Mini Summit 4: Risk Adjustment: Adequate for Specialty Medications in Global Bundled Payment
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1 Mini Summit 4: Risk Adjustment: Adequate for Specialty Medications in Global Bundled Payment Jerry Penso, M.D., M.B. A. Chief Medical and Quality Officer
2 What is AMGA?
3 What is AMGA? 3
4 AMGA By the Numbers Approximately 440 Medical Group Members 170,000 physicians Deliver health care to 120 million Americans Average group size is 348 physicians Median group size is 140 physicians AMGA medical groups treat approximately one in three Americans 4
5 Move to Value Based Payments Fee For Service Fee for Service Value = Quality/Cost
6 Source: Payment/sharedsavingsprogram/Downloads/All-Starts-MSSP-ACO.pdf
7 CMS Bundled Payment Sites 2016
8 MACRA Martini PQRS Meaningful Use Value- Based Modifier Quality Resource Use Improvement Activities Advancing Care Information
9 Merit-Based Incentive Program (MIPS) 4 Domains Determine Payment: Begins in 2017
10 MIPS Payments
11 Quality Payment Program Three Ways to Participate in MACRA Potential financial rewards Not in APM In APM In Advanced APM MIPS adjustments MIPS adjustments + APM-specific rewards If you are a Qualifying APM Participant (QP) = APM-specific rewards + 5% lump sum bonus
12 Factors Affecting Quality/Cost Performance Sociodemographic Clinical Factors Severity of illness Co-morbidities Attribution methodology Quality: Possible more important in outcomes than process measures
13 MIPS Specialty Measure Sets Rheumatology Care Plan Receipt of Specialist Report Documentation of Current Meds in EHR BMI Screen & Follow-Up Screening for HTN & F/u Tobacco Screen & Cessation Tobacco Use and Help Quitting Adolescents TB Prevention for Psoriasis, RA on Immunomodulators RA: Assessment & Classification RA: Functional Status Assessment RA: Glucocorticoid Management RA: Assessment of Disease Activity RA: TB Screening
14 MIPS ACO Measures Breast Cancer Screening Colon Cancer Screening Controlling HTN Depression Remission Diabetic Eye Exam Poor Diabetes Control (A1c >9) Fall Risk Assessment Depression Screen & Plan BMI Screen & Follow-Up Tobacco Use & Cessation Medication Reconciliation Post- Discharge Pneumonia vaccine Flu vaccine Statin Use in CAD Aspirin Use in IVD
15 Potential MIPS Cost Measures (Based on 2017 Final Rule) Total Per Capita Costs for All Attributed Beneficiaries measure 10 Episode-based cost measures: Mastectomy Aortic/Mitral Valve Surgery CAPG Hip/Femur Fracture or Dislocation Treatment Cholecystectomy and Common Duct Exploration Colonoscopy and Biopsy Transurethral Resection of the Prostate (TURP) for Benign Prostatic Hyperplasia Lens and Cataract Procedures Hip Replacement or Repair Knee Arthroplasty (Replacement) Medicare Spending per Beneficiary (MSPB) measure 6/25/2017 Include only part A and B costs Use CMS-HCC risk adjustment Trimming of outliers 15
16 HbA1c Not Measured 740,000 patients, aged 18 75, across 29 medical groups 19% of patients had no HbA1c measured in the last 12 months Copyright 2016 AMGA Analytics LLC and OptumInsight Inc. All rights reserved.
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18 Evidence for Diabetes Provider s Perspective 1.5 million patients with diabetes, aged 18 89, across 32 medical groups Type 1, type 2, type unknown (exclude gestational and secondary diabetes) At least 1 ambulatory E&M visit, July 2014 June 2015 How to identify patients who have diabetes? Diagnosis code (Dx) on a claim for a face-to-face encounter outbound medical claims Exclude Dx on lab orders, where diabetes code may be used in a rule out sense Patient s problem list (EHR) Lab values that are diagnostic of diabetes May be absent if patient is in very good control during the time period (HbA 1C < 6.5%) Medications for glycemic control erx, EHR med list [no pharmacy claims data] Exclude patients with other indications for these medications Some patients are managing their diabetes with diet and exercise EHR data may be missing if patient receives diabetes care from other provider organizations Proportion of patients identified in medical claims alone vs. claims + EHR data Copyright 2016 AMGA Analytics LLC and OptumInsight Inc. All rights reserved. 18
19 Plurality of care: Any specialty 1 ambulatory E&M visit 1,506,000 patients EHR Data vs. Medical Claims (Dx) Med Lab Lab + Med 12% PL only 2.1% + Med 12% Dx/PL + Med 18% PL only + 1.0% Lab + Med Dx/PL + Lab + Med 49% 17% of patients with diabetes are not identified in (medical) claims data Dx/PL + Lab 08% Dx/PL 13% PL only 0.4% + Lab PL only 1.6% Dx + PL 5.0% 13% Dx only 6.5% Copyright 2016 AMGA Analytics LLC and OptumInsight Inc. All rights reserved. 19
20 Conclusions Not including medications Patients with conditions not included in measures Inadequate identification of co-morbidities Inadequate risk adjustment for severity Copyright 2016 AMGA Analytics LLC and OptumInsight Inc. All rights reserved.
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