IT/Analytics Part 1. Medicare Shared Savings Program Boot Camp AMGA. Sheila Johnson, RN, MBA May 16, 2013

Transcription

1 IT/Analytics Part 1 Medicare Shared Savings Program Boot Camp AMGA Sheila Johnson, RN, MBA May 16, 2013

2 Learning Objectives At the end of this session, the participant will be able to: 1. Articulate some of the data sets that CMS provides 2. Demonstrate how to use CMS provided data sets and supplemental data to meet the Triple Aim

3 The Dartmouth-Hitchcock Journey to an ACO CMS Physician Group Practice Demonstration Project Level 3 NCQA Patient Centered Medical Home (28 sites, adult & pediatrics) Cigna Collaborative Accountable Care Citizen s Health Initiative CMS PGP Transition Demonstration Employees & Dependents = Self insurance program Anthem/Well Point and Harvard Pilgrim Health Care Medical Cost Model Pioneer ACO Participant OneCare Vermont MSSP Partnership with Fletcher Allan

4 Becoming an ACO Participant CMS Requirements ACO Commitments Implications for Local Delivery System Getting Started The First Three Months after ACO Effective Date

5 Initial Actions Provider Related National Provider Identification notification of MD adds/leaves Beneficiary Related Understanding who is assigned to the ACO and which MD Data Sharing Preferences Notification Initial CMS provided data reports 5

6 Beneficiary Related Attributed Beneficiary List Need to perform Data Sharing Preference task Letter and opt out form Dataset needed addresses of beneficiaries Share beneficiary list with providers 6

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23 Participant Activity Let s dive deeper into the reports and discuss the data elements and develop a population profile

24 Assigned Beneficiaries = Percent with 7 or greater # of Primary Care Services = Enrollment Type (ESRD, Disabled, Aged) does anything stand out? Age and Gender Are you surprised at the spread? County review are you aware of your service area? Expenditures/Utilization Trend Report what opportunities do you see? Any challenges? Historical Benchmark Determination what calls out to you?

25 Analyze Population Profile Clinical Analysis Who does the patient really belong to? Patient Profile chronic conditions, quality status, utilization Complete ICD-9 coding clinical picture Targeted clinical conditions to focus on? Assess Clinical Structure

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30 Understanding your Potential Patient Population Targeted clinical conditions: CHF : 13%, CAD : 10%, Diabetes: 24%, COPD : 14%, HTN : 62%, High risk : top decile Targeted health expenditure locations : IP : 41%, Hospital OP : 27%, MD : 17% CMS PGP Demo 30

31 Data for Action and Performance Monitoring 31

32 The Claims have arrived now what? Do you have the technical ability to process the claims for: Creating actionable datasets Performance Monitoring 32

33 Beneficiary Level Who does the patient really belong to? Primary Care Provider vs Specialist Attribution Patient Profile chronic conditions, quality status, utilization Complete ICD-9 coding clinical picture Which patients need the most attention? Who do we start with? Tools to guide action?

34 Who uses the Data? Clinical Care Delivery Team Physicians and associate providers Support Staff Outreach and pre-visit planning In office use Care Coordination, Health Coaching, Case Management

35 One Data Approach Low Tech Solution Wise Registry: Claims Data Elements include: Risk Score prospective ED and IP usage (admits & readmits) Expenditures Rx Most Frequent Diagnoses Last Office Visit Date Quality Measures Registries: Internal generated from EHR & Billing Data 35

36 Wise Registry Run Date Insuranc e_pool PCP Practice PCP ID PCP Name PCP Team PCP Specialt y Member Zip Member Last Name Member First Name Member ID MRN Member Date of Birth Member Gender Member Age Member Relation Member Months of Eligibility MM/DD/ YY CMS ACO Geograp hic Site ###### Last, First, Middle Initial Off Main Site A FAMILY PRACTI CE Bungfort h Napolea n ###### ###### MM/DD/ YY M ## SUBSC RIBER 12 MM/DD/ YY CMS ACO Geograp hic Site ###### Last, First, Middle Initial Main Site FAMILY PRACTI TEAM B CE Brunbac k York ###### ###### MM/DD/ YY M ## SUBSC RIBER 12 MM/DD/ YY CMS ACO Geograp hic Site ###### Last, First, Middle Initial Off Main Site B FAMILY PRACTI CE Twist Oliver ###### ###### MM/DD/ YY M ## SUBSC RIBER 12 MM/DD/ YY CMS ACO Geograp hic Site ###### Last, First, Middle Initial (N/A) FAMILY PRACTI CE Kaghtha ne Dale ###### ###### MM/DD/ YY M ## SUBSC RIBER 12 MM/DD/ YY CMS ACO Geograp hic Site ###### Last, First, Middle Initial Off Main Site C FAMILY PRACTI CE Lolball Cecilia ###### ###### MM/DD/ YY F ## SUBSC RIBER 12 MM/DD/ YY CMS ACO Geograp hic Site ###### Last, First, Middle Initial Off Main Site A FAMILY PRACTI CE Sitine Benita ###### ###### MM/DD/ YY F ## SPOUS E 12 36

37 Prospe ctive Wise Registry (cont.) Relative Risk Score Total Number Medical of $ in Chronic past 12 HCCs mths Total Rx $ in past 12 mths Inpatien t $ in past 12 mths Non-DH Trigger $ in 50K past 12 past 12 mths mths Trigger 250K past 12 mths Trigger 3 Admits past 12 mths Trigger Readmi sson in 14 days Trigger Readmi sson in 30 days Trigger 3 ER visits in past 6 mths Number of ER visits in last 12 mths ER visit for same Dx in last 12 mths Num of Office Visits past 12 months Last Office Visit Date Desc of Most Freque nt Diagno sis past 12 months Desc of Second Most Freque nt Diagno sis past 12 months Number of Distinct Rx past 12 months FAILUR RENAL E, GLUCA DISEA SE, 6/18/20 END CONG ESTIVE HEART GEN HYPOK IT 1 MG , ,957 56,687 50K 3AD12 RA14 RA STAGE NOS 24 INJ KIT Yes NAME ATHRS CLR, NTV FAILUR LEVOF ARTRY E, LOXAC, CONG IN 250 EXTRM ESTIVE MG 8/27/20 W/ULC HEART ORAL , ,070 63,172 50K 3AD12 RA14 RA30 3ER6 3 Y RTN NOS 36 TAB Yes NAME LEUKE MIA, LEUKE MIA, ACUTE ACUTE MYELO MYELO 6/12/20 ID W/O ID IN INHL , ,286 4,489 50K 3AD12 RA14 RA30 4 Y RMIS RELAP 18 DSDV Yes NAME MYOPA Most costly Rx past 12 months FLUTIC ASONE - SALME TEROL MCG/D OSE FAILUR E, THY, ACUTE CRITIC NO RX RESPI AL RECOR 7/31/20 RATOR ILLNES DS , , ,626 50K 250K 3AD12 RA14 RA Y S 0 FOUND Yes FAILUR E, SINGU ACUTE LAIR 10 RESPI SYMPT MG 8/16/20 RATOR OM, ORAL , ,412 58,363 50K 250K 3AD12 RA14 RA Y EDEMA 26 TAB Yes NAME OXYCO DONE- ACETA MINOP HEN FIBRIL LATION MG 8/29/20, PARAP ORAL , ,988 26,063 50K 3AD12 RA14 RA ATRIAL LEGIA 26 TAB Yes NAME Membe r Currentl y Enrolle d Most Freq Professi Most Freq onal Professi Provide onal r's Provide Specialt r y NAME PHYSI CAL THERA PIST FAMILY MEDICI NE HEMAT OLOGY /ONCO LOGY PHYSI CAL THERA PIST PHYSI CAL THERA PIST PHYSI CAL THERA PIST

38 Chronic Disease Super Registry (for Population & Patient Management) 38

39 Adult Preventative Registries (for Population & Patient Management) 39

40 Coordinating Care using Data Stratification of the Population Registry: Utilization, Risk Score, Expenditures, Medication, Diagnosis, Service Provider Built from Claims and EHR data or provided by health plan Outreach: Patients with 3 or more admits/12 months Patients with readmission in 14 days Patients with readmission in 30 days Inpatient Census Case Management Referral Closing Gaps in Care 40

41 Another Approach High Tech Solution NNEACC Northern New England Accountable Collaborative Care Dartmouth-Hitchcock, Dartmouth College, Eastern Maine Medical Center, Maine Health Software with embedded algorithms to manage patients and populations 41

42 Care Coordination Application 42

43 This image cannot currently be displayed. CMS ACO Quality Measures Sample View individual patient status on CMS quality measures Care Coordination Monday, July 16, 2012 USER: NNEACCDemo Provider: (All) Practice: (All) TIN: (All) Patient: (All) Patient Search (Last, First): Last Name Grid Key First Name MRN SSN PCP # Incomplete 34% 40% 81% 52% 20% 21% 25% 43% 39% 29% 73% Smith Joe Kay 6 Jones Jane Mann 6 Lee Amy Drake 7 Chang Terry Ricci 5 Brown Ken Wood 7 White Paul Adams 5 Pent Cal Shin 3 Percentage of denominator meeting guidelines 43% Data PRESENT OPPORTUNITY for care Measure DOES NOT APPLY to patient MedRec Fall Screening Influenza Pneumovax BMI Abnl MB f/u Tobacco Use Tobacco Counseling Depression Screening Depression f/u Colon Cancer Screening Northern New England Accountable Care Collaborative 43

44 CMS ACO Quality Measures

45 Quality Standards For MSSP and Pioneer: Four Domains Equal Weighting Patient / Caregiver Experience (HCAPS) Care Coordination / Patient Safety Preventive Health At Risk Population Chronic Diseases; Frail Both Process & Outcome Measures What can your EHR support? Paper records? Incorporate operational definitions from measures specs to create structure data within EHR Harder to Measure Than Would Be Thought 45

46 Lesson Learned Quality Measures Ensure your medical record data captures the technical specifications of the measure

47 Participant Activity A. Use the Wise Registry and Quality Measures registry to identify patients to outreach to B. What actions do you need to take within your organization to generate patient level data to take action on? 47

48 Questions and Answers A. Thank you for your time B. Contact Information: 48

49 Keep in my back pocket remainder of slides 49

50 Performance Monitoring Monitor progress and provide feedback Organization level, Physician Level, Team level, Patient level Patient Satisfaction Quality Measures results Efficiency Internal Data vs. CMS generated data Process Improvement 50

51 How Are We Doing vs. Cost Target? Quarterly Baseline/Benchmark Report for Pioneer ACOs Pioneer ACO P069 - Dartmouth-Hitchcock Health Worksheet S-6: Capped Benchmark Performance Year 1 Quarter 2: January 1, 2012, to June 30, 2012 November 9, 2012 Base Year Perf Year Change % Change Capped benchmark calculation 1. Aligned population 2. ACO baseline $9, Performance period expenditure $9,882 $ % 4. Reference population 5. Adjusted reference baseline $10, Performance period expenditure $10,585 $ % 7. Benchmark calculation 8. ACO baseline $9,773 line 2 9. Reference population trend (%) 1.4% pct. change from line 5 to line Trend applied to aligned pop. baseline $136 line 9 times line Change in reference population exp. ($) $145 line 6 less line Increment to aligned pop. baseline $141 50% of line % of line Benchmark $9,914 line 8 plus line Savings (loss) 15. ACO expenditure per person year $9,882 line Savings (loss) per person-year $32 line13 minus line Percent savings (loss) 0.3% line 16 divided by line 13 Source: CMMI CMS GENERATED REPORT 51

52 Where Are We Spending Money? Pioneer ACO Model Monthly Expenditure Report P069, Performance Year 2012 Aligned Beneficiaries (1): 18,697 Overall Aligned Population (2) Year-to-Date Claims - Component Year-to-Date Claims Paid Claims Paid in (Annualized) for Expenditures as a % of Total September 2012 Service Through Expenditures (3) September 2012 (4) Total Expenditures Per Aligned Beneficiary Expenditures $ $8, % Component Expenditures Inpatient Expenditures Per Aligned Beneficiaries $ $3, % Hospital Outpatient Expenditures Per Aligned Beneficiary $ $2, % Part B Physician / Supplier Expenditures Per Aligned Beneficiary $ $1, % SNF Expenditures Per Aligned Beneficiary $53.02 $ % Home Health Expenditures Per Aligned Beneficiary $36.10 $ % DME Expenditures Per Aligned Beneficiary $20.55 $ % Hospice Expenditures Per Aligned Beneficiary $20.06 $ % CAUTION: Financial settlement will be based on a 3 month run-out of claims. That is, settlement will be based on claims Incurred during the performance year and paid within three months of the end of the performance year. The dollar values reported above do not reflect claims run out nor do they include claims for services provided during the current performance year but not received and processed by Medicare prior to the cut-off date of the report. Notes: (1) Alignment period is from July 1st, 2008 to June 30th, (2) The set of prospectively-aligned beneficiaries are used as the basis for the monthly reports. However, on a quarterly basis, beneficiaries who satisfy any of the following criteria will be dropped from the monthly reports (they will be dropped for the month in which they become excluded and for all future months of that performance period): i. Any months of Medicare Advantage coverage during the performance period. ii. Any months of Medicare as a Secondary Payer during the performance period. iii. Any months without both Part A and Part B coverage during the performance period. (3) Claims paid for services Incurred (provided) during the performance year and paid during the current month. (4) Claims paid for services incurred (provided) during the performance year and paid during the performance year. Source: CMMI CMS GENERATED REPORT 52

53 Are There Areas of Utilization Concern? E1. Pioneer ACO Year 1 Quarterly Utilization Trend Report Quarter 1, Performance Year 2012¹ Number of aligned beneficiaries: 17,910² ACO Specific Aligned Population ² Median Pioneer ACO ³ Additional Utilization Rates (Per 1,000 Person Years)⁶ Annual⁴ Quarter ⁵ Annual⁴ Quarter ⁵ Hospitalizations Emergency Department Visits Emergency Dept visits that lead to hospitalization Avoidable E/R Visits/1, Computed Tomography (CT) Events Magnetic Resonance Imaging (MRI) Events Ambulance Events , Source: Claims ACO GENERATED REPORT 53

54 Highest Cost Area Hospital Inpatient D4. Pioneer Inpatient Utilization for members active as of Sept 12 (incurred Jan-July 12) Site A Site B Site C Site D Site E Unassigned TOTAL Total Admissions Total acute care days Average AC days/admission Admissions/ Total acute care days/ Total days per 1,000 Site A Site B Site C Site D Site E Unassigned TOTAL CCU/ICU BED MEDICAL BED OB BED PSYCH BED SURGICAL BED Site A Site B Site C Site D Site E Unassigned TOTAL Overall Acute Care Cost pmpm $ $ $ $ $ $ $ Prosp Risk Adj pmpm $ $ $ $ $ $ $ Prospective Risk Score Source: Claims 54

55 Other Data Uses Care Coordination Support ratios to patient Clinical Support Staff gaps in care closure

56 Quality Related Actions Benchmark Data Performance Monitoring Data Fulfillment of annual reporting to CMS 56

57 Overview 33 Nationally Recognized Measures in Four Key Domains: Patient / caregiver experience (7 measures total) Care coordination / patient safety (6 measures) Preventive health (8 measures) At-risk population: Diabetes (6 measures) Hypertension (1 measure) Ischemic Vascular Disease (2 measures) Heart Failure (1 measure) Coronary Artery Disease (2 measures) Reference: Centers for Medicare and Medicaid Services 57

58 Pioneer/SSP Quality Performance Standards Measures AIM: Better Care for Individuals QM # Domain Measure Title NQF Measure#/Measure Steward Method of Data Submission 1. Patient/Caregiver Experience CAHPS: Getting Timely Care, Appointments and Information NQF #5, AHRQ Survey 2. Patient/Caregiver Experience CAHPS: How Well Your Doctors Communicate NQF #5, AHRQ Survey 3. Patient/Caregiver Experience CAHPS: Patients Rating of Doctor NQF #5, AHRQ Survey 4. Patient/Caregiver Experience CAHPS: Access to Specialists NQF #5, AHRQ Survey 5. Patient/Caregiver Experience CAHPS: Health Promotion and Education NQF #5, AHRQ Survey 6. Patient/Caregiver Experience CAHPS: Shared Decision Making NQF #5, AHRQ Survey 7. Patient/Caregiver Experience CAHPS: Health Status/Functional Status NQF #6, AHRQ Survey 8. Care Coordination/ Patient Safety 9. Care Coordination/ Patient Safety 10. Care Coordination/ Patient Safety Risk-Standardized, All Condition Readmission CMS Claims Ambulatory Sensitive Conditions Admissions: COPD or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5) Ambulatory Sensitive Conditions Admissions: CHF (AHRQ Prevention Quality Indicator (PQI) #8) NQF #275, AHRQ NQF #277, AHRQ Claims Claims 11. Care Coordination/ Patient Safety Note: NQF = National Quality Forum Percent of Primary Care Physicians who Successfully Qualify for an EHR Program Incentive Payment CMS EHR Incentive Program Reporting 58

59 Pioneer/SSP Quality Performance Standards Measures AIM: Better Care for Individuals QM # Domain Measure Title NQF Measure#/Measure Steward 12. Care Coordination/ Patient Safety Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility NQF #97, AMA- PCPI/NCQA Method of Data Submission GPRO Web Interface 13. Care Coordination/ Patient Safety AIM: Better Health for Populations Falls: Screening for Fall Risk NCQA #101, NCQA QM # Domain Measure Title NQF Measure#/Measure Steward GPRO Web Interface Method of Data Submission 14. Preventative Health Influenza Immunization NQF #41, AMA- PCPI GPRO Web Interface 15. Preventative Health Pneumococcal Vaccination NQF #43, NCQA GPRO Web Interface 16. Preventative Health Adult Weight Screening and Follow-up NQF #421, CMS GPRO Web Interface 17. Preventative Health Tobacco Use Assessment and Tobacco Cessation Intervention NQF #28, AMA- PCPI GPRO Web Interface 18. Preventative Health Depression Screening NQF #418, CMS GPRO Web Interface 19. Preventative Health Colorectal Cancer Screening NQF #34, NCQA GPRO Web Interface 20. Preventative Health Mammography Screening NQF #31, NCQA GPRO Web Interface 59 Note: NQF = National Quality Forum

60 Pioneer/SSP Quality Performance Standards Measures AIM: Better Health for Populations QM # Domain Measure Title NQF Measure#/Measure Steward Method of Data Submission 21. Preventative Health Screening for High Blood Pressure CMS GPRO Web Interface 22. At Risk Population - Diabetes Diabetes Composite (All or Nothing scoring): Hemoglobin A1C Control (<8 percent) NQF #729, MN Community Measurement GPRO Web Interface 23. At Risk Population - Diabetes Diabetes Composite (All or Nothing scoring): Low Density Lipoprotein (< 100) 24. At Risk Population - Diabetes Diabetes Composite (All or Nothing scoring): Blood Pressure (< 140/90) 25. At Risk Population - Diabetes Diabetes Composite (All or Nothing scoring): Tobacco Non-Use NQF #729, MN Community Measurement NQF #729, MN Community Measurement NQF #729, MN Community Measurement GPRO Web Interface GPRO Web Interface GPRO Web Interface 26. At Risk Population - Diabetes Diabetes Composite (All or Nothing scoring): Aspirin Use NQF #729, MN Community Measurement GPRO Web Interface 27. At Risk Population - Diabetes Diabetes Mellitus: Hemoglobin A1C Poor Control (>9 percent) 28. At Risk Population - Hypertension 29. At Risk Population Ischemic Vascular Disease Note: NQF = National Quality Forum NQF #59, NCQA GPRO Web Interface Hypertension (HTN): Controlling High Blood Pressure NQF #18, NCQA GPRO Web Interface Ischemic Vascular Disease (IVD): Complete Lipid Panel NQF #75, NCQA GPRO Web and LDL Control (<100 mg/dl) Interface 60

61 Pioneer/SSP Quality Performance Standards Measures AIM: Better Health for Populations QM # Domain Measure Title NQF Measure#/Measure Steward Method of Data Submission 30. At Risk Population Ischemic Vascular Disease Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic NQF #68, NCQA GPRO Web Interface 31. At Risk Population Heart Failure Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) NQF #83, AMI-PCPI GPRO Web Interface 32. At Risk Population Coronary Artery Disease Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Drug Therapy for Lowering LDL-Cholesterol NQF #74, CMS (Composite) /AMA- PCPI (individual component) GPRO Web Interface 33. At Risk Population Coronary Artery Disease Coronary Artery Disease (CAD) Composite: All or Nothing Scoring: Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Patients with CAD and Diabetes and/or Left Ventricular Systolic Dysfunction (LVSD) NQF #66, CMS (Composite) /AMA- PCPI (individual component) GPRO Web Interface Note: NQF = National Quality Forum; P4P = pay for performance; P = performance; R = reporting 61

62 Clinical Initiatives What types of data will you provide to clinical teams for process improvement? Clinical focused initiatives