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Playing to Win in MSSPFEBRUARY 16, 2016
HEALTH ENDEAVORS 2016 1-888-862-0366 1
CMS Portals – Who is responsible?MFT, HPMS, ACO PORTLET, QNET, EIDM, CAHPS, PUBLIC REPORTING
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EUA – Password Reset, Annual Certification
https://eua.cms.gov/identityiq/login.jsf
MFT – CCLF, Assignment & Aggregate Reports
https://eftp2.cms.hhs.gov:11443/cfcc/login/login.jsp
HPMS - Participant (TIN, CCN, NPI) Management, Application
https://hpms.cms.gov/app/login.aspx
ACO Portlet - CMS Webinar Recordings, File Retrieval
https://portal.cms.gov/wps/portal/unauthportal/home/
CMS UserID – EUA, MFT, HPMS, ACO Portlet
For help with Form CMS-20037 and CMS User ID: [email protected] or (800) 220-2028
EIDM/QNET – PQRS/GPRO (September, 2016) (used to be IACS/QNET)
https://portal.cms.gov/wps/portal/unauthportal/home/
CAHPS (Patient Surveys) (August, 2016)
http://acocahps.cms.gov/Content/ApprovedVendor.aspx
Public Reporting Guidance (January, 2016)
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-Public-Reporting-Guidance.pdf
Primary Care Only
Primary Care + Specialists
Primary Care + Hospital
Primary Care + Specialists + Hospital +Home Health
Hospital Based
Patient History & Demographics
Geography
Management/Governing Body
Organizational Structure
Single EMR
Multiple EMRs
Every ACO Is Different
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Best Practices + Unique Decisions
One Strategy Does NOT Fit All
=Your ACO Strategy
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Quality Program
GPRO/PQRS
Care Coordination & Case Management
Data Analysis
3 Components of Population Health Management
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Quality Improvement
Program
GPRO/PQRS
Control
Out-of-Network Spend
Achieve Shared Savings
Targeted Spend Reduction
Missed Revenue
Opportunities
Physician Engagement
MSSP ACO Goals
Triple Aim
Better care for patients Better health for our communities Lower Costs through improvements for our health care
system
CCM 99490 Annual Wellness Visit After Hours Program/ER Alternatives Specialist Outreach Clinics (Access to Care) Out-of-Network Spend Preventive Care Services (Gaps in Care)
Stop the Admit Visit Stop the ER Visit Preventive Care Services (Gaps in Care) Patient Case Management & Care
Coordination Patient Follow-up & Education Utilization Trends
MRI, CT, Home Health
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How does Shared Savings Work?
COPYRIGHT HEALTH ENDEAVORS 2015
2 Primary Requirements to Earn Shared Savings:
Successful Quality Measures Reporting and Benchmark Performance (GPRO)https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-QM-Benchmarks-2016.pdf
Reduce Spending at least 5% (or a % greater than the assigned Minimum Shared Savings% Rate) below the Historical Benchmark
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How does our ACO know if we are on track to achieve Shared Savings?
COPYRIGHT HEALTH ENDEAVORS 2015
2 Primary Data Analytics to determine your ACO Status:
Year-round GPRO/PQRS Data Collection & Performance Scoring – NPI Level
Actual Benchmark vs. Goal Benchmark (based on Historical Spend) – NPI Level
Quality Accountability Year-round GPRO/PQRS Data Collection & Performance Scoring – NPI Level
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Quality of Care
In order to be eligible to share in any savings generated:
In the first performance year of their first agreement period, ACOs satisfy the quality performance standard when theycompletely and accurately report on all quality measures (pay-for-reporting). Complete and accurate reporting in the ACO’sfirst performance year qualifies the ACO for the maximum sharing rate.
In subsequent performance years, quality performance benchmarks are phased-in for performance measures and the qualityperformance standard requires ACOs to continue to completely and accurately report quality data on all measures but theACO’s final sharing rate is determined based on its performance compared to national benchmarks. In addition, ACO’s mustmeet minimum attainment (30th percentile benchmark) on at least 1 pay-for-performance measure in each domain inorder to be eligible to share in savings. Both attainment and improvement in performance are taken into account whencalculating the final sharing rate for ACOs in their second and subsequent performance years.
ACOs are rewarded up to four additional points in each domain, if they demonstrate quality improvement. In this way, theACO becomes increasingly responsible for quality performance and improvement during the first agreement period. When anACO renews its participation in the program for a second or subsequent agreement period, the quality performance of ACOsis assessed in the same manner as ACOs in the third performance year of their first agreement period.
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Performance scoring
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Financial Accountability Actual Benchmark vs. Goal Benchmark (based on Historical Spend) – NPI
Level
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Data Analysis Action Items – Phase IAssign every patient to an individual NPI
◦ Apply algorithms utilizing claims data and patient assign data
◦ Primary Care vs. Specialist
◦ Plurality of Visits
◦ TIN visits and associated NPI visits
HCC Risk Score every patient
◦ Start HCC comparison 2015 vs. 2016
Identify Patient Disease & Wellness Gaps in Care
◦ Provider Patient Profile
◦ Care Coordination & Case Management
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Data Analysis Action Items – Phase IActual Benchmark vs. Goal Benchmark (based on Historical Spend) – NPI Level
◦ Establish NPI goal benchmark based on historical spend
Aggregate Expenditure & Utilization
◦ Map CCLF individual patient data back to CMS Aggregate Report
◦ Compare to National FFS Average and MSSP ACOs
Patients Trending to be Costly
◦ Top 30% HCC Score
◦ ED visit and Hospitalization in last 12 months
◦ 2 or more chronic conditions
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Get your arms around Patient Population
Use your Claims Data for GPRO!
Who are they?
Who is treating them?
Where are they?
Who is sharing data?
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What is HCC Score? Who is Potentially Costly?
What are their disease & wellness gaps in
care?
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Assign every patient to an individual NPI
Apply algorithms utilizing claims data and patient assign data
Primary Care vs. Specialist
Plurality of Visits
TIN visits and associated NPI visits
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HCC Risk Score every patient
Start HCC comparison 2015 vs.
2016
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Identify Patient Disease & Wellness Gaps in Care
Provider Patient Profile
Care Coordination & Case Management
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Actual Benchmark vs. Goal Benchmark (based on Historical Spend) – NPI Level
Establish NPI goal benchmark based on historical spend
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Aggregate Expenditure & Utilization
Map CCLF individual patient data back to CMS Aggregate Report
Compare to National FFS Average and MSSP ACOs
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Patients Trending to be Costly
Top 30% HCC Score
ED visit and Hospitalization in last 12 months
2 or more chronic conditions
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Data Analysis Action Items – Phase IISpecialist Spend
Out-of-Network Spend
Admissions & Readmissions Spend
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GPRO/PQRS Readiness Action ItemsAssign every patient to individual NPI◦ Apply algorithms utilizing claims data and patient assign data
◦ Primary Care vs. Specialist
◦ Plurality of Visits
◦ TIN visits and associated NPI visits
EMR Gap Analysis◦ Incomplete, Non-performing responses
◦ Quality Measure Central Repository [EMR, CCLF, Manual Key, Lab]
Provider Education on 2016 PQRS/GPRO◦ QM 2016 Measure Requirements
◦ QM 2016 Audit Document
Assess Performance Year Round◦ Email Performance and Progress Scorecards to Providers
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Assign every patient to an individual NPI
Apply algorithms utilizing claims data and patient assign data
Primary Care vs. Specialist
Plurality of Visits
TIN visits and associated NPI visits
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March 1, 2014 1-888-862-0366/WWW.HEALTHENDEAVORS.COM 55
Quality Measures 2014 LEGEND – Bottom of Screen
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Filters:Patient Claims = Claims Data Available for this patient to assist in answering the Quality Measure
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Claims Data will display above the applicable question/module
Click on the Pink Bar to Expand
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Claims Summary for this Measure will display including CPT and ICD9 codes
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Click on red plus button to view NPI information for Rendering Provider and Facility
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EMR & Chart Gap Analysis
Not on Chart(EMR)
Can’t Report
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Work Flows/EMR Gap Analysis--
Who/What/Where/When/How
--Quality Measure conducted and documented on a
consistent basis? [What?]
--Responsibility for conducting and documenting the
Quality Measure assigned to staff or providers? [Who?]
--Quality Measure conducted and documented in the
hospital or physician setting [Where?]
--Quality Measure documented in the EMR, paper chart
or other method? [How?]
--Staff aware of the timeframes for capturing each
Quality Measure? [When?]
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QM 2016 Import Chart
--CCLF Imports
--EMR Report Imports
--Abstracted by Facility
--Abstracted by Health Endeavors
--EMR CCDA Imports
--Abstracted by Facility
--Abstracted by Health Endeavors
--Manual Key
--Preferences/Defaults
--Carry-Over Pneumonia Module from 2014
--Lab Imports (Hemoglobin A1c)
--Lab Displays
By Patient
By Facility (TIN)
By NPI
ACO (aggregate)
Scorecards – Performance & ProgressQuality & Financial
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GPRO/PQRS Data Abstraction & Integration to Central Repository
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Facility abstract data from EMR into Electronic
Report or CCDA
Facility remit EMR Data (Electronic
Report or CCDA) for Import
using Submit a Request
Health Endeavors
import EMR Data into
QM 2016 GPRO Tool
Facility abstract EMR Report or CCDA Data to import into
the Health Endeavors QM 2016 Reporting Tool
to complete the GPRO Measures
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Health Endeavors
import CCLF data
(monthly) into QM 2016
Imported CCLF data completes QM 2016
Based on the CPT and ICD9
Codes
Health Endeavors imports CCLF data to complete QM 2016
responses based on CPT and ICD9 and ICD10 codes
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Complete QM 2016 Import Chart Preferences
Health Endeavors applies your QM 2016
Import Chart Preferences to QM 2016
Tool
Preferences & Defaults – QM 2016 Chart
Default Applicable Modules/Responses to “No” or “Not Done”
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Pull Charts and Key Data
Health Endeavors QM
2016 Tool
Manual Chart Abstraction
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Approaches to GPRO1. Do nothing and hope for the best
2. 8 weeks of manual chart abstraction
3. Year Round Plan of Action◦ Provider & Staff Education
◦ EMR Gap Analysis
◦ Central Repository of Data
◦ Distribution of Performance Scorecards to NPIs
◦ Patient Gaps in Care
◦ Readiness for Physician Compare Public Posting
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Out-of-Network Migration
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In-Network/Out-Network MigrationOut-of-Network Leakage
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ACO Distribution Model
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Example Distribution Criteria Example Distribution Point System
TIN Benchmark2 – met benchmark
1 – did not meet benchmark
Quality Measures2 – successful reporting of quality measures to ACO
0 – did not successfully reporting quality measures to ACO
Patient Survey Results
2 – Satisfied successful percentage per CMS Standards
0 – Did not satisfy the percentage per CMS Standards.
EMR Use and Integration
2 – stage 2 MU attestation
1 – stage 1 MU attestation
0 – no stage 1 MU attestation
Leadership and Participation
2 – took on leadership role
1 – participated on committee
0 – no leadership or committee involvement
CCM 99490
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Compliance1. Do not use unsecure text or email of Patient Health Information
2. Do not send CMS TINs or NPIs in a non-secure email.
3. Conduct Conflict of Interest annually.
4. Prepare an ACO Compliance Plan and Medical Practice Compliance Plan.
5. Conduct HIPAA education.
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Final & Proposed ACO Rules
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https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News-and-Updates.html
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Recap – Beneficiary Assignment1. Identify all beneficiaries that had at least 1 primary care service with a physician who is anACO professional in the ACO and who is a primary care physician.
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Recap – Beneficiary Assignment2. Identify all primary care services furnished to beneficiaries identified by ACO professionals ofthat ACO who are primary care physicians, non-physician ACO professionals and physicians withspecialty designations.
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Recap – Beneficiary Assignment3. Under First Step, a beneficiary identified is assigned to an ACO if the allowed charges forprimary care services furnished to the beneficiary by primary care physicians who are ACOprofessionals and non-physician ACO professionals in the ACO are greater than the allowedcharges for primary care services furnished by primary care physicians, nurse practitioners,physician assistants and clinical nurse specialists who are:
◦ ACO professionals in any other ACO;
◦ Not affiliated with any ACO and identified by a Medicare-enrolled billing TIN.
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Recap – Beneficiary Assignment4. The second step considers the remainder of the beneficiaries identified who have not had a primary careservice rendered by any primary care physician, nurse practitioner, physician assistant or clinical nursespecialist, either inside the ACO or outside the ACO.
The beneficiary will be assigned to an ACO if the allowed charges for primary care services furnished to thebeneficiary by physicians who are ACO professionals with specialty designations specified by CMS aregreater than the allowed charges for primary care services furnished by physicians with specialtydesignations who are:
◦ ACO professionals in any other ACO;
◦ Not affiliated with any ACO and identified by a Medicare-enrolled billing TIN.
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Non-Physician ACO Professional
1. CCN List
2. NPI List for Physicians and Non-Physician ACO Professional
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99495, 99496 – Transitional Care Management (TCM) Services
99490 – Chronic Care Management (CCM) Services
Company Overview
Since 2008, Health Endeavors has been on the cutting edge ofhealthcare technology development and has quickly become thecountry’s most reliable healthcare vendor from coast to coast.
Our unique technology is why the nations largest healthcareproviders rely on Health Endeavors year in and year out to keepthem on the forefront of healthcare technology and challenges.
With offices based in in Scottsdale, Arizona and Omaha, Nebraskasince 2008, we are strategically located to be readily available toclients in any time zone.
Our cloud-based Patient Health Integrated Tools (PHIT) andHospital Admin Tools (HAT) technology are used on a daily basisby over 1.5 million users to improve the care of over 10 millionpatients.
Click here to visit our website!
Recent Regional Contract Announcement:
Greater New York Hospital Association (GNYHA) Contract: GNYHA-IT-054
HEALTH ENDEAVORS 2016 1-888-862-0366 97
Kris Gates, J.D., CEO of Health Endeavors, is the primary architect of the Health Endeavors technology suite. Using her
extensive experience gained in both the business, population health management and legal sectors, Health Endeavors
developed a suite of technology solutions to assist healthcare providers with the management and utilization of
administrative and clinical data.
Currently, the Patient Integrated Health Tools (PHIT) and Healthcare Admin Tools (HAT) suites are used by over 1.5
million users. In addition, the PHIT Tools manage over 10 million patients on a daily basis.
Kris worked in programming and SQL database service positions prior to law school for MidAmerican Energy and IBP,
Inc. with a focus on patient health management and data analysis.
In 2001, she earned her juris doctor from Creighton University School of Law with cum laude recognition. In addition to
her technology development experience, Kris provided legal services in private practice and served as corporate counsel to
several large nonprofit health systems, including Banner Health, Alegent Health and Norton Healthcare.