2014 ACO GPRO Audit What this means for your practice. Sheree M. Arnold ACO Clinical Transformation Specialist

Transcription

1 2014 ACO GPRO Audit What this means for your practice Sheree M. Arnold ACO Clinical Transformation Specialist

2 Agenda Catholic Medical Partners ACO overview Attribution and sampling of patients ACO quality measures

3 Catholic Medical Partners ACO Overview 3-year contract with Medicare for Medicare Shared Savings Program Made up of providers who voluntarily agree to work together to coordinate care for patients while meeting certain quality standards to share in any savings they achieve for the Medicare program. 273 participating practices 860 primary and specialty providers (188 primary care physicians & 672 specialty care physicians) The ACO has the following institutional providers: Catholic Health Hospitals, Mt. St. Mary s Hospital and Health Centers, Bertrand Chaffee Hospital, Bry- Lin Behavioral Health System Take care of a defined population of patients Medicare FFS beneficiaries only ~25,400

4 ACO GPRO Attribution CMS assigns a Medicare beneficiary to Shared Savings Program ACO based on current program rules Beneficiaries are assigned to the Shared Savings Program ACO if they: Have at least one month of Part A and Part B enrollment Do not have any months of Medicare group (private) health plan enrollment (i.e., Medicare Advantage) Reside in the United States or U.S. territories and possessions Have a primary care service with a provider at the ACO Have the largest share of their primary care services (by Medicare allowed charges) provided by the participating ACO, defined as: Step (1): having more primary care services furnished by primary care physicians at the participating ACO than furnished by primary care physicians at any other entity; or Step (2): (for those beneficiaries who have not received any primary care services from a primary care physician) having at least one primary care service furnished by specific types of physicians and had more primary care services furnished by professionals at the participating ACO than at any other entity (Participating Specialist) Timing of attribution: Shared Savings Program ACO attribution: Use beneficiaries attributed for the rd quarter report A patient attributed in one year of Shared Savings Program ACO may or may not be attributed to the ACO in the following reporting years

5 ACO GPRO Sampling CMS analyzes Medicare claims submitted and captured in the Integrated Data Repository (IDR) from January 1, 2014 through October 31, 2014 (i.e., sampling period) Patients are sampled using a methodology that increases the likelihood of patients being sampled into multiple modules Assigned/Aligned beneficiaries who meet additional quality eligibility criteria may be sampled into GPRO Web Interface modules through a three-step process described in the following slides

6 Attribution and Sampling Overview The GPRO Reporting requires ACOs to report data on a pre determined population of patients Beneficiaries are attributed to the ACO Attributed beneficiaries are assessed for quality measurement eligibility and then randomly sampled based on measurement and disease criteria. Sample is used for quality reporting

7 ACO QUALITY MEASURES

8 ACO Quality Measures Goal = 90 th percentile Domain Measure Description 90th perc. Patient/Caregiver Experience ACO #1 Getting Timely Care, Appointments, and 90 Patient/Caregiver Experience ACO #2 How Well Your Doctors Communicate 90 Patient/Caregiver Experience ACO #3 Patients Rating of Doctor 90 Patient/Caregiver Experience ACO #4 Access to Specialists 90 Patient/Caregiver Experience ACO #5 Health Promotion and Education Patient/Caregiver Experience ACO #6 Shared Decision Making Patient/Caregiver Experience ACO #7 Health Status/Functional Status N/A Care Coordination/Patient Safety ACO #8 Risk Standardized, All Condition Readmissions Care Coordination/Patient Safety ACO #9 ASC Admissions: COPD or Asthma in Older Adults 0 Care Coordination/Patient Safety ACO #10 ASC Admission: Heart Failure 0.18 Care Coordination/Patient Safety ACO #11 Percent of PCPs who Qualified for EHR Incentive Care Coordination/Patient Safety ACO #12 Medication Reconciliation 90 Care Coordination/Patient Safety ACO #13 Falls: Screening for Fall Risk 73.38

9 ACO Quality Measures cont. Domain Measure Description 90th perc.. Preventive Health ACO #14 Influenza Immunization 100 Preventive Health ACO #15 Pneumococcal Vaccination 100 Preventive Health ACO #16 Adult Weight Screening and Follow up 100 Preventive Health ACO #17 Tobacco Use Assessment and Cessation 90 Preventive Health ACO #18 Depression Screening Preventive Health ACO #19 Colorectal Cancer Screening 100 Preventive Health ACO #20 Mammography Screening Preventive Health ACO #21 Proportion of Adults who had blood pressure screened in past 2 years 90 Diabetes ACO #22. Hemoglobin A1c Control (HbA1c) (<8 percent) ACO #23. Low Density Lipoprotein (LDL) Composite ACO (<100 mg/dl) ACO #24. Blood Pressure (BP) < At Risk Population Diabetes # /90 ACO #25. Tobacco Non Use ACO # At Risk Population Diabetes ACO #27 Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) 10 At Risk Population Hypertension ACO #28 Percent of beneficiaries with hypertension At Risk Population IVD ACO #29 Percent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl At Risk Population IVD ACO #30 Percent of beneficiaries with IVD who use Aspirin or other antithrombotic At Risk Population HF ACO #31 Beta Blocker Therapy for LVSD 90 At Risk Population CAD CAD Composite ACO #32 33 ACO #32. Drug Therapy for Lowering LDL Cholesterol ACO #33. ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes 79.84

10 CARE-1: Medication Reconciliation Measure Description Percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician providing on-going care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented Guidance This measure is reported for each discharge found for the patient The practice may verify the discharge date if evidence of hospitalization or discharge is found in the record within 1-2 days of the pre-populated discharge date

11 CARE-2: Falls: Screening for Future Fall Risk Measure Description Percentage of patients aged 65 years and older who were screened for future fall risk at least once during the measurement period Guidance Screening for future fall risk must include: Documentation of no falls in the past year or only one fall without injury in the past year or documentation of two or more falls in the past year or any fall with injury in the past year

12 Diabetes Mellitus (DM) Module The Diabetes Mellitus (DM) Module contains one measure and one composite measure made up of five component measures: DM-2: Percentage of patients aged 18 through 75 years with diabetes who had most recent hemoglobin A1c greater than 9.0% Optimal Diabetes Care (All or Nothing Scoring) DM-13: Diabetes Mellitus: High Blood Pressure Control DM-14: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control DM-15: Diabetes Mellitus: Hemoglobin A1c Control (< 8%) DM-16: Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes and Ischemic Vascular Disease DM-17: Diabetes Mellitus: Tobacco Non-Use

13 HF-6: Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Measure Description Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge Guidance If the patient has ever had an LVEF < 40% or a documented LVEF as moderate or severe answer Yes to the presence of LVSD Bisoprolol, carvedilol, or sustained release metoprolol succinate are the ONLY beta-blockers allowed for this measure

14 PREV-5: Breast Cancer Screening Measure Description Percentage of women 50 through 74 years of age who had a mammogram to screen for breast cancer within 27 months Guidance Screening includes breast imaging, breast x-ray, diagnostic mammography, digital mammography, mammogram, screening mammography

15 PREV-6: Colorectal Cancer Screening Measure Description Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening Guidance FOBT includes ColoCARE, Coloscreen, EZ Detect, Fecal occult blood test, flushable reagent pads, flushable reagent stool blood test, guaiac smear test, Hemoccult, Seracult, stool occult blood test, FIT Colorectal screening does not include: virtual colonoscopy, Barium enema, or Colovantage Patient refusal is not a reason to exclude

16 PREV-9: Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Measure Description Percentage of patients aged 18 years and older with a documented BMI during the encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter Normal Parameters: Age 65 years and older BMI 23 and < 30 Age years BMI 18.5 and < 25 Guidance Follow-up may include, but is not limited to: documentation of education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional, or surgeon), pharmacological interventions or dietary supplements, exercise counseling or nutrition counseling Follow-up plan is not required for normal BMI

17 PREV-11: Screening for High Blood Pressure and Follow-Up Documented Measure Description Percentage of patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated Guidance Patients with a Medicare claim indicating a history of hypertension prior to the first day of the measurement period (1/1/2014) will not be included in your sample for this measure A normal blood pressure reading (<120 systolic and < 80 diastolic) requires no documentation of follow-up Recommended follow-up based on BP classification includes: recommending screening interval follow-up, lifestyle modifications, referrals to alternative/primary care provider, antihypertensive pharmacological therapy, laboratory tests, or an electrocardiogram Need to link the recommended follow-up to the elevated blood pressure using guidance provided

18 PREV-12: Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan Measure Description Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen Guidance Screening includes completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition even in the absence of symptoms This measure requires the screening to be completed in the office of the provider filing the code Follow-up plan may include a proposed outline of treatment to be conducted as a result of positive clinical depression screening Use a normalized and validated depression screening tool developed for the patient population where it is being utilized. Examples of depression screening tools include but are not limited to: Adolescent Screening Tools (12-17 years) Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care Version (BDI-PC), Mood Feeling Questionnaire, Center for Epidemiologic Studies Depression Scale (CES-D) and PRIME MD-PHQ-2

19 What s next GPRO starting! January-March 2015 Keep eye out for charts reviews Weekly Q&A Conference line-march2015 Questions? Please contact Sheree Arnold (716) or David Nielsen (716)