Accountable Care Organization (ACO) 2014 Quality Performance Report

Transcription

1 Accountable Care Organization (ACO) 2014 Quality erfmance ept About this ept Who provides this rept? What infmation is contained in this rept? Why is this rept provided to you? What s different in this rept relative to last year s rept? How to interpret this rept? repared F: (A1175) Memial Hermann Accountable Care Organization The Centers f Medicare and Medicaid Services (CMS) provides this Quality erfmance ept to all Accountable Care Organizations participating in the Shared Savings rogram (SS) after the completion of each contract year. This rept is f the calendar year (CY) This rept contains infmation on: Your ACO s perfmance rate f each of the 33 ACO quality f the 2014 repting period, regardless of whether not your ACO completely repted on that measure. A summary sce f each of the four quality measure domains, calculated as the sum of the points earned in the domain divided by the total possible points in the domain Summary statistics (means and medians) of each of the 33 across all ACOs in the SS f relative comparison. The percent of ay f erfmance (4) in each domain where your ACO s perfmance achieved minimum attainment, to identify areas requiring attention. F each measure, your ACO s perfmance rate is calculated based on a representative sample of beneficiaries assigned aligned to your ACO. The purpose of this rept is to enable you to see how your ACO perfmed on a set of quality metrics in CY 2014, and compare how your ACO perfmed relative to the average perfmance of other SS ACOs. This infmation will help you to identify areas f quality improvement in the next repting period. An ACO's final overall quality sce is multiplied by the ACO's maximum sharing rate to determine the final sharing rate. F me infmation, please refer to the Shared Savings and Losses and Assignment Methodology Specifications ayment/sharedsavingsprogram/financialandassignment Specifications.html. A column has been added to the Summary Infmation table to indicate the percentage of ay f erfmance the ACO passed the minimum attainment threshold 1. A column has been added to the tables on pages 46 to indicate which are pay f repting (4) 4. The rightmost columns of the rept now display the 30 th percentile benchmark and the percentile benchmark in lieu of summary statistics. Several summary statistics columns have been removed in the interest of space. lease see the document entitled Shared Savings rogram Quality erfmance ept Supplemental Documentation f a detailed explanation of how to interpret this rept. NOTE: 1 Minimum Attainment defined as 30 percent the 30th percentile of the perfmance benchmark per (b)(3) of the 2011 Medicare Shared Savings rogram Final ule. repared f A1175 roduced on 7/1/2015 age 1 of 7

2 About this ept, continued What s Next? If your ACO completely and accurately repted and met minimum attainment on at least one 4 measure in each domain, then your ACO will be eligible to share in any savings earned. If your ACO failed to completely and accurately rept failed to meet minimum attainment on at least 70% of 4 in each domain, then your ACO may be placed on a crective action plan (CA). Additionally, if your ACO has completely and accurately repted each ACO Group ractice epting Option (GO) Web Interface measure f the 2014 repting period, your ACO participants with eligible professionals will receive incentive payments under the hysician Quality epting System (QS) f the 2014 repting period in Fall 2015 and avoid the QS payment adjustment in F me infmation on quality repting in 2015, please refer to resources available to you on the Shared Savings rogram Quality Measures, epting and erfmance Standards webpage and the Shared Savings rogram ACO tal. All ACO are available f public repting. Those ACO GO and CAHS quality that are chosen f public repting will be repted on hysician Compare with the same plain language measure titles and descriptions as used f the equivalent group practices that are repted under QS. CMS encourages you to share your results with your ACO providers so that they can help you identify ways to improve and assist your ACO in capturing the required data efficiently. repared f A1175 roduced on 7/1/2015 age 2 of 7

3 Summary Infmation Domain oints Earned/ Total ossible oints Domain Sce Minimum Attainment by Domain 1 atient/caregiver Experience 12.50/14 points 89.29% Met minimum attainment on 6 of 6 (100.00%) 4 Care Codination/ atient Safety 11.75/14 points 83.93% reventive Health 13.90/16 points 86.88% Met minimum attainment on 6 of 6 (100.00%) 4 Met minimum attainment on 5 of 5 (100.00%) 4 Met minimum attainment on 3 of 3 (100.00%) 4 At isk opulation 12.65/14 points 90.36% NOTE: 1 Minimum Attainment defined as 30 percent the 30 th percentile of the perfmance benchmark per (b)(3) of the 2011 MSS Final ule. ACO Quality Sce: 87.61% ACO completely repted on 100% of ; ACO achieved minimum attainment on at least one 4 measure in each domain; ACO achieved minimum attainment on at least 70% of 4 in each domain. repared f A1175 roduced on 7/1/2015 age 3 of 7

4 30 oints Earned/Total th Measure Your ACO erfmance ate ossible oints 2 ercentile 3 Domain: atient/caregiver Experience Surveys Completed Getting Timely Care, Appointments, and Infmation (ACO1) How Well Your Docts Communicate (ACO2) atients ating of Doct (ACO3) Access to Specialists (ACO4) Health romotion and Education (ACO5) Shared Decision Making (ACO6) Health Status/Functional Status (ACO7) repared f A1175 roduced on 7/1/2015 age 4 of 7 ercentile / / / / / / /2 oints Earned in Domain: 12.50/14 NOTES: 1 = ay f erfmance, = ay f epting; 2 oints are calculated based on the ACO s perfmance compared to the quality measure benchmarks; 3 F a complete list of benchmarks f each measure, please see the MSS Quality Measure s f the 2014 epting Year document; 4 F me infmation on CAHS perfmance rates, please refer to the detailed CAHS rept provided separately Measure Denominat Numerat Your ACO erfmance ate oints Earned/Total ossible oints 2 30 th ercentile 3 ercentile Domain: Care Codination/atient Safety isk Standardized, All Condition eadmissions 4,5 (ACO8) / ASC Admissions: COD Asthma in Older Adults 4,6 (ACO9) / ASC Admission: HF 4,6 (ACO10) / ercent of Cs who Qualified f EH Incentive ayment % 3.70/ % 90.91% (ACO11) Medication econciliation (ACO12) % 2.00/ % 90.00% Falls: Screening f Fall isk (ACO13) % 1.40/ % 73.38% oints Earned in Domain: 11.75/14

5 4 4 1 Measure Denominat Numerat repared f A1175 roduced on 7/1/2015 age 5 of 7 Your ACO erfmance ate oints Earned/Total ossible oints 2 30 th ercentile 3 ercentile Domain: reventive Health Influenza Immunization (ACO14) % 1.55/ % % neumococcal Vaccination (ACO15) % 1.25/ % % Adult Weight Screening and Followup (ACO16) % 1.55/ % % Tobacco Use Assessment and Cessation Intervention (ACO17) % 2.00/ % 90.00% Depression Screening (ACO18) % 1.55/2 5.31% 51.81% Colectal Cancer Screening (ACO19) % 2.00/ % % Mammography Screening (ACO20) % 2.00/ % 99.56% roption of Adults who had blood pressure screened in past 2 years % 2.00/ % 90.00% (ACO21) oints Earned in Domain: 13.90/16 Domain: At isk opulation Subdomain: Diabetes Beneficiaries with diabetes who met of all the following criteria: % 2.00/ % 36.50% Hemoglobin A1c Control (HbA1c) (<8 percent) (ACO22)* % Low Density Lipoprotein (LDL) (< 100 mg/dl) (ACO23)* % Blood ressure (B) < 140/90 (ACO24)* % Tobacco NonUse (ACO25)* % Aspirin Use (ACO26)* % ercent of beneficiaries with diabetes whose HbA1c in po control (>9 percent) % 1.70/ % 10.00% (ACO27)

6 4 4 1 Measure Denominat Numerat Your ACO erfmance ate oints Earned/Total ossible oints 2 30 th ercentile 3 ercentile Subdomain: Hypertension ercent of beneficiaries with hypertension whose B < 140/ % 1.25/ % 79.65% (ACO28) Subdomain: Ischemic Vascular Disease (IVD) ercent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl % 2.00/ % 78.81% (ACO29) ercent of beneficiaries who use Aspirin other antithrombotic % 1.70/ % 97.91% (ACO30) Subdomain: Heart Failure BetaBlocker Therapy f LVSD (ACO31) % 2.00/ % 90.00% Subdomain: Conary Artery Disease (CAD) ercent of beneficiaries with CAD who met all of the following criteria: % 2.00/ % 79.84% Drug Therapy f Lowering LDLCholesterol (ACO32)* % ACE Inhibit AB Therapy f atients with CAD and Diabetes and/ LVSD (ACO33)* % oints Earned in Domain: 12.65/14 NOTES: 1 = ay f erfmance, = ay f epting; 2 oints are calculated based on the ACO s perfmance compared to the quality measure benchmarks displayed in the Appendix 3 F a complete list of benchmarks f each measure, please see the MSS Quality Measure s f the 2014 epting Year document 4 F ACO8, ACO9, ACO10, and ACO27, a lower perfmance rate indicates better perfmance. 5 The measure repts a single summary isk Standardized eadmission ate, derived from the volumeweighted results of five different models, one f each of the following specialty cohts (groups of discharge condition categies procedure categies): surgery/gynecology, general medicine, cardiespiraty, cardiovascular, and neurology. 6 ACO9 and ACO10 are expressed as a ratio of observed over expected rate. Hence, a ratio >1.00 indicates the ACO has higher than expected admission rate, thus poer quality 7 ACO11, ercent of Cs who Successfully Qualify f an EH Incentive rogram ayment, is doubleweighted f scing purposes. * Measure is sced as part of either the Diabetes composite the Conary Artery Disease composite measure repared f A1175 roduced on 7/1/2015 age 6 of 7

7 Appendix: Summary Statistics Measure Description Mean Median ACO1 Getting Timely Care, Appointments, and Infmation ACO2 How Well Your Docts Communicate ACO3 atients ating of Doct ACO4 Access to Specialists ACO5 Health romotion and Education ACO6 Shared Decision Making ACO7 Health Status/Functional Status ACO8 isk Standardized, All Condition eadmissions ACO9 ASC Admissions: COD Asthma in Older Adults ACO10 ASC Admission: Heart Failure ACO11 ercent of Cs who Qualified f EH Incentive ayment ACO12 Medication econciliation ACO13 Falls: Screening f Fall isk ACO14 Influenza Immunization ACO15 neumococcal Vaccination ACO16 Adult Weight Screening and Followup ACO17 Tobacco Use Assessment and Cessation Intervention ACO18 Depression Screening ACO19 Colectal Cancer Screening ACO20 Mammography Screening ACO21 roption of Adults who had blood pressure screened in past Diabetes Composite ACO22 through ACO26 ACO27 years ACO22. Hemoglobin A1c Control (HbA1c) (<8 percent) ACO23. Low Density Lipoprotein (LDL) (<100 mg/dl) ACO24. Blood ressure (B) < 140/90 ACO25. Tobacco Non Use ACO26. Aspirin Use ercent of beneficiaries with diabetes whose HbA1c in po control (>9 percent) ACO28 ercent of beneficiaries with hypertension whose B < 140/ ACO29 ercent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl ACO30 ercent of beneficiaries with IVD who use Aspirin other antithrombotic ACO31 BetaBlocker Therapy f LVSD CAD Composite ACO32 through ACO33 ACO32. Drug Therapy f Lowering LDL Cholesterol ACO33. ACE Inhibit AB Therapy f atients with CAD and Diabetes and/ LVSD NOTES: Statistics include ACOs participating in the Shared Savings rogram in The total number of SS ACOs ranges from 322 to 333, depending on the measure. repared f A1175 roduced on 7/1/2015 age 7 of 7