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Agenda
Stars: Medicare Advantage Quality
Changes for 2017 Pay for Quality and PCMH Programs – Important Announcements!
Topics
Diabetes Incentive Program
High Performer Program
Dual Special Needs Metrics
Medication Management
Medication Reconciliation Post Discharge
Medication Therapy Management
Medication Review
Blood Pressure Control
9
CMS Asks:
How Good is Your Medicare Advantage
Plan?
CMS wants to:
Inform beneficiaries as they choose a plan
Encourage best evidence-based practices
Improve/maintain health and well-being
Payments for VALUE rather than volume
10
What Gets Scored?
Preventive Screenings Breast Cancer Colorectal Cancer
Chronic Disease Monitoring and Control Diabetes Hypertension Rheumatoid Arthritis Osteoporosis
Medication Oversight Medication Adherence Medication Reconciliation Post Discharge Medication Therapy Management
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Diabetes Incentive
Program
Akamai Advantage
Diabetes Incentive Program
741 members participating (out of 8,700 with diabetes)
Potential to earn $100 in gift cards
Services during 2016
It’s not too late to sign up!
HbA1c Testing
Eye Exam
PCP Visit for Diabetes
Diabetes Education
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What is the program?
15
You have patients who struggle with preventive services, so you were invited to participate
We selected members who need the most assistance with gaps in care
The program aligns bonus payments with the extra effort from your team
High Performer Program Update
527 Providers invited
Packets mailed early September
Initial gap for each member: $20
Additional gaps for each member: $5
Office incentives: gift cards
40 gaps = $100
Each additional 20 gaps = $50 more in gift cards
10 Offices with the most gaps closed = additional $100
Questions? Call 952-7822
16
DSNP: What Gets Measured?
Members who are eligible for BOTH Medicare and Medicaid
All standard Medicare Quality Metrics
Preventive Screenings
Diabetes/Chronic Disease Measures
Medication Management
Four DSNP specific measures
Health Risk Assessment
Care for Older Adults
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Care for Older Adults: Dual Special Needs
Once per calendar year
Four-part assessment:
Medication Review
Functional Status Assessment
Pain Assessment
Advance Care Planning
COA form available with coding
and checklist assessments
• Complete the assessments • Add completed form to your
medical record • File a claim
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Medication
Management
CMS Emphasis: Medication Oversight
Medication Reconciliation Post Discharge
All Akamai Advantage Members
Within 30 days of hospital discharge
Medication Therapy
Management (MTM)
3 Chronic Conditions
8 or more Medications
Refer to Pharmacy
Vendor
Medication Review
Dual Special Needs (DSNP)
Enrollees
Once
per calendar year
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Medication Reconciliation
Post Discharge
Hospital Discharge
30-day window – Medication Reconciliation
Document on claim
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The Quick Version of Documentation
MRP:
Medication
Reconciliation
Post-Discharge
(Medicare)
The percentage of
discharges from 1/1-12/1 of
the measurement year for
members 18+ for whom
medications were
reconciled on or within 30
days of discharge.
Documentation needed: • Medication reconciliation completed by the
prescribing practitioner, clinical pharmacist,
or registered nurse on or within 30 days of
discharge.
• Need documentation that it was completed
and the date that it was done in the
outpatient chart.
Any of the following evidence meets criteria: • Notation that, “I have reviewed patient’s
discharge medications and reconciled
against pre-admit medications”
-or-
• Notation that “no medications were
prescribed upon discharge”
Submit CPT II Code: 1111F
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Medication Therapy Management
Patient receives a free
comprehensive medication
review by a pharmacist
Help for your most complex
patients
3+ chronic diseases
8+ maintenance medications
spend >$ 876.75/quarter on
medications
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Refer patient to HMSA’s vendor: Mirixa (866) 208-1223
Take Home Thoughts
Diabetes Incentives
High Performer Program (including office bonuses)
Dual Care: COA forms
Medication Measures
Med Recon help from Pharmacare
Med Management help from Mirixa
Blood Pressure – last chance for
in-control values!
26
Akamai Advantage
27
Review of Chronic Conditions (RCC) • Deadline for RCC and supplemental
reporting is December 31, 2016. Plan aiming for highest possible completion
Pay for Quality PCPs: Best strategy: work to achieve 4 to 5 stars (90%-95%) on RCC! Payment Transformation PCPs: Goal is 95% or higher for Maximum
74.5%
RCC rate as of 10/24/16
RCC Supplemental Reporting
Most supplemental reporting for RCC requires upload of
medical record into Cozeva. Deadline is December 31.
Disconfirm – Condition has improved; medical record required
Disconfirm – Condition has resolved; medical record required
Disconfirm -- Insufficient evidence of this condition. Medical
record is NOT required. Be sure to submit your complete
attestation in the Cozeva comment box, or upload a document that
contains the attestation.
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Disconfirm - Insufficient Evidence
PCP may choose to allow office staff (e.g., Cozeva Delegates)
to complete attestation and submit supplemental data for
disconfirmation on the PCP’s behalf
Sample: “I, [staff member name], report that Dr. Aloha Lee,
attests that this patient does not have the diagnosis of chronic
renal disease. Dr. Lee has reviewed the pertinent medical
information and finds that the patient has had normal creatinine
levels over the past two years.”
PCPs will be held accountable for all submissions by Cozeva
Delegate users.
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2017: A Transition Year
Staggered starts for Payment Transformation
January 1, 2017 – PCPs in identified Physician Organizations will move fully into Payment Transformation (global monthly payment + new measures), joining the 2016 pilot
April 1, 2017 – Some PCPs begin global monthly payment, but remain on Pay for Quality measures through 2017
July 1, 2017 – Last group of PCPs begins global monthly payment, but remain on Pay for Quality measures through 2017
32
Expectation that most PCPs will move to Payment Transformation payment and metrics by 2018
PCPs in Transition to Payment
Transformation
Payment Transformation
(Pilot, April 2016)
Payment Transformation (January 2017)
Payment Transformation
(April 2017)
Payment Transformation
(July 2017)
33
Important
Announcements
In 2017, global monthly payment will be made on or about the 15th of the month, with patient attribution from one month earlier
New! Engagement measure to build PCP’s profile on Sharecare find-a-provider application
New! Performance measure – Well-Being 5 being replaced by Sharecare RealAge Assessment
Report to Provider will give more information about processing of each claim; will make account reconciliation easier
Cozeva view will be reset in January 2017
Coming! PO training sessions and webinars 34
Important
Announcements
Supplemental data (commercial, QUEST Integration and Akamai Advantage) for January 2017 class ONLY must be entered into Cozeva by Dec. 31, 2016
Cozeva Pay for Quality view will be locked down for transition to Payment Transformation-only view for January 2017
All other PCPs have regular deadlines for submitting supplemental data:
Jan. 31, 2017 for commercial, QUEST Integration and Akamai Advantage measures
Dec. 31. 2016 for Review of Chronic Conditions
35
Payment Transformation
Transition
36
Starting Date Cozeva View
January 2017 Only Payment Transformation view
April 2017 July 2017
Pay for Quality and Payment Transformation views; Will be scored on Pay for Quality measures
PCPs starting in April or July will remain on Pay for Quality program (rolling 12 months, quarterly payment). Will use familiar Cozeva dashboard
Will also have “sneak peek” of Payment Transformation Cozeva dashboard
All PCPs will work on 2 Physician Organization quality measures on the Payment Transformation dashboard
Payment Transformation View
38
Colored chiclets and stars replaced by bars Red = below 50th percentile Yellow = Minimum (earning 40% ) Green = Target (earning 100%)
Quality Measures
Changes for 2017
39
Being dropped for P4Q because of small denominators; already dropped for Payment Transformation
Appropriate testing for children with pharyngitis
Appropriate treatment for children with upper respiratory infection
Avoidance of antibiotic treatment in adults with acute bronchitis
Quality Measures
Changes for 2017
40
Being dropped as a scored PCP measure, will remain as a Physician Organization measure that depends on PCP’s performance
Controlling high blood pressure
Physician Organization measure
Children with Special Health Care Needs Screener
Reporting Blood Pressure
Report both systolic AND diastolic values on claims
For patients age 60 to 85 with hypertension, BP is considered adequately controlled when BP is below 150/90 mm Hg. Report compliant blood pressure values using Cozeva supplemental data.
For patients age 60 to 85 with diabetes, BP considered in control if the blood pressure is below 140/90 mm Hg.
For patients with Medicare primary/HMSA secondary, report using supplemental data on Cozeva or submit secondary claim to HMSA
41
CPT codes Description
3074F Most recent systolic BP less than 130 mm Hg
3075F Most recent systolic BP 130-139 mm Hg
3078F Most recent diastolic BP less than 80 mm Hg
3079F Most recent diastolic BP 80-89 mm Hg
Reporting CSHCN Screener
Measure Procedure Code ICD-10 Code
CSHCN Screener© (NEW: ages 3-17, done every 3 years)
Screening done; positive finding for chronic or special health care needs: E/M CPT code + HA modifier + Z87.898
Z87.898 Personal history of other specified conditions
Screening done; negative finding: E/M CPT code + HA modifier
42
HA HCPCS code modifier = Child/adolescent program For screener tool: http://www.cahmi.org/wp-content/uploads/2014/06/CSHCNS-Survey-and-scoring.pdf
PCMH for 2017
43
Monthly PCMH payments continue until PCP moves to Payment Transformation global payment in January, April or July
At that time, PCMH payment is wrapped into monthly global payment
Old PCMH requirements dropped. Regardless of global payment start date, all PCPs work on PCP Engagement measures
PCMH level advancement discontinued in 2017
Engagement to Encourage Active
Participation
• These are foundational, relatively easy-to-achieve engagement
steps
• Ensures providers are engaged in the systems to succeed in the
new payment model
• Examples: • Use of Cozeva
• Engage all attributed members annually through visit, call, email, mail,
text, online care
• Referring patients to ecosystem programs (e.g.,HMSA Care Model,
HMSA health education workshops, Dr. Dean Ornish Program for
Reversing Heart Disease, community programs )
• New! Sharecare Engagement – build provider profile and upload PCP’s
photo for find-a-provider application
44
Engagement to Encourage Active
Participation
• Will be displayed on Cozeva for ALL PCPs in 2017
• Payment Transformation Pilot – will be scored in 2018
• Payment Transformation January 2017 – will be scored in 2018
• Payment Transformation April and July 2017 – will be scored in
2018
45
Measure Commercial Akamai Advantage
QUEST Integration
PCP/staff log into Cozeva at least once a month [pass = 100%]
5% 5% 4%
Check on well-being of all patients in panel [patient survey; pass = 75% of respondents report contact]
5% 5% 4%
Refer patients to health programs [Cozeva attestation; pass/fail]
5% 5% 4%
New! Sharecare Engagement 5% 5% 4%
Submit EPSDT forms [audit] 4%
TOTAL 20% 20% 20%
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Engagement: Details
In Payment Transformation, each measure is all-or-nothing across all plans. Performing well adds up to 20 pct. points to the 80% base PMPM the following year. Doing poorly could result in loss of up to 20 pct. points.
PCMH Meets
Payment Transformation
47
To calculate global payment PMPMs for 2017, HMSA will use FFS data for 2013-2015 + your PCMH level (Level 1, 2 or 3) as of December 1, 2016
To advance to PCMH level 2 or 3, request and documentation needs to be submitted to HMSA by November 4 for review and approval in time for a Dec. 1 effective date to affect global payment for 2017
PCMH Level Credited for PMPM
Level 1 $1 PMPM
Level 2 $3 PMPM
Level 3 $3.50 PMPM
PCP Affiliation with Physician
Organization
If you are joining or switching to a new Physician Organization, PO must notify HMSA by Dec.15
Be mindful of PO’s Payment Transformation transition date (Jan, April, or July 2017). Affects your quality/performance measures
January 2017 – Payment Transformation performance measures
April 2017 and July 2017
Remain on Pay for Quality measures through 2017
Switch to Payment Transformation measures in Jan 2018
48
2017 Trigger
Cancer screenings Breast cancer
Cervical cancer Colorectal cancer
Yes Patient age
Diabetes measures HbA1c in control
Eye exam Attention for nephropathy
Blood pressure control
Yes 2 visits with diabetes as DX
Advance care planning Yes Includes 65+
Patient age
BMI assessment for adults Yes Any outpatient visit with PCP, specialists
Review of Chronic Conditions for Akamai Advantage members
Yes Patient age and DX
Controlling Blood Pressure Yes PO measure
1 visit with hypertension as DX
49
Adult Measures
Payment Transformation:
Adult Measures
2017 Trigger
Screening for depression and anxiety (age 18 and older) [Patient Health Questionnaire-4]
Yes Outpatient visit with an eligible PCP type *
Tobacco cessation and followup
Yes Outpatient visit with an eligible PCP type *
Influenza shots Yes Patient age
New! Sharecare RealAge Assessment
Yes Patient age
Patient Experience (survey) N/A [Not a measure in 2017]
50
* Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths
2017 Trigger
Well-child visits in first 15 months Yes Patient age
Well-child visits, 3 to 6 years Yes Patient age
Childhood immunizations by age 2 Yes Patient age
Immunizations for adolescents Yes Patient age
Weight assessment and counseling for nutrition and physical activity
Yes Outpatient visit with PCP or
ob/gyn*
51
Pediatric Measures
* Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths
Payment Transformation:
Pediatric Measures
2017 Trigger
Developmental screening in child’s first 3 years (annually)
Yes Patient age
Adolescent well-care visit (ages 12 to 21) Yes Patient age
Screening for symptoms of clinical depression and anxiety (ages 12 to 17) [Patient Health Questionnaire-2, -4, -9, -Adolescents]
Yes Outpatient visit with an eligible PCP type *
CSHCN Screener© completion (ages 3 to 17, every 3 years)
Yes PO Measure
Patient age
Patient Experience (survey) N/A [Not a measure in 2017]
52
* Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths
Sharecare RealAge Assessment New!
Commercial members 18 and older who complete
Sharecare RealAge assessment at least once during the measurement year. Gauges how fast you’re aging based on lifestyle and medical history.
Replaces Well-Being 5
More information to be provided. Explore at https://www.sharecare.com/static/realage-test
53
Support for PCPs
Your Physician Organization is your quality and transformation leader
Call Cozeva at 1-888-448-5879 for questions or training about Cozeva display
Call HMSA at 948-6820 on Oahu or 1 (877) 304-4672, toll-free or email [email protected]:
Need training/support from HMSA’s Training Unit for you and your practice team
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