Quality Soup: The Ingredients for Success in Managing Multiple - - PowerPoint PPT Presentation

Quality Soup:

The Ingredients for Success in Managing Multiple Quality Programs

Holly Arends, CHSP Program Manager Great Plains Quality Innovation Network holly.arends@area-a.hcqis.org www.greatplainsqin.org

11SOW QIN-QIO Map

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Objectives

• Managing multiple quality initiatives
• Explain the Requirements
• Provide tips on How to be successful
• Taking responsibility for a population
• Strategies to develop a plan
• Utensils/Tools to use
• Guidance on resources and how to use them

What are the Drivers?

National Quality Strategy CMS Quality Strategy Physician Quality Programs Strategic Vision

CMS Quality Strategy

AIMS PRIORITIES

• 1. Better Care
• 2. Healthier People, Healthier

Communities

• 3. Smarter Spending
• 1. Make Care Safer by Reducing Harm

Caused in the Delivery of Care

• 2. Strengthen Person and Family

Engagement as Partners in Their Care

• 3. Promote Effective Communication and

Coordination of Care

• 4. Promote Effective Prevention and

Treatment of Chronic Disease

• 5. Work with Communities to Promote

Best Practices of Healthy Living

• 6. Make Care Affordable

Future State Vision

Vision Statement Indicator of Success

CMS quality reporting programs are guided by input from patients, caregivers and healthcare professionals

• Patients, caregivers, and healthcare professionals are key contributors and active participants in

measure development, reporting, and quality improvement efforts Feedback and data drives rapid cycle quality improvement

• Technology enables healthcare professionals to monitor quality measure performance on an
• ngoing basis at the point of care.
• Quality measurement results drive the planning of quality improvement initiatives.

Public reporting provides meaningful, transparent, and actionable information

• Meaningful, actionable performance data are accessible to and used by variety of audiences

(e.g., patients, caregivers, and healthcare professionals).

• Patients and caregivers have timely access to performance information tailored to their needs.

Quality reporting programs rely on an aligned measure portfolio

• An aligned portfolio of health IT-enable quality measures supports all CMS public reporting,

quality improvement, and value-based purchasing programs.

• A stable and robust infrastructure exists for developing and implementing health IT-enabled

quality measures. Quality reporting and value-based purchasing program policies are aligned

• Principles, policies and processes for all CMS quality reporting and value-based purchasing

programs are coordinated.

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APM Framework

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Medicare Access and CHIP Reauthorization Act (MACRA)

• Ends the Sustainable Growth Rate (SGR) formula for

determining Medicare payments for health care providers’ services.

• Make a new framework for rewarding health care providers for

giving better care not more just more care.

• Combines our existing quality reporting programs into one new

system.

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MACRA Challenges to Providers

• Attribution of patients
• Controlling spending
• Population Management
• Risk Adjustments

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Managing It All

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CMS Quality Programs

• Physician Quality Reporting System (PQRS)
• EHR Incentive Program (MU)
• Value Modifier (VM or VBM)
• Transforming Clinic Practice Initiative(TCPI)
• Comprehensive Primary Care Initiative (CPCI)
• …..
• Actually, 30 different programs that are using quality measures

Future: Aligning Quality Programs

Merit-Based Incentive Payment System (MIPS)

PQRS Value Modifier EHR Incentive Program (MU)

MACRA NPRM Released TODAY!!!!!

• Merit Based Incentive Payment System (MIPS) Proposed

Framework

• Quality
• Advancing Care Information
• Clinical Practice Improvement Activities
• Cost
• January 2017 performance year
• 2019 payment year

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Proposed MIPS

• All eligible clinicians will report through MIPS
• Medicare Part B clinicians
• Physicians
• Physician Assistants
• Nurse Practitioners
• Clinical Nurse Specialists
• Certified Nurse Anesthetists
• Exempted
• Newly enrolled in Medicare
• Less than or equal to $10K in Medicare charges and less than or equal to 100

Medicare patients; OR

• Are significantly participating in an Advanced Alternative Payment Model (APM)

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Proposed MIPS

• Quality
• Replaces PQRS and Quality component of VBM
• 50% of score
• 6 measures versus 9- choose one cross cutting measure and one
• utcome
• Population Health Measures
• Individual and Grps 2-9 – 2 measures based on claims data
• Groups 10 or more- 3 measures based on claims data
• 200 measures with 80% specialty focused

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Proposed MIPS

• Advancing Care Information
• Replaces Medicare EHR Incentive Program (MU)
• 25% of score (year 1)
• Base Score- 6 MU objectives/measures
• Performance Score- 3 objectives/measures
• Focus on interoperability and information exchange
• Not all or nothing reporting as was seen in MU
• Customizable selections

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Proposed MIPS

• Clinical Practice Improvement
• Rewards
• Care Coordination
• Patient Safety
• Beneficiary Engagement
• 15% of score (year 1)
• Select activities from 90 options
• Expanded Practice Access
• Population Management
• Care Coordination
• Beneficiary Engagement
• Patient Safety and Practice Assessment
• Participation in an APM, including a medical home model
• Achieving Health Equity
• Emergency Preparedness and Response
• Integrated Behavioral and Mental Health
• Credit for APM and PCMH activity

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Proposed MIPS

• Cost
• Based on Medicare claims- no reporting requirement
• 10% of score (year 1)
• 40 episode specific measures

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Proposed MIPS

• Advanced Alternative Payment Models
• These include:
• Comprehensive ESRD Care Model (Large Dialysis Organization

arrangement)

• Comprehensive Primary Care Plus (CPC+)
• Medicare Shared Savings Program – Track 2
• Medicare Shared Savings Program – Track 3
• Next Generation ACO Model
• Oncology Care Model Two-Sided Risk Arrangement (available in 2018)
• List update annually
• Non Medicare models considered in 2019

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Proposed MIPS

• Budget neutral
• Negative payment adjustments no more than 4%
• 4%, 5%, 7%, 9%- increase over time
• Positive payment adjustment no more than 4% -increase over time
• $500 million for exceptional performance (exception to budget

neutrality) up to 10% additional, first 5 years

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Proposed MIPS

• Bear Certain Amount of Financial Risk
• If CMS would withhold payments, reduce rates or require repayment

if actual expenditures exceeded expenditures

• Total risk ( max amt. of losses possible under Adv APM) must be at least 4% of

APM spending target

• Marginal risk (the % of spending above the APM benchmark (or target price

for bundles) for which the Adv APM Entity is responsible (i.e. sharing rate) must be at least 30%

• Minimum loss rate (amt. by which spending can exceed the APM benchmark

(or bundle target price) before the Adv APM Entity has responsibility for losses) must be no greater than 4%

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Requirements for Incentive Payments for Significant Participation in Advanced APMs (Clinicians must meet payment or patient requirements)

Payment Year 2019 2020 2021 2022 2023 2024 and later Percentage of Payments through an Advanced APM 25% 25% 50% 50% 75% 75% Percentage of Patients through an Advanced APM 20% 20% 35% 35% 50% 50%

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Managing Multiple Quality Initiatives

• Aggregate data from disparate sources
• Risk Stratification- Identify High Risk Patient Populations
• Filter and view through the measure’s lens
• Provide feedback to clinicians and staff
• Real time administrative and clinical tracking
• Simplified reporting of quality data
• Transparency to Consumers
• Focus on Outcome Measures, when possible

Future: Core Quality Measures Collaborative

• The core measures are in the following seven sets:
• Accountable Care Organizations (ACOs), Patient Centered Medical

Homes (PCMH), and Primary Care

• Cardiology
• Gastroenterology
• HIV and Hepatitis C
• Medical Oncology
• Obstetrics and Gynecology
• Orthopedics

Quality Program Requirements Impact on Your Office

• Data collection
• Data aggregation
• Workflow assessment
• Quality Improvement
• Data reporting
• Data feedback to providers
• Resources
• Time
• Financial
• Reputational

First Things First….

• Commitment and Involvement
• Leadership
• Clinician

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What are Your Drivers? What is Your Vision?

• Mission
• Vision
• Values
• Stakeholders
• Measures and Indicators of Success

Build your business case for improvement activities!

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Vision Examples

• Imagine
• Fully Engaged Consumer and Patients
• Transparency of Quality Data
• Feedback reports support rapid cycle improvement
• Full view of patient –all data sources
• Graduated participation in Alternative Payment Model

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Future State Vision

Vision Statement Indicator of Success

CMS quality reporting programs are guided by input from patients, caregivers and healthcare professionals

• Patients, caregivers, and healthcare professionals are key contributors and active participants in

measure development, reporting, and quality improvement efforts Feedback and data drives rapid cycle quality improvement

• Technology enables healthcare professionals to monitor quality measure performance on an
• ngoing basis at the point of care.
• Quality measurement results drive the planning of quality improvement initiatives.

Public reporting provides meaningful, transparent, and actionable information

• Meaningful, actionable performance data are accessible to and used by variety of audiences

(e.g., patients, caregivers, and healthcare professionals).

• Patients and caregivers have timely access to performance information tailored to their needs.

Quality reporting programs rely on an aligned measure portfolio

• An aligned portfolio of health IT-enable quality measures supports all CMS public reporting,

quality improvement, and value-based purchasing programs.

• A stable and robust infrastructure exists for developing and implementing health IT-enabled

quality measures. Quality reporting and value-based purchasing program policies are aligned

• Principles, policies and processes for all CMS quality reporting and value-based purchasing

programs are coordinated.

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Integrate and Aggregate Data

• Complex data
• Data Silos
• Unstructured Data
• Asset Inventory
• Data
• Systems
• Sources

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Risk Auditing

• Where is highest risk and impact
• Financial
• Clinical
• Use Technology to it’s fullest potential
• Claims and Clinical data- Whole picture!!!
• Quantitative
• Claims data
• Qualitative
• Patient and referral data

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Identify Your Patients

Table 1 2012 Mean Annual Expenditures per Individual by Spending Group Spender Tier Spending per Person Percent of Total Spending Top 1% $97,859 21.8% Top 5% $43,038 49.5% Top 10% $28,452 65.2% Top 30% $12,951 89.6%

Source: NIHC Concentration of Health Care Spending (Washington, DC: National Institute for Health Care Management Foundation, July 2012), http://www.nihcm.org/pdf/DataBrief3%20Final.pdf

Risk Stratification

• Patient Categories
• Patients with Advanced Illness
• Patients with Persistent High Spending
• Patients with Episodic High Spending

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Patients With Advanced Illness- Strategies

• Patients with Advanced Illness
• Advance Directives, Informed Choice, Advanced Care Plan
• Hospice
• Palliative Care
• Community End of Life versus Hospital

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Patients With Advanced Illness- Strategies

• What are your utilization rates of the interventions?
• What are your hospital admission and readmission rates for

this population?

• Mortality rates and location of death in your counties served?
• Patients in rural and frontier area usually have shorter lifespans
• Are you tracking NQF 326/PQRS 47?

Readmission Rates Among Discharge Locations

20140401-20150301 GPQIN used Medicare claims data provided by the National Coordinating Center (NCC)

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14.5% 21.9% 18.9% 20.1% 15.1% 14.1% 14.2% 15.1% 1.6% 1.0% 1.5% 2.0% 16.9% 17.1% 15.1% 16.8%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% Rapid City Sioux Empire South Dakota Great Plains QIN Home Health Home Hospice SNF

Advance Care Plan

50.41% 60.28% 57.82% 0.00% 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 100.00% SD Mean National Mean CMS Benchmark

PQRS 47 NQF 326 Advance Care Plan- Performance Rate PQRS 2014

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Filter Through Measure Len

• eCQMs
• Dashboard
• Audit denominator and numerator
• Vendor Accountability

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Feedback Reports

• Feedback
• Individual performance
• Aggregate (TIN level) performance
• Progress towards goals

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Administrative and Clinical Tracking

• Leadership Responsibility
• Progress
• Regular Monitoring

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Simplified Reporting

• Identify Quality Program Participation
• Identify data reporting requirements
• Plan for submission
• Seek assistance

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Transparency

• CMS Physician Compare
• How will you be transparent to your consumers and patients?

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Tools to Use

• Quality Resource and Utilization Report
• Mid Year
• Annual
• Supplemental
• Two essential components
• Quality
• Cost

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Performance on Cost: Cost Composite Structure

• Summarized at TIN level
• Summarizes cost performance
• Calculates domain scores for which your TIN had at least 20 eligible cases

for at least one cost measure.

• 2 Value Modifier Cost Domains, 6 Measures
• Domain 1-Per Capita Costs for All Attributed Beneficiaries
• Per Capita Costs for All Attributed Beneficiaries
• Medicare Spending per Beneficiary
• Domain 2-Per Capita Costs for Beneficiaries with Specified Conditions
• Diabetes
• COPD
• CAD
• Heart Failure

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Cost Composite Structure

• Based on claims data
• Part A & B, Part D not included
• Exhibits 9-11 on QRUR, Exhibits 5-10 on Supplementary
• Uses tiering to place the TIN in a Cost Tier Designation -

Average, High, Low

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Claims Data

Domain/Measure Part A and B claims submitted by ALL providers for Medicare Beneficiaries Attributed to a TIN Per episode costs based on Part A and B expenditures surrounding specified inpatient hospital stay (3 days prior through 30 days post discharge) Supplementary Exhibit for full details Domain 1/ Per Capita Costs for All Attributed Beneficiaries X Exhibit 5 Domain 1/ Medicare Spending per Beneficiary(MSPB) X Exhibit 6 Domain 2/ Diabetes X Exhibit 7 Domain 2/ COPD X Exhibit 8 Domain 2/ CAD X Exhibit 9 Domain 2/ Heart Failure X Exhibit 10

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Services Included

• E&M Services billed by Eligible Professionals (EPs)
• Major Procedures billed by EPs
• Ambulatory/Minor Procedures billed by EPs
• Ancillary Services
• Hospital Inpatient Services
• Emergency Services not included in Hospital Admission
• Post-Acute Services
• Hospice
• All Other Services

*Sub Category – ‘Other Facility-Billed Expenses…’ are those that are billed at facility level versus EP, for example FQHC or RHC *Review Supplementary Exhibit 5 for full details of applicable Cost Measures, excluding MSPB, which is found in Supplementary Exhibit 6

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How Can Our Costs Be Accurately Compared With Other TINs?

• Each measure is
• Payment-standardized
• Risk-adjusted
• Specialty-adjusted

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Payment Standardized

• Make comparisons of service use within or across geographic

areas.

• Maintains differences in choice of care setting, types of

providers, and multiple services within encounters

• Utilizes a conversion factor x payment modifiers to standardize

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Risk Adjustment

• Account for differences in beneficiary level risk-factors
• More accurate comparison across settings with varying

beneficiary case complexities

• Compares TIN actual costs to CMS determined beneficiary

expected costs, uses CMS-HCC model

• Per Capita Cost Measures – All TIN Attributed beneficiaries Part

A&B costs / # of TIN Attributed Beneficiaries

• Medicare Spending Per Beneficiary Measure – adjusted by

beneficiary age and severity of illness (MS DRG)

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Specialty Adjustment

• Different than risk adjustment
• Performed at the TIN level
• Compares TIN’s risk adjusted costs with TINs of the same

specialty

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Exhibit 9: Your TIN’s Performance in 2015, by Cost Domain

• Lower score indicates better performance
• Higher score indicates opportunity for improvement
• See Exhibit 10 for specific measures
• Three columns in table
• Cost Domain
• Number of Cost Measures included in Composite Score
• Standardized Performance Score (Cost Tier Designation)
• Domain Scores represent equally-weighted average,

standardized scores in the domain

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Exhibit 9

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Measures, with 20 eligible cases, included Your TINs Cost Tier

• Designation. ‘Average’ is

shown if the TINs score falls within one Standard Deviation from the mean

Exhibit 10 – Per Capita or Per Episode Costs For Your TIN’s Attributed Medicare Beneficiaries

• Summarized at TIN level
• Payment-Standardized, risk-adjusted, and specialty adjusted

per capita or per episode costs for each measure

• Only measures with 20 or more eligible cases or episodes are

included

• Use this exhibit and it’s supplementary exhibits to identify

specific areas of opportunity

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Exhibit 10 – Per Capita or Per Episode Costs For Your TIN’s Attributed Medicare Beneficiaries

• For per capita costs detail use Supplementary exhibits 2B and 5

to identify types of costs incurred for beneficiaries

• For MSPB costs detail use Supplementary exhibit 4 and 6 to

identify to improve care

• Identifying patterns of use and costs are the main goal of this

and the supplementary exhibits

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Exhibit 10

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National Benchmark

Exhibit 11:Differences between Your TIN Per Capita Costs and Mean Per Capita Costs

• Displays Amount By Which Your TIN’s Costs were higher or

lower

• All Attributed Beneficiaries
• Beneficiaries with Diabetes
• Beneficiaries with COPD
• Beneficiaries with CAD
• Beneficiaries with Heart Failure

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Exhibit 12: Differences Between Your TIN’s Per Episode and Mean Per Episode Costs

• Displays the Amount by which your TIN’s Costs were Higher or

Lower than the Benchmark

• MSPB

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How Can I Use the Cost Information?

• Develop Strategies
• Identify complex patients
• Develop condition specific practice standards
• Identify opportunities to reduce costs
• Procedures
• Condition specific
• Complex Chronic Care
• Follow up Care
• Identify Shared Savings/Shared Risk partners
• Identify partners in care coordination

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Management

• Identify patient populations
• Segment into High risk or high spender categories
• Clinically
• Financially
• Audit for accuracy of segmentation
• Stratification
• Quantitative
• Claims based algorithms
• Qualitative
• Patient and/or referral algorithms

Risks List Becomes Solutions List

• Break down your Risks
• 5 WHYS
• What is the abnormal occurrence/condition?
• 1. Why is this happening? Do you need to confirm? Method
• 2. Why is this happening?
• Repeat 5 times
• ROOT CAUSE

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The Right Tools

• Decision Trees
• Quality and Resource Use report (QRUR)
• Strategic Vision Plan

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Determine Cost

• Participate or Not Participate What will it Cost You?

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2016 Medicare Quality Program 2018 Payment Adjustments PQRS

• 2%

EHR Incentive Program (MU)

• 3%

Value Modifier

• 4%x (adjustment factor determine by CMS annually)

Let’s run the numbers

Example of 2016 Payment Adjustment: applicable to 10+ EPs, group,

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Low Quality Average Quality High Quality Low Cost 0.0% +1x%= +15.92% +2x%= +31.84% +2x% = +31.84% +3x% = +47.74% Average Cost 0.0% / -1.0% 0.0% +1x%= +15.92% +2x%= +31.84% High Cost 0.0% / -2.0% 0.0% / -1.0% 0.0% Low Quality Average Quality High Quality Low Cost $0 +$47,760 +$95,820 +$95,820 +$143,220 Average Cost

• $3000

$0 +$47,760 +$95,820 High Cost

• $6000
• $3000

$0

Wrap-Up

• Leadership
• Aggregating Data
• Stratifying Patients
• Ongoing Tracking and Monitoring
• Feedback
• Rapid Cycle Improvements
• Knowledge Sharing

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• HCP LAN APM Framework
• HCP LAN Patient Attribution
• HCP LAN Financial Benchmarking
• Health Care Payment Learning and Action Network
• https://hcp-lan.org/

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Contact Information

Holly Arends, CHSP Program Manager Great Plains Quality Innovation Network holly.arends@area-a.hcqis.org www.greatplainsqin.org

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