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MIPS TO AN APMPART TWO: OVERCOMING THE CHALLENGES OF TRANSITIONING TO AN APM
MOVING FROM
Sponsors and Coverage Areas
COMPASS PTN
Telligen QIN-QIO
Telligen QPP SURS
COMPASS PTN Telligen QPP SURS
Telligen QIN-QIO All
Don Klitgaard, MD, FAAFP
• Founding CEO of MedLink Advantage (MLA)
• Serves on AAFP Commission on Quality and Practice
• Past physician champion in the AAFP’s TransforMED National Demonstration Project
• Educator and consultant on PCMH and ACO transformation
Emily Tyrrell, RN, BSN
• Administrator for Hornet Healthcare in Vinita, OK
• Accounts Payable, Payroll, and Accounting
• Leads the clinic’s MIPS and Quality Improvement initiatives with assistance of Shana Hartley and Anita Maxwell
• Helped with inception and opening of The Spa at Shangri-La, where she still works as an RN
Shana Hartley, RN, BSN, IBCLC• Nurse Manager for Dr. Mickey Tyrrell, MD at Hornet Healthcare in Vinita, OK
• Assists with care management
• Promoted quality improvement efforts for MIPS and graduation from the Transforming Clinical Practice Initiative (TCPi)
• Coordinates the Vaccines for Children program, Inventory & Purchasing
• Lactation consultant
• General manager of The Spa at Shangri-La (where Dr. Tyrrell is the medical director)
Carol Baldridge, MSN, RN, CCPC
• Senior Quality Improvement Advisor with Telligen
• Implements the Compass Practice Transformation contract in Oklahoma
• Executes TCPi in both urban and rural clinics
• Extensive history of healthcare quality improvement in a variety of care settings
• Led efforts to incorporate mental and behavioral health into primary care settings and reduce the associated stigma
What is an Accountable Care Organization (ACO)?
• A set of health care providers—including primary care physicians, specialists, and hospitals—that work together collaboratively and accept collective accountability for the cost and quality of care delivered to a defined population of patients
• The ACO has a contract with a payer, such as CMS, a commercial payer, or Medicaid, that:• Defines the quality measures the ACO practices will be responsible for
delivering• Sets a benchmark – the cost of care expected for the patients
(beneficiaries) in the ACO• Defines the benefits the ACO is eligible for if the cost falls below the
benchmark, usually a percentage of the savings achieved over the benchmark (upside), as well as any potential payback required if costs run higher than the benchmark (downside risk)
National Policy Driver
• The Triple Aim is Better Care, Smarter
Spending, and Healthier People.
• The Quadruple Aim adds...Improved
Clinician Experience.
Why Participate in an APM/ACO?
• Shared Savings – access to these revenue streams while continuing FFS or current payment model, including cost-based reimbursement
• Quality score education, QI training, improvement efforts – important in ACO work, better patient care, can give market advantages
• Data – access to claims data and risk adjustment data• Claims data – new insights on patients populations, costs, local healthcare market,
opportunities for improved care and improved revenue• Risk adjustment data – essential to understand well if participating in an APM. Can
bring short and long-term value to practice in VBP world
• MIPS scoring advantages under MACRA – APMs/ACOs get significant MIPS scoring advantages and can maximize MACRA fee increases
• 5% Bonus payment/MIPS exclusion for Advanced APMs
• Support – ACO work is not the same as FFS clinical care, so support is needed to function well in an ACO
Why Participate in an APM/ACO?
• Education on details of how ACOs and Pay for Value functions –providers, staff and administrators all need to learn about the transition to VBP
• Learning Collaboratives – chance to learn alongside other leaders, providers and practices
• Best practices – Gain insights from those who have experience in these models locally, regionally, and nationally
• Networking – connect with others in similar roles with similar concerns. New support networks develop.
• Contracting advantages – Plant your flag in the ground. Once organized as an ACO, you have significantly improved leverage to negotiate in the pay-for-value space
Success in Value-Based Healthcare
The degree of APM/ACO success achieved is in large part determined by the degree to which we understand and actively manage these three factors using a thoughtful, balanced approach.
▪Quality – Improve
▪ Cost – Lower
▪ Risk – Manage
Barriers
• Cost – Is joining an APM/ACO worth an upfront investment?• Know the costs – direct and indirect• Consider what participation might do to improve revenue, therefore offsetting or
overshadowing any costs• AWV, TCM, CCM, improved Chronic care, prevention, immunizations…• Shared savings potential
• Consider what new opportunities participation can bring• Better connections with employers, payer benefits, marketing advantages, new patients, etc.
• Time/Staff – what are the opportunity costs?• Know what your responsibilities will be to perform in the APM/ACO
• Reporting, quality work, efforts addressing costs, etc.
• Decide if this time/work will benefit your practice in tangible ways – most ACO practices find themselves becoming more organized, more efficient, working better as teams, able to make changes effectively, etc.
• Risk – Is there downside risk? If so, is it acceptable?• Often, participating earlier means the chance to learn the ropes before downside risk
becomes a part of the APM/ACO equation
When are you ready to join an APM?
• If you are asking the question, then you probably are…
• The most important factor is the willingness to:• Look at new data – claims, utilization, risk, quality
• Think about and organize around how to improve the care you provide
• Collaborate with others – teach and learn together
• Dedicate time/resources – especially important to identify a physician champion if at all possible!
• You don’t have to have it all together and be a highly-functional, high-performing practice up front (most aren’t even close!)
• APM/ACO work is the pathway not the destination
How do you join an APM/ACO?
• Consider the options of ACOs to join. • MSSP - Check out the CMS website for APMs in your area. All MSSPs
are required by CMS to have a public reporting page that details participants, leadership, contact information, shared savings and quality results, etc.
• Commercial - Contact your major payers and inquire about ACO/APM options.
• Medicaid – explore the state Medicaid and/or MCO websites and reach out
• Important distinctions when considering APM/ACO options• Health system-led vs. physician-led/independent• Upside only vs. downside risk ACO contract
How do you join an APM/ACO?
• Some more detailed questions to ask whenever considering an opportunity• Who else is in the ACO?• Who is the leadership/on the Board of Directors?• How are decisions made?• What quality metrics will I be accountable for?• What are the upfront costs ?• What are the indirect costs?• What support/data/technology will I receive? How? When?• What education is provided to physicians/administrators/staff?• How are any savings distributed?• How are any potential losses shared/covered?
• Timing• Most ACOs operate on a calendar year basis, with sign-up for the next year occurring
sometime between June-September, depending on the payer
New Program Structure
* Agreement Period 5 years (increase from current 3 years)
2020 MSSP Application Timeline
• Notice of Intent to Apply for new ACOs will be due in May
• New ACO applications will be due by July 28
• MSSP ACO Practice sign up for these ACOs (either new or existing) will occur between June- September
• Therefore, practices interested in joining an MSSP ACO for 2020 will have the following opportunity to do so:• June - September 2019 for the January 1, 2020 start date.
• For those that don’t join then, the next opportunity to join an MSSP would be in Summer 2020 for a January 1, 2021 start date
• All MSSP ACOs will be required by CMS to move to downside risk by at least year three, so it is important for practices to consider getting experience in an ACO early, while still in upside-only years.
“The best way to predict your future
is to create it”
— Peter Drucker
Summary Thoughts on APMs
• Find an APM whose culture/goals match the best with the culture/goals of your practice or organization
• While shared savings can be a big incentive, it is more important to also look at APM/ACO work as your practice’s path forward as the healthcare system undergoes some foundational changes. Therefore consider which APM/ACOs are going to:• Help you take the best care of your patients/community• Equip you to succeed in our changing system – long-term skills and
success, as well as short-term improvement• Offer the best support in terms of data, education, practice/QI support,
networking opportunities, engagement of providers, etc.
Small Practice Success Story: MIPS to APM
Hornet Healthcare
Mickey Tyrrell, MD, PLLC
• Vinita, OK
• 1 MD, 1 NP, 2 RNs, 3 MAs
One main goal: Improving patient outcomes by providing the best patient care possible.
Transforming Clinical Practice Initiative (TCPi) Participation
Primary Drivers
Secondary Drivers
To achieve a person and family-centered care delivery system,
seven drivers should be considered. 1.1 Patient and family engagement
1.2 Team-based relationships
1.3 Population management
1.4 Practice as a community partner
1.5 Coordinated care delivery
1.6 Organized, evidence-based care
1.7 Enhanced access
To achieve a practice culture of continuous quality improvement,
four drivers should be considered. 2.1 Engaged and committed leadership 2.2 Quality improvement strategy supporting a culture of quality and safety 2.3 Transparent measurement and monitoring 2.4 Optimal use of Health Information Technology (HIT)
To achieve a practice with long-term sustainable business
operations, four drivers should be considered. 3.1 Strategic use of practice revenue 3.2 Workforce vitality and joy in work 3.3 Capability to analyze and document value 3.4 Efficiency of operation
TCPi Phases of Transformation for Clinic
• Phase 1 (Aims): May 2017
• Phase 2 (Data): November 2017
• Phase 3 (Progress): April 2018
• Phase 4 (Benchmark): October 2018
• Phase 5 (Thrive): November 2018
• Graduated from TCPI and transitioned into ACO: December 2018
Focus Areas to Improve Patient Outcomes
• Leadership and Culture• Participated in state Medicaid quality improvement initiative• Implemented regular staff meetings• Bulletin board showing quality data graphs on performance and patient
reviews• Staff satisfaction surveys
• Electronic Health Record (EHR) Optimization • Coordination with e-Clinical Works (eCW) for proper data mapping and data
entry, text messaging, portal usage, and smart forms
• Depression Screening Tool• Optimized mapping and staff training on the administration and
documentation of the tool for proper data collection• Started doing manual registry and tracking as eCW wasn’t tracking
appropriately the entire time
Focus Areas to Improve Patient Outcomes
• Connected to the Health Information Exchange (HIE)• We contacted eCW and gave permission to outside health systems to
access a portal into our EHR. Once permissions granted from both sides, it was set up.
• Can see prescription histories, reports from outside, continuation of care, documents, diagnostic imaging, referrals, and hospital encounter summary
• By connecting to the HIE, we are now able to share patient data with affiliated health partners
• Logins to EPIC (used by several health systems)• Used by several health systems (ER, labs, radiology, op notes, etc)• Separate from HIE
Unanticipated Challenges
• Inability to capture all necessary quality measure data in EHR • Smart forms built for us to capture everything needed for quality
measures weren’t mapped to give us credit • Closing the Referral Loop: Receipt of Specialist Report (Qual ID: 374)
• eCW couldn’t capture data accurately; no indication of when it will be fixed
• Couldn’t use this measure,
• Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) (Qual ID: 008)
• Wasn’t recognizing when patient on Beta blocker therapy
• Tobacco/Cessation (Qual ID: 226)
Unanticipated Challenges
• Actively working with vendor to remedy situation so we can keep these measures in our screenings.
• Run quality data early and often
• Different free trial with another HIE ended up trying to charge them so they stopped using that HIE.
Data Results
Preventive Care and Screening: Screening for Depression and Follow-Up Screening (Qual ID: 134)
• Practice – March 2018: 39.24%
• PTN Avg – March 2018: 28.17%
• Practice – October 2018: 82.26%
• PTN Avg – October 2018: 74.04%
Data Results
Diabetes: Hemoglobin A1c Poor Control (<9%) (Qual ID: 001)*
• Practice – September 2017: 7.06%• PTN Avg – September 2017: 46.90%
• Practice – November 2018: 20.00% • PTN Avg – November 2018: 28.57%
*Lower % is better
Data Results
Documentation of Current Medications in the Medical Record (Qual ID: 130)
• Practice – October 2017: 99.30%
• PTN Avg – October 2017: 82.06%
• Practice – November 2018: 99.73%
• PTN Avg – November 2018: 88.78%
Data Results
Controlling High Blood Pressure (Qual ID: 236)
• Practice – September 2017: 79.84%
• PTN Avg – September 2017: 75.76%
• Practice – August 2018: 90.00%
• PTN Avg – August 2018: 80.91%
Data Results
Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention (Qual ID: 226)
• Practice – September 2017: 79.84%
• PTN Avg – September 2017: 75.76%
• Practice – July 2018: 51.25%
• PTN Avg – July 2018: 103.61% (According to PTN)
Joining the ACO
• Former employee now works for ACO and suggested they contact the practice
• We knew we needed help, especially with Cost-savings measures
• ACO came to talk with us
• ACO wants practices to be accountable
• Provide reassurance of support
• Monthly webinars to watch through ACO portal
LESSONS LEARNED
• Decide goals in the beginning to keep focus when times get difficult –PATIENTS ARE OUR PRIORTY!Run your quality reports early and often• Educate staff
• Re-run reports to make sure changes in workflows were made consistently
• If you find inconsistencies in quality measures, report to EHR vendor immediately with examples• Tobacco Use and Cessation Intervention
• Depression Screening
• Closing the Referral Loop
• Find another way – Closing the Referral Loop quality measure
• Education to other clinics necessary for summary of care requirements
• QI Team to meet before visit from advisor to make sure prepared.
Work In Progress
• Patient portal usage is increasing through updating demographics; not a lot of messages yet• Clinic will work on texting patients; need training
• Staff Satisfaction Surveys • Small practice size makes it difficult for honesty with anonymity
• Closing care gaps
• Improving patient access to care• Depression Screening – Started doing manual registry to track who had
what done because we couldn’t rely on EHR; eCW was able to eventually fix
• Referrals
Work In Progress
• ACO Informational Sessions and Reporting on Ten Measure for 2019
• Quality Improvement is important; it is worthy of our time• Not just paper pushing
• Improves quality of patient’s lives and job satisfaction of all
• Data shows physical improvement or lack of improvement directly correlates to patient care/outcomes and quality of life!
CELEBRATION!
• Met our TCPi aims and targets
• Graduated from TCPi
• Joined an ACO in January 2019
• Continuing our work
• MIPS 2018 Score 93.75%
Resources
• Moving from MIPS to an APM: Part 1 Webinar
• Moving from MIPS to an APM: Part 1 Slides
• 2019 Shared Savings Program ACO Map
• Advanced Alternative Payment Models (APMs) 2019
• CMS QPP Resource Library
Moving from MIPS to an APM Series
Questions Encouraged!
Contact information:Don Klitgaard, MD, FAAFPCEO, MedLink Advantage
Excellent Educational Opportunity to Prepare Physician Leaders
Ascent Physician Leadership program• To prepare physician leaders to lead through the opportunities and
challenges presented by today’s healthcare world• Beginning with session on June 28-29, 2019 in Denver with ongoing,
rolling enrollment • www.ascentphysicianleadership.org for more information
Thank you for joining us!
Th
Sandy Swallow515-223-2105
Michelle Brunsen515-453-8180
Ellyn [email protected]
Nicky [email protected]
www.ihconline.org/compass-ptn
