PulseThe

ofSpring 2019

continued on page 2

The Physician Alliance participates in Blue Cross Blue Shield of Michigan’s Resource Stewardship Initiative (RSI) to promote the use of evidence-based medicine for health care stewardship decisions. The initiative works to help physicians improve decision making when using medical services, procedures and tests that have been identified as areas of over-utilization and encourages conversations between physicians and patients about appropriate and necessary care.

The RSI council identified medical services, procedures and tests that may be overused or of questionable value

and that have significant variation in use among physician organizations in Michigan. Some of these “over utilized” services are included in the Health Effectiveness Data Information Set (HEDIS), a national metric system that payers use to evaluate a practice’s quality performance.

TPA selected new measures to target in 2019 due to improvement in previous RSI metrics. The selected target areas help practices identify patterns of overuse and develop approaches to improve resource stewardship. A lower metric value indicates a higher quality score.

In 2017, more than $3.5 trillion was

spent on healthcare costs in the United States.

A study by the National Academy of Medicine

found that an estimated $765 billion a year is

spent on unnecessary medical tests and care.

decrease healthcare services

New targets to

2

Dear members,

As decreasing cost of care becomes more of a key focus in healthcare, accurate diagnostic coding plays an increasingly important role. An example is Blue Cross Blue Shield of Michigan (BCBSM) will be using risk adjustment scoring as part of Physician Group Incentive Program (PGIP) cost scoring and subsequent physician organization (PO) incentive dollar distribution. As such, The Physician Alliance Board of Managers endorsed the dissemination of unblinded reports by specialty, outlining the number of diagnosis codes per claim for BCBSM patients. These reports will be distributed to TPA specialty physicians on a quarterly basis to highlight opportunities to more accurately code. Our goal is to help our physicians identify areas of improvement and understand the interconnectivity of each TPA member to others.

The Physician Alliance continues to develop education and information to assist our members with coding. Our website holds many videos, tip sheets and guides that can be viewed by physicians and practice staff, and new education opportunities will be available throughout the year. We also offer custom coding services through Ethica, a subsidiary of TPA (see article in this issue). I hope you’ll take advantage of all of these resources.

Our team understands the many challenges facing our physicians and their staff. Changing requirements and information continue to be present in this industry. TPA staff and the practice resource team members are committed to helping our practices meet these challenges as we work together to improve patient care.

In good health,

Michael R. MaddenPresident & CEO

President’s MESSAGE

New targets to decrease healthcare services continued from page 1

The measures identified for reduction in utilization are based on current physician scores and TPA’s ranking among other physician organizations in these specific areas, indicating the physician organization has significant opportunity for improvement due to providers over-utilizing specific

tests. Decreasing low back pain imaging continues to be a measure because TPA still has significant opportunity for improvement in this area.

A study by The Dartmouth Institute found that many physicians put responsibility for unnecessary health tests, prescriptions and more on patients who insist that a healthcare provider “do something,” like write a prescription or perform a test. Educating patients on the value, or lack of value, of specific healthcare procedures is an important task in improving these metrics and lowering cost of care.

The Physician Alliance will be developing new and updated education materials related to these measures to assist physicians and practice staff with educating patients on these measures. These materials and others can be found under the Learning Center tab on TPA’s website at www.thephysicianalliance.org. <

TPA’s RSI measures for 2019 include:

• Decrease routine annual Pap tests in women 30-65 years of age

• Decrease annual vitamin D testing

• Decrease HPV testing, alone or in combination with Pap tests for cervical cancer, in women younger than 30 years old

• Decrease imaging for low back pain

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Are you utilizing TPA MOBILE APPS?

The Physician Alliance (TPA) launched two free mobile applications (app) to easily bring information to providers and patients. One app helps physicians stay updated on new education and industry information, and the other assists patients with managing contact information for their physicians, pharmacy and more.

The Physician Education app provides tips for improving adult and pediatric HEDIS measures, BMI, quality scores, and much more! Physicians have access to valuable tips and up to date information directly on smartphones, tablets and laptops.

The Physician Education app has several value-added features:

• Billing codes for condition specific care

• Overview of pay for performance programs, including PGIP

• Transitional care management tip sheets

• Link to TPA’s secure physician portal for members to access PGIP performance reports

• Links to educational videos

This app is very beneficial for physicians. Utilizing information and important tips on the app aids in saving time, improving knowledge, and accesses quality scores and incentive payments.

The My Doctors app is patient-focused and allows users to save multiple physicians’ contact information (addresses, phone/fax numbers), pharmacy and urgent care contacts in a secure mobile application. This app will aid in ensuring accurate exchanges of information between patients, their physicians and other health care providers along the care continuum.

The My Doctors app is preloaded with more than 2,200 TPA primary care and specialty doctors. Users can search for their doctor(s) by name or can manually add new doctors. The newest features include adding preferred pharmacy information and searching for an urgent care location within a selected zip code.

This app can help:

• Search for an urgent care center

• Add pharmacy contact information

• Create tags for multiple family members

• Directly connect to maps

In compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), My Doctors app requires users to create a secure access code that is used every time the application is opened.

Both the My Doctors app and Physician Education app are free to download from the Apple store and Google Play. <

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Congratulations to The Physician Alliance members receiving a value-based reimbursement from Blue Cross Blue Shield of Michigan!

The value-based reimbursement (VBR) provides 5-10 percent additional reimbursement to Relative Value Units (RVU) billing. Physicians must meet certain criteria to be nominated by their physician organization. TPA saw an increase of 89 percent in the number of specialists receiving the 10 percent VBR.

Congratulations to the specialists and their practice staff for the hard work and dedication to improving quality of care.

Increase in specialists receiving value-based reimbursement

2019 value-based reimbursement achievements:

of all TPA specialty physicians in PGIP are receiving a VBR (compared to 89% in 2018)

of TPA PGIP physicians receive a 10% VBR (604 TPA specialists). This is an 89% increase from 2018 in the number of specialists receiving a 10% VBR.

of TPA PGIP physicians receive a 5% VBR (275 TPA specialists)

96%

31%

69%

93%

of TPA PGIP specialty physicians nominated by TPA earned a value-based reimbursement (879 specialists)

*Ethica is a wholly-owned subsidiary of The Physician Alliance.

Contact info@ethicaholdings.com for a consultation to learn more. <

Physicians are now being rated by key payers based off total cost of care. Payers are basing health care dollars on the patient’s health status and risk adjusted cost of care score. Accurate diagnostic coding reflects the disease burden of the patient population that physicians treat and subsequently adjusts the cost of care.

Ethica* offers diagnostic coding education, specialty specific diagnostic codes per claim reports, Medicare coding education and other customized services to meet your practice’s needs.

Get assistance with diagnostic coding

5

Diagnosis codes are used to identify “why” a patient is being seen by a doctor. This could be a disease, disorder, symptoms, injury, or other reason for a patient encounter with a provider.

Procedure codes are used to identify “where,” “how,” and “what” was done or given to the patient during the encounter. This could include surgeries, medical equipment, vaccines, counseling sessions, or any type of encounter with the provider.

The implementation of the International Classification of Diseases, Tenth Revision, or ICD-10, increased the amount of codes available for selection, allowing more specificity when diagnosing patients. Where the previous version, ICD-9 had approximately 13,000 codes, ICD-10 has over 70,000 codes.

ICD-10‘s more specified codes can help justify clinical decision-making to the insurance company or government

payer (Medicare/Medicaid). In ICD-10, the laterality specific codes remove questions the payers may have had in the past with ICD-9 causing payments to be delayed. For example, “fracture of the forearm” becomes a “torus fracture of lower end of right radius, initial encounter for closed fracture” in ICD-10 coding.

Diagnosis codes are used as part of the reimbursement process for insurance companies and government payers. They are also used for statistics and collecting data that provide better information for identifying diagnosis trends, public health needs, and epidemic outbreaks. A more precise code can have the potential benefit for fewer rejected claims and improved benchmarking data, patient care management and health reporting.

Much of the information documented in the patient record is translated into coding. Diagnosis codes require specificity to give a complete and accurate description of a patient. Everyone involved with the medical record should be familiar with the impact coding has on overall continuation of care for a patient. Translating each patient record using accurate and up-to-date codes is crucial to this effort. There is potential for new diagnosis codes or a change in documentation guideline every year. New ICD-10 code books are released and become effective on October 1.

DOCUMENTATION for diagnosis coding

The importance ofCODING C

OR

NER

Example of diabetes documentation requirements for ICD-10 include:

• Type of diabetes

• Body system affected

• Complication or manifestation

• A secondary code for long term insulin use is required if patient is using insulin

Example: Codes E11.51 and Z79.4 are used for a Type II diabetes mellitus patient with diabetic peripheral angiopathy without gangrene who has used insulin for many years. <

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More than 100 million U.S. adults live with diabetes or prediabetes, according to the Centers for Disease Control and Prevention.

The Physician Alliance has been working with practices to target patients with prediabetes and high-risk diabetic patients to help educate and improve health outcomes. Last year, TPA launched several pilot projects related to these target populations, as well an outreach and education program with support from Merck. Diabetes HEDIS quality metrics are also measures that need improvement within the physician organization.

TPA created several education materials focusing on diabetes that can be distributed to patients. These are great conversation starters for education and action.

The following patient education materials are available to download or order from TPA’s website:

• Patient diabetes self-management form

• Patient diabetes action plan form

• 6 ways to manage your diabetes poster

• 6 tips for lowering diabetes risk poster

• Diabetic eye exam poster

EDUCATION targets diabetic measures

This health alert is brought to you by:

Source: American Medical Association, Centers for Disease Control and Prevention, American Diabetes AssociationThese items are provided solely for informational purposes and are not intended as a substitute for consultation

with a medical professional. Patients with any specific questions about the items on this list or their individual

health should consult their physician.

Join a diabetes prevention program if your physician diagnoses you with prediabetes or abnormal blood glucose. This program offers support and tips to help reduce your risk of type 2 diabetes and improve your health! Your doctor can direct you to a program near you, or visit doihaveprediabetes.org to find a program in your area.

for lowering your risk of diabetesTIPS6

Eat healthy. Cutting out foods high in sodium, fried food and saturated fats can help improve your weight, blood glucose, blood pressure, cholesterol numbers and overall health. A food and activity tracker is a great tool for maintaining your goals.

Be active. A minimum of 2.5 hours (150 minutes) of light aerobic activity every week is recommended. Go for a walk, take the stairs, ride a bike or any activity that gets you moving.

Manage your weight. Studies show that being overweight is a major risk factor in developing type 2 diabetes. Losing 5–7 percent of your body weight can help slow or reverse prediabetes (this is only 10–20 pounds if you weigh 200 pounds).

1

2

Share your personal health history and family health history with your doctor to ensure appropriate testing. Some ethnic groups have a higher risk of developing diabetes.

Know your numbers. Your blood glucose (sugar) and your A1C are important to follow your progress.

Quit smoking. Stopping tobacco use is a benefit for many reasons – lowers risk of heart disease, diabetes, cholesterol, blood pressure, lung and mouth cancers, and more. Talk to your doctor about a stop smoking program.

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5

63

Did you know that 84 million Americans are at risk for prediabetes?Prediabetes means your blood glucose (sugar) is higher than normal, but not yet diabetes. Diabetes is a

disease that may cause kidney failure, stroke, blindness, loss of feet or legs, or heart attack. Many people

can lower their risk of type 2 diabetes through lifestyle changes that include physical activity and healthier

eating habits. These tips can help:

This health alert is brought to you by:

Source: U.S. Health & Human Services; Centers for Disease Control and Prevention;

American Diabetes Association

These items are provided solely for informational purposes and are not intended

as a substitute for consultation with a medical professional. Patients with any specific

questions about the items on this list or their individual health should consult their physician.

Being proactive can save your life

so talk to your doctor today about

managing your diabetes!

to manage your diabetes

WAYS6

Share your personal health history

and family health history with your

doctor to ensure appropriate testing.

Get healthy and active. Being overweight

is a major risk factor in developing type 2

diabetes. Roughly 30 percent of overweight

people have the disease, and 85 percent of

diabetics are overweight. A healthy meal

plan can help improve your blood glucose,

blood pressure, and cholesterol numbers.

Exercising can also help control your blood

glucose. Don’t smoke.

Know your diabetes ABCs. Talk to

your doctor about how to manage your

A1C (blood sugar or glucose) and Blood

pressure and Cholesterol to help lower

your chances of having a stroke, heart

attack or other diabetes problems.

2

3

Look down at your feet. Diabetes can

cause foot problems, including neuropathy

(nerve damage), skin changes, poor

circulation and ulcers. Alert your doctor

to any redness, swelling or pain to avoid

serious complications.

Don’t miss appointments with

your doctor. Regular monitoring of your

diabetes will help catch any changes or

complications before things get serious.

Make sure to be honest about any changes

in your health so your doctor can advise

you accordingly.

Get your eyes checked. Regular eye

exams can help diagnose eye problems

due to diabetes and eye doctors can treat

many of these problems before there is

damage which can cause blindness.

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6

5

1

This health alert is brought to you by:

Sources: National Eye Institute, National Institutes of Health; Centers for

Disease Control and Prevention.

These items are provided solely for informational purposes and are not intended as a

substitute for consultation with a medical professional. Patients with any specific questions

about the items on this list or their individual health should consult their physician.

If you have any changes in vision,

contact your doctor immediately!

Being proactive can save your vision.

to get a diabetic eye exam

REASONS6

An annual diabetic eye exam can find

and detect progression of diabetic

retinopathy. Laser surgery and injections

of medications have prevented vison loss in

diabetics who visit eye care professionals.

Diabetic retinopathy is a leading

cause of blindness in people with

diabetes. This is caused when blood

vessels in the retina increase in

number or weaken and leak fluid or

bleed, causing blurred vision. There

are often times no symptoms or pain

in the early stages.

People with diabetes are at risk for eye disease, leading to vision loss or

blindness. Diabetic retinopathy, cataracts and glaucoma are common eye

diseases affecting people with diabetes. Early detection can prevent blindness.

Here are some tips for protecting your eyes:

1

2A cloudy eye lens, which blurs your vision,

is caused by cataracts. Glaucoma

causes damage to the optic nerve, leading

to vision loss. People with diabetes are

two times more likely to develop these

diseases than those without diabetes.

Know your diabetes ABCs. Talk to your

doctor about how to manage your A1C

(blood sugar or glucose), Blood pressure

and Cholesterol to help prevent eye

diseases as well as reduce to your chances

of having a stroke, heart attack or other

diabetes problems.

Cataracts and glaucoma are more

common in diabetics and can also be

detected at annual eye exams and treated

with medications or surgery.

Keep your doctor updated on your health.

If you experience a sudden change in vision

notify your doctor immediately. Monitoring

of your diabetes will help catch any changes

or complications before things get serious.

Be honest about changes in your health so

your doctor can best advise you.

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Visit thephysicianalliance.org, click on Learning Center, then

Patient Education Materials.

Congratulationson improving your practice’s care coordination.

Service Excellence Awardin

Thank you for your dedication to the Patient Centered Medical Home – Neighborhood care model and improving patient quality of care.

Care Coordination

7

It is with deep sorrow that The Physician Alliance shares the loss of our friend and colleague, Steve Gil.

Steve joined the St. John Medical Group in 2009 and transitioned to The Physician Alliance in 2011, serving as the first staff member of the information technology department. He successfully led the integration of TPA’s disease registry, from 17,000 patients to more than 1.3 million today. This registry and many of Steve’s other developments helped practices better understand their patient population, identify gaps in care and improve quality metrics.

Steve epitomized TPA’s paradigm of creating innovation, always pursuing opportunities to solve problems and help others. His focus on customer service and building better systems to ease burdens on physicians and practice staff led to many best practices, new ideas and improved patient care.

Prior to TPA, Steve worked as an IT statistician analyst for General Motors for 33 years at the Tech Center in Warren. He also served 5 years in the U.S. Navy and received the first Good Conduct Award and Meritorious Unit Commendation National Defense Service Medal.

In honor of Steve’s commitment and positive impact on our work, one of TPA’s meeting rooms will be renamed the Steve Gil Innovation Room. <

The Physician Alliance mourns the loss of our friend and colleague

Collaboration and communication between specialty and patient-centered medical home primary care practices is important to improving care coordination and quality improvement in healthcare.

The Physician Alliance developed the Service Excellence Awards to encourage specialists to implement and maintain patient-centered medical home - neighborhood capabilities that improve patient care. These awards recognize specialty practices that demonstrate excellence in care coordination and quality improvement.

In 2019, 54 practices received 4- or 5-star rating in care coordination. Nineteen practices earned the quality improvement award.

Achieving the Service Excellence Awards provides a mechanism for specialty practices to be recognized among their peers and their patients, help identify potential areas of improvement in care coordination and quality improvement, guide practices to be successful in a rapidly changing healthcare environment, and will assist primary care physicians in identifying specialty practices that demonstrate excellence in care coordination and quality improvement processes.

For a complete list of practices receiving the Service Excellence Award in Care Coordination and Quality Improvement, visit TPA’s website, click on Incentive Programs/Patient Centered Medical Home Neighborhood. <

Congratulations to practices receiving a

Service Excellence Award!

20952 12 Mile, Ste. 130St. Clair Shores, MI 48081

PRE SORTEDNON PROFIT MAIL

US POSTAGE

PAIDST. JOHN HEALTH

Dennis Ramus, MD Chairperson

Daniel Megler, MD Vice Chairperson

Trpko Dimovski, MD Treasurer

William Oppat, MD Secretary

Eugene Agnone, MD

Mazin Alsaqa, MD

Bruce Benderoff, DO

Paul Benson, MD

Dennis Bojrab, MD

Michael Little, MD

Sidney Simonian, DO

Robert Takla, MD

Kevin Thompson, MD

Robert Zaid, DO

Michael R. Madden President & CEO

Robert Asmussen Senior Business Advisor

Heather Hall Executive Director, Corporate Communications

Jennie Lekich Director, Clinical Informatics

Michele Nichols Vice President, Administrative Services & Business Development

Carolyn Rada, RN, MSN Vice President, Operations

Sharon Ross, RN, MSN, NP Executive Vice President, Population Health

Oleg Savka Director, Systems and Informatics

Ashley Shreve Director, Practice Transformations

Karen Swanson, MD Chief Medical Officer

TPA Leadership Team TPA Board of Directors

www.thephysicianalliance.org

Help us keep connected with you!

To ensure TPA news and announcements reach you, please make certain any changes in contact information (name, email, address, phone) are shared with us. Send to thephysicianalliance@thephysicianalliance.org.

(586) 498-3555