures with Periodic Updates of Performance
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Continually Challenging Physicians
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The Metrics Required for Participation in CI Network
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CI Network Existence
Met
rics
Req
uire
d fo
r Par
ticip
atio
n
• Active CI member in good standing with the program
• Attends one campus meeting
• Completes 1 CME
• Active CI member in good standing with the program
• Attends one campus meeting
• Completes 2 CMEs • Attains 50% quality
reporting threshold
• Active CI member in good standing with the program
• Attends two campus meetings
• Completes 5 CMEs • Attains 80% quality
reporting threshold
CI Program 2011
CI Program 2012
Population-Based Contracts
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Physician Level Scorecard - 2012
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APCP Incentive – 2014
Participation Targets Opp per physician
Adopt standardized data fields to support data collection (CCR3) $2,000
HCC Coding and Training Participation Medicare risk adjustment – Medicare Advantage Increase .05 Increase .10 Increase .15
$2.50 PMPM $5.00 PMPM $7.50 PMPM
Improved Care Coordination Regional Performance 3% $1,000 5% $2,000 >7% $3,000
$3,000
Working with embedded Care Coordinators / Clinical Pharmacist as per care management protocol* $2,000
$7,000 +PMPM 83
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Original MSSP Distribution Model
Earned Performance Payment
Tier 1.0
PCP Preferred Distribution Care Coordination Fee
$3 PMPM x Member/PCP Attribution
ACO Preferred Distribution Population Mgt. Innovation Fund
6%
One Time Reimbursement Direct ACO Organizational Costs
$500,000
Tier 2.0 (Balance After Tier 1.0)
2.1 Part A – Facility Fund Surplus 2.2 Part B – Professional Fund Surplus
Physicians = 25% Hospital = 75% Physicians = 100%
ACO Participant Groups/Phy = 50%
ACO Affiliate Groups/Phy = 50%
ACO Participant Groups/Phy = 60%
ACO Affiliate Groups/Phy = 40%
1.1 1.2 1.3
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2015 Incentive Simplification
Single Incentive Program
MSSP
Payer 2
Payer 1
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Bonus Pools 2015
• Source • Potential
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Contract Bonus Contract 1 $1.1M
Contract 2 $252K
Contract 3 $1.8M
Contract 4 $2.03M
Contract 5 $408K
MSSP $7.5-8.0M
Contract 7 $2.2M
Total $15.3-15.8M
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2015 Proposed Incentive Model
APCPs 1. 100% MSSP Quality
Reporting for PY2 2. 100% Responsiveness
to Medicare audit in defined timeframe
3. Attain Quality metrics as defined
****Any funds not paid will return to MHMD****
All Other CI Specialists
1. CPC or Credentialing Committee meeting
attendance (majority of meetings must be
attended) 2. Evidence of PQRS,
MU, or Levy Letter for XXX time period
Incentive Pool
CI Attendance or Approved Alternative Meeting / CME
Completion / Current with ECW AR
In-network Utilization based on claims
analysis
Decrease Cost determined by attaining shared savings
Gateway
Represent deduction
s to maximum
bonus payout by Provider
Represent deduction
s to maximum
bonus payout by Provider
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APCP Quality Metrics (2015) Quality Metrics Source Allocation Threshold
50% Payout Target 75%
Payout Distinguished 100% Payout
A1c Control (% over 9) MSSP Quality 17% 25% tile 75%tile 100%tile
Hypertension Control (<140/90)
MSSP Quality 17% 25% tile 75%tile 100%tile
ER visits per 1,000 vs Third Party Marketscan Benchmark Claims* 17% 95% of
Benchmark At
Benchmark 105% of
Benchmark
Communication of Doctor ACO Measure #2
CAHPS Scores 17% 25% tile 75%tile 100%tile
Rating of Doctor ACO Measure #3
CAHPS Scores 17% 25% tile 75%tile 100%tile
Generic Usage vs Third Party Marketscan Benchmark Claims* 17% 95% of
Benchmark At
Benchmark 105% of
Benchmark
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POPULATION HEALTH METRICS IMPROVE
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Clinical Economics Improved
0 50 100 150 200
CT Scans and MRIs /1,000
High -Tech RadiologyVisits /1,000
Impactable Surgical BedDays /1,000
Impactable Medical BedDays /1,000
Impactable Surgical Admits/1,000
Impactable Medical Admits/1,000
Impactable Admits /1,000
Effic
ienc
y M
etric
s
90
ACO Network, YOY performance
27.1% lower
26.6% lower
28.3% lower
47.0% lower
5.7% lower
42.4% lower
47.8% lower
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50%55%60%65%70%75%80%85%90%95%
100%
Asthma:Use of
appropriatemedications
Breastcancer
screening
Cervicalcancer
screening
Colorectalcancer
screening
Diabetes:Lipid profile
Diabetes:HemoglobinA1c testing
Payer NationalAverage
2014 MHMD Performance
Clinical Quality Improved
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Better Cost and Quality for Employers
92
Efficiency Results TARGET RESULT DELTA “Impactable” Medical Admissions/1,000 55.0 16.7 69.6%
Potentially Avoidable ER Visits/1,000 95.4 65.7 31.1%
High Tech Radiology Visits/1,000 170.3 149.0 12.5%
CT Scans and MRIs/1,000 66.3 60.5 8.7%
15% lower
20% increase
Enrollment 2014
2015
Medical Costs Target
Actual
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BEST IN THE COUNTRY MSSP PERFORMANCE
93
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MSSP Performance Year 1 (18mo)
94
MSSP ACO State Total Savings ACO Share
Memorial Hermann Accountable Care Organization
TX $57.83 M $28.34 M
Palm Beach Accountable Care Organization, LLC
FL $39.57 M $19.34 M
Catholic Medical Partners-Accountable Care IPA, Inc. NY $27.92 M $13.68 M
Southeast Michigan Accountable Care, Inc. MI $24.68 M $12.09 M
RGV ACO Health Providers, LLC TX $20.24 M $11.90 M
ProHEALTH Accountable Care Medical Group, PLLC
NY $21.91 M $10.74 M
Triad Healthcare Network, LLC NC $21.51 M $10.54 M
WellStar Health Network, LLC GA $19.88 M $9.74 M
Accountable Care Coalition of Texas, Inc. TX $19.10 M $9.36 M
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PY1 Performance
95
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PY1 Quality Score
MHACO – 82.8%
96
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MSSP Performance Year 2 (12mo)
97
MSSP ACO State Total Savings ACO Share
Memorial Hermann Accountable Care Organization TX $52.93M $22.72M
Palm Beach Accountable Care Organization, LLC FL $32.17M $14.46M
Physician Organization of Michigan ACO MI $27.07M $12.08M
Oakwood ACO, LLC MI $19.07M $8.15M
Millennium ACO FL $17.49M $7.98M ProHEALTH Accountable Care Medical Group, PLLC NY $17.15M $8.02M
Allcare Options, LLC FL $16.99M $6.06M Qualuable Medical Professionals, LLC VA, TN $16.62M $7.41M
Accountable Care Coalition of Texas, Inc. TX $16.04M $6.34M
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PY2 Performance
98
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PY2 Quality Score
99
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Final Thoughts/Opinions • There are no silos in medicines, there are “castles” of
information and influence that give their owner’s power. • Make friends with your organizational HIPAA-chondriac. You
may have to overcome them at some point. • Consistent transparency of process and data support ongoing
physician alignment. Data is shared to support improvement, not “shaming.”
• There is currently no unified software platform that has all the functionality needed for robust population health management on a comprehensive data warehouse.
• Efficient scalability is the greatest challenge in population management.