SUCCESS IN A VALUE - BASED PAYMENT ARRANGMENT

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "SUCCESS IN A VALUE - BASED PAYMENT ARRANGMENT"

Transcription

1 SUCCESS IN A VALUE - BASED PAYMENT ARRANGMENT October 3 rd, 2017 David Evangelista MediSys Health Network 1

2 Who is MediSys? Jamaica Hospital is a 431-bed not-for profit teaching hospital. Jamaica is a Level 1 Trauma Center and Stroke Center. It has one of the busiest Emergency Departments in the US, with almost 130,000 patients treated each year. Flushing Hospital is a 293-bed not-for-profit teaching hospital. Flushing services one of the most one of the most ethnically diverse populations in the United States. Employ 500+ physicians, and have relationships with community physicians as well as large community based IPA s. Employ ~ 100 staff members in a value based care management role. We bet the farm on Value Based Reimbursement! MediSys takes full capitated risk on 133,000 lives and has 15,000 lives in other Value Based Reimbursement contracts Shared Savings/Shared Risk. Majority of the lives are in a Managed Medicaid product. Looking to grow this number. 45% of our patient revenue comes through value based reimbursement. Administration has been in leadership roles at MediSys for 40+ years each. Part of Advocate Community Partners (ACP) PPS for DSRIP. This is the only physician-led PPS in New York State. MediSys Health Network serves as the safety net for the surrounding community. MediSys includes a state of the art Skilled Nursing Facility known as the Trump Pavilion, a large ambulatory care network, a free standing mental health clinic with two locations, and are integrated into the NYC 911 EMS system with our hospital based ambulances. MediSys also offers physical rehabilitation, psychiatric and chemical dependency services. 2

3 Medisys Health Network 45% of our organizations revenues are from Value- Based Payments 133,000 fully capitated lives that we take full risk for 750,000 Ambulatory care visits 165,000 Emergency department visits 5,500 Newborn deliveries 6,000 employees 3

4 Hospital Market Queens County Most culturally diverse county of the 3,000 counties in United States Over 135 spoken languages 4

5 5

6 MediSys Health Network Payer Mix Medicaid - 60% Medicare - 20% Self pay - 5% Commercial - 15% 6

7 Organizational Priority High quality + Low cost = Value 7

8 Healthcare Reimbursement Shift from volume based payment to value based payment. Hospitals and physicians that provide patient-centered, high quality, low cost healthcare will be the leaders. Hospitals and physicians will be rewarded for meeting quality objectives for their entire patient population, not just those patients actively seeking care. 8

9 Critical Issues to be Addressed Success on Risk Contracts is essential to overall MediSys success We developed a contracting plan to successfully manage the contracts Many services are delivered at provider locations other than MediSys Increase the proportion of hospital services provided by MediSys by ten percent. Achieve through physician education, PCP connectivity and effective Care Management. 9 We needed data infrastructure to manage this size risk population Worked with our IT Dept on data development and claims data tools. MCO needed to increase reporting and data sharing.

10 Critical Issues to be Addressed Many MediSys staff are involved with managing the risk contracts, but no one is fully devoted to it. We didn t set up a dedicated department but rather created a team of multi-disciplinary staff, including Administration. Our CEO and CFO are involved in every aspect of our risk agreements. It takes a village Significant downside risk, so one bad year could be very harmful. Get it right the first time as we can t be wrong. Track early indicators for advance warning of negative results. Physicians not fully engaged in shift to Value Based Payment. Collaborate w. employed and independent physicians to drive improvement on value based arrangements. Takes a while to change culture. 10

11 Key Findings The most costly 5% of all patients account for 70% of costs The 5% became our focus. Throw out the outliers and care management focused on the remainder to reduce the total cost of care. Identify your high cost beneficiaries, both today and tomorrow. Two-thirds of IP care goes out of network (based on costs). Higher for behavioral health services. Utilize care management programs as a differentiator. Focus on services you provide, not ones you do not. PCP connectivity. 11 ED utilization for Medicaid beneficiaries was high compared to benchmarks DSRIP initiatives helped. Flagged members in EPIC to connect members back to PCP. Care Management initiatives assisted.

12 12 Value-Based Contracts (VBC) How ready is your organization, your physicians, and the key players you have contracts with for VBC? Neighborhood Health Providers (NHP) HealthFirst Depending on type of value-based arrangement, performance is measured differently. Full risk Shared risk Shared savings

13 What are the goals? Population Health Minimize the cost of care. Enhance the overall health status of a given population. Provide care at the earliest practical point, not treating disease at the acute care level. Minimize expensive interventions, i.e. hospitalizations, emergency room visits, or expensive diagnostic testing. 13

14 Where to begin Before you start any meaningful population management, you need to have information to analyze. This itself is challenging because you need information about services performed inside and outside your network to get the full picture. Data has been more forthcoming and advancements such as DSRIP, risk arrangements and Health Information Exchanges should supply a lot of this data going forward. 14

15 Care Management Even with somewhat limited external data, we made our first step at Care Management by identifying high cost high frequency patients. Within that cohort, identifying those than can be potentially impacted by intervention. These actions will likely provide the biggest bang for the buck, as a relatively small number of members make up an extraordinary portion of the cost. 5% of the patients represent 70% of the cost. 15

16 Care Management Following at-risk patients to prevent 30 day readmissions. Engagement with patients in house at the hospital. Initiatives to reach out to members discharged from other facilities, something we were not always comfortable doing. Readmission rates have been historically higher for our members discharged from other facilities. 16

17 Care Management Goals & Focus Improve the health of our community Reduce/avoid unnecessary hospitalizations Close gaps in care 17

18 Top Members by Utilization Frequently Admitted Members Currently Engaged in CM Program Top 50 Members by Dx Diagnosis Count Diagnosis Count Sickle Cell 6 CHF & Asthma 1 Alcohol Abuse & Dependence 5 ESRD 1 CHF 4 CHF & Chest Pain 1 Alcohol & Drug Dependence, Psych 2 Intracranial Hemorrhage 1 COPD 2 CHF & Diabetes 1 Drug & Alcohol Abuse 1 Nephritis & Nephrosis 1 Pneumonia 1 CHF, Cirrhosis & Alcoholic Hepatitis 1 Myocardial Infarction, Respiratory Failure 1 Pancreas Disorder 1 Bronchiolitis & Pneumonia 1 Cirrhosis & Alcoholic Hepatitis 1 Seizures 1 Psychoses 1 Cancer 1 Asthma 1 Hepatic Coma 1 Schizophrenia 1 Chest Pain, Anxiety 1 Type 1 Diabetes 1 Opioid Abuse & Dependence 1 Septicemia 1 Chest Pain, Circulatory 1 Diabetes 1 Renal Failure 1 Digestive Malignancy 1 Alcohol & Drug Dependence 1 Alcohol & Drug Dependence 1 Asthma & Interstitial Lung Disease 1 Coronary Atherosclerosis 1 18 Grand Total 50 Cost Savings $4,509,269

19 Care Management Results Top Members by Utilization Frequently Admitted Members Currently Enaged in CM Program Spend Comparison Member Name Member Diagnoses Spend Before Engagement Baseline Monthly Medical Costs Spend Since Engagement Post Engagement Monthly Medical Costs Monthly Savings Post Engaement Annual Savings Post Engagement Patient 1 Alcohol & Drug Dependence $46, $82, $30, $8, $73, $878, Patient 2 Sickle Cell $356, $54, $0.00 $0.00 $54, $651, Patient 3 Sickle Cell $73, $68, $50, $17, $51, $613, Patient 4 Chest Pain, Anxiety $323, $46, $8, $1, $45, $546, Patient 5 Myocardial Infarct, Resp Failure $418, $41, $2, $ $40, $489, Patient 6 CHF, Cirrhosis & Alcoholic Hepatitis $123, $19, $0.00 $0.00 $19, $234,

20 Value-Based Contract Successes Care Management programs reduced cost by $4.5M annually. Membership growth to 133,000 fully capitated lives. 143% growth since Consistently positive excess medical revenue. Top Rankings in quality ratings. Substantial quality incentive payments annually. Reduction in out of our network services. 20

21 21 Quality Incentive Payments

22 Excess Medical Revenue EMR (All Product Lines) EMR (All Product Lines)

23 23 Covered Lives in Global Risk

24 24 Importance of PCP Connectivity

25 Importance of PCP Connectivity 25 Relationship is the link in the value based arrangement 5% churn within membership The PCP relationship is also what can drive more in network utilization, preventative care, disease management, etc. Our efforts in that regard have been to focus on new member outreach from Day 1, to contact members with gaps in care, and constantly try to connect patient back to PCP after an inpatient or ED visit.

26 Goals to Managing Value-Based Arrangements Improve patient care and group profitability Maximize premiums through risk adjustment activities Increase patient/pcp connectivity, especially with chronic or acute care management Resolve patient care gaps (i.e. Quality and HCC chronic care) Review Financial and Membership trends Review Clinical Trends and Integration 26

27 Goals to Managing Value-Based Arrangements There have been extraordinary increases in Pharmacy related costs. Determine if Pharmacy is to be included in the arrangement. Market price increases are out of control. A single Hep-C fill can cost over $25K. Linking patients to in-network OB s is important because deliveries can lead to costly out of network NICU spend. Select a few things to concentrate on first, then build on success. 27

28 28 HEDIS/QARR Team Effort Managed Care Department Sorts monthly missing services list by site-pcp-member-missing services, adds members with missing services to bottom of previous list and distributes Analyzes performance trends and provides reports to Coordinating team Site Management Review missing services list and address at point of service Managers oversee Patient Navigators at their site to ensure work is completed Patient Navigators Scrubs list for providers they are assigned to and recall patients with missing services Care management Quarterback for HIV and Post Partum exam measures Home visits to complete Post Partum exam and other missing services Performance Improvement Review Age out Measures Review documentation deficiencies Submit encounter files to MCO MCO Provides MMS data Provides consultative support Receives and processes Lab and Encounter file submissions

29 Team Effort Ambulatory Care Managers Administration Care Management Physician Leadership HEDIS/QARR Coordinating Committee Navigators Call Center Quality Department 29 Finance MCO Managed Care

30 HEDIS/QARR Improvement Process Monthly MMS Reports Recall Patients Sorting and Distribution Submit corrections Scrubbing Medical Records 30

31 31 Process for most measures Managed Care Department (MCD) obtains Monthly Missing Member Services (MMS) report from Managed Care Organization (MCO) MCD sorts and distribute MMS by Site and Physician to Patient Navigators and Site Manager Patient Navigators and/or site Managers scrub MMS records to identify services already received Missing services found during scrub submitted to Performance Improvement group which reviews and sends back to MCO to update MCO database Patient Navigators recall patients Home visits by Care Management Department as needed Mailings to non-utilizers (one-time mailing) Phone calls to members missing services Members advised about incentive program Teams authorized to arrange livery transportation Process repeats each month

32 32 Advances In Technology Internal MCO Quality Database - Monthly MMS is loaded into Database and numerator hits are automatically flagged - Data can be grouped by site to measure performance - Helps to avoid duplication of efforts Internal MCO Claims Application - Monthly raw claims data file uploaded from MCO - Monthly member roster uploaded - App used to identify high cost members - Helpful in monitoring out-of-network utilization Flagging of Value Based Contract members in Epic

33 Challenges Locating patients Patient compliance with appointments Data integrity Patients using providers outside of the MediSys system and documentation of services 33

2017 Quality Reporting: Claims and Administrative Data-Based Quality Measures For Medicare Shared Savings Program and Next Generation ACO Model ACOs

2017 Quality Reporting: Claims and Administrative Data-Based Quality Measures For Medicare Shared Savings Program and Next Generation ACO Model ACOs 2017 Quality Reporting: Claims and Administrative Data-Based Quality Measures For Medicare Shared Savings Program and Next Generation ACO Model ACOs June 15, 2017 Rabia Khan, MPH, CMS Chris Beadles, MD,

More information

STATISTICAL BRIEF #9. Hospitalizations among Males, Highlights. Introduction. Findings. June 2006

STATISTICAL BRIEF #9. Hospitalizations among Males, Highlights. Introduction. Findings. June 2006 HEALTHCARE COST AND UTILIZATION PROJECT STATISTICAL BRIEF #9 Agency for Healthcare Research and Quality June 2006 Hospitalizations among Males, 2003 C. Allison Russo, M.P.H. and Anne Elixhauser, Ph.D.

More information

Next Generation Physician Compensation Design in a Schizophrenic Payer Environment

Next Generation Physician Compensation Design in a Schizophrenic Payer Environment Next Generation Physician Compensation Design in a Schizophrenic Payer Environment Presented to: 2015 Spring Managed Care Forum Friday, April 24, 2015 Today s agenda Setting the Stage Why are we Here?

More information

Deriving Value from a Health Information Exchange. HIMSS17 DA-CH Community Conference Healthix I New York I February 20, 2017

Deriving Value from a Health Information Exchange. HIMSS17 DA-CH Community Conference Healthix I New York I February 20, 2017 Deriving Value from a Health Information Exchange HIMSS17 DA-CH Community Conference Healthix I New York I February 20, 2017 About Healthix About Healthix Hundreds of healthcare organizations at more than

More information

QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program:

QUALITY IMPROVEMENT. Molina Healthcare has defined the following goals for the QI Program: QUALITY IMPROVEMENT Molina Healthcare maintains an active Quality Improvement (QI) Program. The QI program provides structure and key processes to carry out our ongoing commitment to improvement of care

More information

Focus On Observation

Focus On Observation Focus On Observation Introduction CPT and CMS Requirements CPT Codes Documentation Requirements Observation Coding: Facility Considerations 2 LogixHealth s unsurpassed service stems from the fact that

More information

Medicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP)

Medicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP) Medicare Advantage Quality Improvement Project (QIP) & Chronic Care Improvement Program (CCIP) Medicare Drug and Health Plan Contract Administration Group Donna Williamson & Brandy Alston December 6, 2016

More information

Using SAS Programing to Identify Super-utilizers and Improve Healthcare Services

Using SAS Programing to Identify Super-utilizers and Improve Healthcare Services SESUG 2015 Paper 170-2015 Using SAS Programing to Identify Super-s and Improve Healthcare Services An-Tsun Huang, Department of Health Care Finance, Government of the District of Columbia ABSTRACT Super-s

More information

Planning a Course to Population Health Management

Planning a Course to Population Health Management Planning a Course to Population Health Management A Complimentary Webinar From healthsystemcio.com Your Line Will Be Silent Until Our Event Begins at 12:00 ET Thank You! Slide Deck: http://goo.gl/1w119j

More information

The Role of Analytics in the Development of a Successful Readmissions Program

The Role of Analytics in the Development of a Successful Readmissions Program The Role of Analytics in the Development of a Successful Readmissions Program Pierre Yong, MD, MPH Director, Quality Measurement & Value-Based Incentives Group Centers for Medicare & Medicaid Services

More information

Using Data to Yield High Impact Business Intelligence Wednesday, July 25, 2012

Using Data to Yield High Impact Business Intelligence Wednesday, July 25, 2012 Using Data to Yield High Impact Business Intelligence Wednesday, July 25, 2012 Brent J. Estes President and CEO, Rush Health About Rush Rush University Medical Center 673 Beds 36,000 admissions 391,700

More information

Tennessee Health Care Innovation Initiative

Tennessee Health Care Innovation Initiative Tennessee Health Care Innovation Initiative More information available at: http://www.tn.gov/hcfa/strategic.shtml State Innovation Model grant 2 1 State Innovation Model (SIM) funding Last week the Centers

More information

Jumpstarting population health management

Jumpstarting population health management Jumpstarting population health management Issue Brief April 2016 kpmg.com Table of contents Taking small, tangible steps towards PHM for scalable achievements 2 The power of PHM: Five steps 3 Case study

More information

Risk Adjusted Diagnosis Coding:

Risk Adjusted Diagnosis Coding: Risk Adjusted Diagnosis Coding: Reporting ChronicDisease for Population Health Management Jeri Leong, R.N., CPC, CPC-H, CPMA, CPC-I Executive Director 1 Learning Objectives Explain the concept Medicare

More information

O U T C O M E. record-based. measures HOSPITAL RE-ADMISSION RATES: APPROACH TO DIAGNOSIS-BASED MEASURES FULL REPORT

O U T C O M E. record-based. measures HOSPITAL RE-ADMISSION RATES: APPROACH TO DIAGNOSIS-BASED MEASURES FULL REPORT HOSPITAL RE-ADMISSION RATES: APPROACH TO DIAGNOSIS-BASED MEASURES FULL REPORT record-based O U Michael Goldacre, David Yeates, Susan Flynn and Alastair Mason National Centre for Health Outcomes Development

More information

Potentially Preventable Readmissions (PPRs) in the Texas Medicaid Population, Fiscal Year Hospital Seminars January 2011

Potentially Preventable Readmissions (PPRs) in the Texas Medicaid Population, Fiscal Year Hospital Seminars January 2011 Potentially Preventable Readmissions (PPRs) in the Texas Medicaid Population, Fiscal Year 2009 Hospital Seminars January 2011 Agenda 1. Overview 2. 3M All Patient Refined Diagnostic Related Groups (APR-DRGs)

More information

"Strategies for Enhancing Reimbursement " September 16, 2015

Strategies for Enhancing Reimbursement  September 16, 2015 "Strategies for Enhancing Reimbursement- 99080" September 16, 2015 Chat box feature Chat Box is available to you to ask questions or make comments anytime throughout today s webinar. Submit to Host and

More information

1/11/2016. The Metro Care Transitions Program (CCTP) OUR GOAL OUR HISTORY

1/11/2016. The Metro Care Transitions Program (CCTP) OUR GOAL OUR HISTORY The Metro Care Transitions Program (CCTP) OUR GOAL Build patient/caregiver confidence. Engage patients to take a more active role in self-management of chronic health conditions. Foster independence and

More information

The Metro Care Transitions Program (CCTP)

The Metro Care Transitions Program (CCTP) The Metro Care Transitions Program (CCTP) OUR GOAL Build patient/caregiver confidence. Engage patients to take a more active role in self-management of chronic health conditions. Foster independence and

More information

DSRIP Demonstration Year 1, Quarter 1-2 Domain 1 Patient Engagement Data Request

DSRIP Demonstration Year 1, Quarter 1-2 Domain 1 Patient Engagement Data Request DSRIP Demonstration Year 1, Quarter 1-2 Domain 1 Patient Engagement Data Request Webinar: Monday, October 5, 2015 Time: 1:30pm-3:00pm Presented by Suffolk Care Collaborative (SCC) Suffolk County Performing

More information

2016 Embedded and Rapid Response Care Management

2016 Embedded and Rapid Response Care Management 2016 Embedded and Rapid Response Care Management Program Evaluation Our mission is to improve the health and quality of life of our members 2016 Embedded and Rapid Response Care Management Program Evaluation

More information

HEALTH CARE REFORM IN THE U.S.

HEALTH CARE REFORM IN THE U.S. HEALTH CARE REFORM IN THE U.S. A LOOK AT THE PAST, PRESENT AND FUTURE Carolyn Belk January 11, 2016 0 HEALTH CARE REFORM BIRTH OF THE AFFORDABLE CARE ACT Health care reform in the U.S. has been an ongoing

More information

Hospital Payments and Quality Initiatives

Hospital Payments and Quality Initiatives Hospital Payments and Quality Initiatives December 2014 John McCarthy Ohio Medicaid Director Today s Overview How Ohio Medicaid pays hospitals - Prospective Payment Methods - Inpatient Hospital Payment

More information

Troubleshooting Audio

Troubleshooting Audio Welcome! Audio for this event is available via ReadyTalk Internet Streaming. No telephone line is required. Computer speakers or headphones are necessary to listen to streaming audio. Limited dial-in lines

More information

Medicaid Update Special Edition Budget Highlights New York State Budget: Health Reform Highlights

Medicaid Update Special Edition Budget Highlights New York State Budget: Health Reform Highlights Page 1 of 6 New York State April 2009 Volume 25, Number 4 Medicaid Update Special Edition 2009-10 Budget Highlights David A. Paterson, Governor State of New York Richard F. Daines, M.D. Commissioner New

More information

Definitions/Glossary of Terms

Definitions/Glossary of Terms Definitions/Glossary of Terms Submitted by: Evelyn Gallego, MBA EgH Consulting Owner, Health IT Consultant Bethesda, MD Date Posted: 8/30/2010 The following glossary is based on the Health Care Quality

More information

Reducing Medicaid Readmissions

Reducing Medicaid Readmissions Reducing Medicaid Readmissions Webinar 3: High Impact Medicaid-Specific Strategies Amy E. Boutwell, MD MPP Co-Principal Investigator AHRQ Reducing Medicaid Readmissions Project March 25, 2015 Overview:

More information

ENGAGING PHYSICIANS FOR IMPROVED OUTCOMES: CLINICAL DOCUMENTATION, FINANCIAL & PATIENT CARE

ENGAGING PHYSICIANS FOR IMPROVED OUTCOMES: CLINICAL DOCUMENTATION, FINANCIAL & PATIENT CARE ENGAGING PHYSICIANS FOR IMPROVED OUTCOMES: CLINICAL DOCUMENTATION, FINANCIAL & PATIENT CARE Northeast Ohio HFMA GHALI May 20, 2016 James Begley, MD, MS Physician Champion, ICD-10 & Medical Records Committee

More information

The Camden Coalition of Healthcare. Management

The Camden Coalition of Healthcare. Management Camden Coalition of Healthcare Providers Camden Coalition of Healthcare Providers The Camden Coalition of Healthcare Providers Approach to Risk Stratified Care Management Presentation by: Kennen S. Gross,

More information

ABOUT THE CONE HEALTH NETWORK OF SERVICES

ABOUT THE CONE HEALTH NETWORK OF SERVICES THE MOSES H. CONE MEMORIAL HOSPITAL (536 beds) Critical Care Services All system ICU patients are monitored with the help an electronic ICU monitoring system (VISICU ). Emergency Services Medical Intensive

More information

Using Clinical Criteria for Evaluating Short Stays and Beyond. Georgeann Edford, RN, MBA, CCS-P. The Clinical Face of Medical Necessity

Using Clinical Criteria for Evaluating Short Stays and Beyond. Georgeann Edford, RN, MBA, CCS-P. The Clinical Face of Medical Necessity Using Clinical Criteria for Evaluating Short Stays and Beyond Georgeann Edford, RN, MBA, CCS-P The Clinical Face of Medical Necessity 1 The Documentation Faces of Medical Necessity ç3 Setting the Stage

More information

The 5 W s of the CMS Core Quality Process and Outcome Measures

The 5 W s of the CMS Core Quality Process and Outcome Measures The 5 W s of the CMS Core Quality Process and Outcome Measures Understanding the process and the expectations Developed by Kathy Wonderly RN,BSPA, CPHQ Performance Improvement Coordinator Developed : September

More information

Hospice Codes. Table 1 ALS Diagnosis. Table 2 Alzheimer s Disease and Related Disorder Diagnoses. Table 3 Heart Disease Diagnoses

Hospice Codes. Table 1 ALS Diagnosis. Table 2 Alzheimer s Disease and Related Disorder Diagnoses. Table 3 Heart Disease Diagnoses I N D I A N A H E A L T H C O V E R A G E P R O G R A M S P R O V I D E R C O D E S E T S Hospice Codes Table 1 ALS Diagnosis Table 2 Alzheimer s Disease and Related Disorder Diagnoses Table 3 Heart Disease

More information

Hospitalizations and Preventable Conditions in Adults with Spina Bifida

Hospitalizations and Preventable Conditions in Adults with Spina Bifida Hospitalizations and Preventable Conditions in Adults with Spina Bifida Brad E. Dicianno, MD Associate Professor University of Pittsburgh Medical Center Dept. of PM&R Director, Adult Spina Bifida Clinic

More information

Thank you for joining us!

Thank you for joining us! Thank you for joining us! We will start at 1:00 p.m. CT. You will hear silence until the session begins. Audio Options: Recommended: Audio broadcast using your computer speakers (automatically join the

More information

Course Module Objectives

Course Module Objectives Course Module Objectives CM100-18: Scope of Services, Practice, and Education CM200-18: The Professional Case Manager Case Management History, Regulations and Practice Settings Case Management Scope of

More information

News SEPTEMBER. Hospital Outpatient Quality Reporting Program. Support Contractor

News SEPTEMBER. Hospital Outpatient Quality Reporting Program. Support Contractor Volume 1, Issue 4 Hospital Outpatient Quality Reporting Program Support Contractor News SEPTEMBER 2011 In This Issue... Emergency Department Arrival and Departure Times Page 2 Hospital OQR Benchmarks Page

More information

Start with the Problem

Start with the Problem Start with the Problem Jen Godreau, BA, CPC, CPEDC Director of Development & Operations Supercoder.com jenniferg@supercoder.com December 2011 Phone: (866)-228-9252 E-Mail: customerservice@supercoder.com

More information

Telecare Services 7/19/2017

Telecare Services 7/19/2017 Telecare Services 7/19/2017 Rebecca Sienko, RN Manager, Nurse Care Line 15,000 Employees 1,900 MDs/APCs 15 Hospitals 17 Clinics 7 Long Term Care Facilities 2 Assisted Living 4 Independent Living 5 Ambulance

More information

An Overview of NCQA Relative Resource Use Measures. Today s Agenda

An Overview of NCQA Relative Resource Use Measures. Today s Agenda An Overview of NCQA Relative Resource Use Measures Today s Agenda The need for measures of Resource Use Development and testing RRU measures Key features of NCQA RRU measures How NCQA calculates benchmarks

More information

READMISSION ROOT CAUSE ANALYSIS REPORT

READMISSION ROOT CAUSE ANALYSIS REPORT USE RESTRICTED TO ABC Hospital READMISSION ROOT CAUSE ANALYSIS REPORT State: Community Name: YZ Cohort: Hospital: A ABC Hospital Reviewer: Jane Doe Abstraction Period: 1/1/2014 6/30/2014 Charts Abstracted:

More information

CPAs & ADVISORS. experience support // ADVANCED PAYMENT MODELS: CJR

CPAs & ADVISORS. experience support // ADVANCED PAYMENT MODELS: CJR CPAs & ADVISORS experience support // ADVANCED PAYMENT MODELS: CJR Andy M. Williams Partner BKD Eric M. Rogers Managing Consultant BKD Will McLeod VP of Patient Services McLeod Health Emily Adams Associate

More information

Domain 1 Patient Engagement Speed Data Reports & Schedule

Domain 1 Patient Engagement Speed Data Reports & Schedule Domain 1 Patient Engagement Speed Data Reports & Schedule Suffolk Care Collaborative (SCC) Suffolk County Performing Provider System (PPS) Delivery System Reform Incentive Payment (DSRIP) Program 2 PRESENTATION

More information

Healthy Aging Recommendations 2015 White House Conference on Aging

Healthy Aging Recommendations 2015 White House Conference on Aging Healthy Aging Recommendations 2015 White House Conference on Aging Chronic diseases are the leading causes of death and disability in the U.S. and account for 75% of the nation s health care spending.

More information

INTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH

INTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH INTEGRATION OF PRIMARY CARE AND BEHAVIORAL HEALTH Integrating silos of care Goal of integration: no wrong door to quality health care Moving From Moving Toward Primary Care Mental Health Services Substance

More information

Essentials for Clinical Documentation Integrity 2017

Essentials for Clinical Documentation Integrity 2017 Essentials for Clinical Documentation Integrity 2017 Prepared and Published By: MedLearn Publishing A Division of Panacea Healthcare Solutions, Inc. 287 East Sixth Street, Suite 400 St. Paul, MN 55101

More information

2016 Complex Case Management. Program Evaluation. Our mission is to improve the health and quality of life of our members

2016 Complex Case Management. Program Evaluation. Our mission is to improve the health and quality of life of our members 2016 Complex Case Management Program Evaluation Our mission is to improve the health and quality of life of our members 2016 Complex Case Management Program Evaluation Table of Contents Program Purpose

More information

2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions

2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions 2.b.iv Care Transitions Intervention Model to Reduce 30-day Readmissions for Chronic Health Conditions Project Objective: To provide a 30-day supported transition period after a hospitalization to ensure

More information

Aligning Health IT with Delivery System Reform: Technology Gaps in Coordinating Patient Care

Aligning Health IT with Delivery System Reform: Technology Gaps in Coordinating Patient Care Aligning Health IT with Delivery System Reform: Technology Gaps in Coordinating Patient Care Peggi M. Czinger MPH Director, Network Care Management COE The Care Management Company of Montefiore The Bronx:

More information

KY Medicaid Co-pays Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following:

KY Medicaid Co-pays Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant

More information

Place of Service Code Description Conversion

Place of Service Code Description Conversion Place of Conversion CMS Place of Code Place of Name The place of service field indicates where the services were performed Possible values include: Code Description Inpatient Outpatient Office Home 5 Independent

More information

MEDICARE ENROLLMENT, HEALTH STATUS, SERVICE USE AND PAYMENT DATA FOR AMERICAN INDIANS & ALASKA NATIVES

MEDICARE ENROLLMENT, HEALTH STATUS, SERVICE USE AND PAYMENT DATA FOR AMERICAN INDIANS & ALASKA NATIVES American Indian & Alaska Native Data Project of the Centers for Medicare and Medicaid Services Tribal Technical Advisory Group MEDICARE ENROLLMENT, HEALTH STATUS, SERVICE USE AND PAYMENT DATA FOR AMERICAN

More information

Hospital Inpatient Quality Reporting (IQR) Program

Hospital Inpatient Quality Reporting (IQR) Program Hospital IQR Program Hybrid Hospital-Wide 30-Day Readmission Measure Core Clinical Data Elements for Calendar Year 2018 Voluntary Data Submission Questions and Answers Moderator Artrina Sturges, EdD, MS

More information

SWAN Alerts and Best Practices for Improved Care Coordination

SWAN Alerts and Best Practices for Improved Care Coordination SWAN Alerts and Best Practices for Improved Care Coordination IHIN and SWAN Course Overview Our Goal: To educate healthcare providers in how to manage SWAN alerts for meaningful impact at the point of

More information

Retrospective Bundles

Retrospective Bundles Bundled Payment for Care Improvement (BPCI) Overview Shawn Matheson MBA, LNHA, FACHCA Market Manager Idaho Health Care Association Annual Convention Boise, ID July 13, 2017 Retrospective Bundles Surgeon

More information

Discharge checklist and follow-up phone calls: the foundation to an effective discharge process

Discharge checklist and follow-up phone calls: the foundation to an effective discharge process Discharge checklist and follow-up phone calls: the foundation to an effective discharge process Shari Aman, BSN, RN, MBA, CPHQ Denise Andrews, MBA Stephanie Storie, BSN, RN, CMSRN Deb Nation, RN, CMSRN

More information

Central Ohio Primary Care (COPC) Spotlight on Innovation

Central Ohio Primary Care (COPC) Spotlight on Innovation Central Ohio Primary Care (COPC) Spotlight on Innovation BY BETTER MEDICARE ALLIANCE MARCH 2017 Central Ohio Primary Care Spotlight on Innovation 1 Central Ohio Primary Care (COPC) Spotlight on Innovation

More information

3/14/2014. Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking. Objectives. Background Information

3/14/2014. Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking. Objectives. Background Information Preventing Rehospitalizations How to Change Your When in Doubt, Send em Out Way of Thinking Jennifer Moore, RN Content Developer Objectives Describe two reasons why returns to the hospital are not desirable

More information

The Importance of the Nurse Navigator in Value Based Care. Walter LeStrange, Senior Executive VP/COO ProHEALTH Medical Management, LLC May 23, 2017

The Importance of the Nurse Navigator in Value Based Care. Walter LeStrange, Senior Executive VP/COO ProHEALTH Medical Management, LLC May 23, 2017 The Importance of the Nurse Navigator in Value Based Care Walter LeStrange, Senior Executive VP/COO ProHEALTH Medical Management, LLC May 23, 2017 Today s Agenda Overview of ProHEALTH Trends in Healthcare:

More information

From Risk Scores to Impactability Scores:

From Risk Scores to Impactability Scores: From Risk Scores to Impactability Scores: Innovations in Care Management Carlos T. Jackson, Ph.D. September 14, 2015 Outline Population Health What is Impactability? Complex Care Management Transitional

More information

1. Measures within the program measure set are NQF-endorsed or meet the requirements for expedited review

1. Measures within the program measure set are NQF-endorsed or meet the requirements for expedited review MAP Working Measure Selection Criteria 1. Measures within the program measure set are NQF-endorsed or meet the requirements for expedited review Measures within the program measure set are NQF-endorsed,

More information

Observation Coding and Billing Compliance Montana Hospital Association

Observation Coding and Billing Compliance Montana Hospital Association Observation Coding and Billing Compliance Montana Hospital Association Sue Roehl, RHIT, CCS sroehl@eidebaill.com 701-476-8770 IP versus Observation considerations Severity of patient s signs and symptoms

More information

Special Needs Plan Provider Education

Special Needs Plan Provider Education Special Needs Plan Provider Education Learning Goals What is a Special Needs Plan (SNPs) What differentiates a SNP from other MA plans What SNPs are offered by Freedom Health and Optimum Healthcare 2 Care

More information

Patient Navigator Program

Patient Navigator Program Using Patient Navigators and Education to Improve Post-Acute Transitions Emerging innovators in post-acute care delivery models are finding ways to provide patient-centered, quality care to integrate today

More information

Sandra Robinson, RN, MSN, ACM, CEN

Sandra Robinson, RN, MSN, ACM, CEN Developing and Measuring Care Coordination Outcome Goals and Objectives ACMA National Conference April 28, 2015 Cleveland Clinic Care Management Sandra Robinson, RN, MSN, ACM, CEN (robinss12@ccf.org) Joan

More information

Transitioning Care to Reduce Admissions and Readmissions. Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH

Transitioning Care to Reduce Admissions and Readmissions. Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH Transitioning Care to Reduce Admissions and Readmissions Sven T. Berg, MD, MPH Julie Mobayed RN, BSN, MPH Disclaimer: Potential for Error Type One Error Rejecting the null hypothesis when it is true

More information

Readmission Reduction and the ACO

Readmission Reduction and the ACO Readmission Reduction and the ACO Jeffrey E. Epstein, MD Medical Director Atlantic Health System Morristown Medical Center Morristown, NJ 07960 JeffreyEpsteinMD@gmail.co m Morristown Medical Center Why

More information

Regulatory Advisor Volume Eight

Regulatory Advisor Volume Eight Regulatory Advisor Volume Eight 2018 Final Inpatient Prospective Payment System (IPPS) Rule Focused on Quality by Steve Kowske WEALTH ADVISORY OUTSOURCING AUDIT, TAX, AND CONSULTING 2017 CliftonLarsonAllen

More information

How Title Xx Vermont s Broadening

How Title Xx Vermont s Broadening How Title Xx Vermont s Broadening Subtitle Xx APCD Offers New Opportunities to Drive Value & Efficiencies Adam Moody, Director of Analytic Operations Onpoint Health Data Pat Jones, Assistant Director Presenter,

More information

Population health and potentially preventable events 3M solutions for population health, patient safety and cost-effective care

Population health and potentially preventable events 3M solutions for population health, patient safety and cost-effective care 3M Health Information Systems Population health and potentially preventable events 3M solutions for population health, patient safety and cost-effective care Challenge: Shifting the financial risk The

More information

Press Release: CMS Office of Public Affairs, Monday, January 31, 2005 MEDICARE "PAY FOR PERFORMANCE (P4P)" INITIATIVES

Press Release: CMS Office of Public Affairs, Monday, January 31, 2005 MEDICARE PAY FOR PERFORMANCE (P4P) INITIATIVES Press Release: CMS Office of Public Affairs, 202-690-6145 Monday, January 31, 2005 MEDICARE "PAY FOR PERFORMANCE (P4P)" INITIATIVES Medicare has various initiatives to encourage improved quality of care

More information

Bundled Payment Primer

Bundled Payment Primer Bundled Payment Primer CMS Opened Application February 14, 2014 Why this matters to you! Bundling is a New Business Model Bundling is a focused opportunity to manage risk and achieve gain Control of a

More information

Welcome to the Agency for Health Care Administration (AHCA) Training Presentation for Managed Medical Assistance Specialty Plans

Welcome to the Agency for Health Care Administration (AHCA) Training Presentation for Managed Medical Assistance Specialty Plans Welcome to the Agency for Health Care Administration (AHCA) Training Presentation for Managed Medical Assistance Specialty Plans The presentation will begin momentarily. Please dial in to hear audio: 1-888-670-3525

More information

Minnesota health care price transparency laws and rules

Minnesota health care price transparency laws and rules Minnesota health care price transparency laws and rules Minnesota Statutes 2013 62J.81 DISCLOSURE OF PAYMENTS FOR HEALTH CARE SERVICES. Subdivision 1.Required disclosure of estimated payment. (a) A health

More information

Designing & Delivering Whole-Person Transitional Care Coordinating care across settings and over time to drive outcomes

Designing & Delivering Whole-Person Transitional Care Coordinating care across settings and over time to drive outcomes Designing & Delivering Whole-Person Transitional Care Coordinating care across settings and over time to drive outcomes Amy E. Boutwell, MD, MPP CNYCC Annual Meeting November 6, 2017 Agenda Design data,

More information

Section IX Special Needs & Case Management

Section IX Special Needs & Case Management Section IX Special Needs & Case Management Special Needs and Case Management 181 Integrated Health Care Management (IHCM) The Integrated Health Care Management (IHCM) program is a population-based health

More information

Value-Based Care Contracting and Legal Issues

Value-Based Care Contracting and Legal Issues Session 4b Value-Based Care Contracting and Legal Issues Presented by: Janet Walker Farrer General Counsel and Insurance Legal Department Chair Ascension Health Leah Stewart Associate Vice President for

More information

Sage Medical Center New Patient Forms

Sage Medical Center New Patient Forms Sage Medical Center New Patient Forms Patient Name: DOB: Providers and Suppliers of Your Medical Care: Please list all providers and suppliers of your medical care such as primary care physicians, specialty

More information

REDUCING READMISSIONS

REDUCING READMISSIONS REDUCING READMISSIONS - 2015 Expanding efforts to drive to hospital-wide results Amy E. Boutwell, MD, MPP Collaborative Healthcare Strategies January 2015 Objectives What are hospitals with hospital-wide

More information

L8: Care Management for Complex Patients: Strategies, Tools and Outcomes

L8: Care Management for Complex Patients: Strategies, Tools and Outcomes The Triple Aim 16 th Annual Summit: Institutes for Healthcare Improvement - Improving Patient Care in the Office Practice and the Community March 16, 2015 Dallas, Texas L8: Care Management for Complex

More information

Ambulatory-care-sensitive admission rates: A key metric in evaluating health plan medicalmanagement effectiveness

Ambulatory-care-sensitive admission rates: A key metric in evaluating health plan medicalmanagement effectiveness Milliman Prepared by: Kathryn Fitch, RN, MEd Principal, Healthcare Management Consultant Kosuke Iwasaki, FIAJ, MAAA Consulting Actuary Ambulatory-care-sensitive admission rates: A key metric in evaluating

More information

The Centers for Dialysis Care

The Centers for Dialysis Care Our mission: CDC is a leader in providing patient centered quality care to all individuals with kidney disease. The Centers for Dialysis Care David Oppenlander, CPA Finance and Clinical Collaboration Bio

More information

Team Building Storyboard Template

Team Building Storyboard Template Team Building Storyboard Template Storyboard purpose: To assist teams in telling their team members and organization s story. Behavioral Health Discharge Management Team Motto: We provide quality patient

More information

Turning Big Data Into Better Care

Turning Big Data Into Better Care Turning Big Data Into Better Care Dickson Advanced Analytics DA 2 Who is CHS and What is DA 2? 2 Who is CHS? Hospitals 42 Employees 62K Care Centers 900+ Physicians 3K Licensed Beds 7,800 Nurses 14K 3

More information

The Patient Protection and Affordable Care Act Summary of Key Health Information Technology Provisions June 1, 2010

The Patient Protection and Affordable Care Act Summary of Key Health Information Technology Provisions June 1, 2010 The Patient Protection and Affordable Care Act Summary of Key Health Information Technology Provisions June 1, 2010 This document is a summary of the key health information technology (IT) related provisions

More information

ACOs: California Style

ACOs: California Style ACOs: California Style ACO Congress John E. Jenrette, M.D. Chief Executive Officer Sharp Community Medical Group November 2, 2011 California Style California Style A CO California Style California Style

More information

Creating a Patient-Centered Payment System to Support Higher-Quality, More Affordable Health Care. Harold D. Miller

Creating a Patient-Centered Payment System to Support Higher-Quality, More Affordable Health Care. Harold D. Miller Creating a Patient-Centered Payment System to Support Higher-Quality, More Affordable Health Care Harold D. Miller First Edition October 2017 CONTENTS EXECUTIVE SUMMARY... i I. THE QUEST TO PAY FOR VALUE

More information

SNF * Readmissions Bootcamp The SNF Readmission Penalty, Post-Acute Networks, and Community Collaboratives

SNF * Readmissions Bootcamp The SNF Readmission Penalty, Post-Acute Networks, and Community Collaboratives SNF * Readmissions Bootcamp The SNF Readmission Penalty, Post-Acute Networks, and Community Collaboratives Lindsay Holland, MHA Associate Director, Care Transitions Health Services Advisory Group (HSAG)

More information

PACT Patient experience and Anticipatory Care Planning Team. Dr Eleanor Halloran Consultant Liaison Psychiatrist Edinburgh

PACT Patient experience and Anticipatory Care Planning Team. Dr Eleanor Halloran Consultant Liaison Psychiatrist Edinburgh PACT Patient experience and Anticipatory Care Planning Team Dr Eleanor Halloran Consultant Liaison Psychiatrist Edinburgh Project proposers Dr David Caesar Dr Carl Bickler Clinical Director GP Clinical

More information

The Patient Experience: Challenges and Opportunities in the Safety Net

The Patient Experience: Challenges and Opportunities in the Safety Net The Patient Experience: Challenges and Opportunities in the Safety Net Leon L. Haley Jr., MD, MHSA, FACEP Executive Associate Dean, Clinical Services Grady Chief Medical Officer, EMCF Associate Professor

More information

Collaborative Activation of Resources and Empowerment Services Building Programs to Fit Patients vs. Bending Patients to Fit Programs

Collaborative Activation of Resources and Empowerment Services Building Programs to Fit Patients vs. Bending Patients to Fit Programs Organization: Solution Title: Calvert Memorial Hospital Calvert CARES: Collaborative Activation of Resources and Empowerment Services Building Programs to Fit Patients vs. Bending Patients to Fit Programs

More information

ACO Congress. Using Analytics to Improve ACO Performance November 5, 2013

ACO Congress. Using Analytics to Improve ACO Performance November 5, 2013 ACO Congress Using Analytics to Improve ACO Performance November 5, 2013 Introductions Deb Davis OPTUM General Manager, West Region Accountable Care Solutions Jay Hazelrigs OPTUM National Lead, ACO Actuary

More information

Hi-Tech Software and the Triple Check Process

Hi-Tech Software and the Triple Check Process Hi-Tech Software and the Triple Check Process Contents How Hi-Tech Software Assists the Triple Check Process... 1 Census... 1 Stay Tables... 2 Hi-Tech Helps you Avoid Incorrect Assessments... 3 Diagnosis

More information

THE ART OF DIAGNOSTIC CODING PART 1

THE ART OF DIAGNOSTIC CODING PART 1 THE ART OF DIAGNOSTIC CODING PART 1 Judy Adams, RN, BSN, HCS-D, HCS-O June 14, 2013 2 Background Every health care setting has gone through similar changes in the need to code more thoroughly. We can learn

More information

NGA Paper. Using Data to Better Serve the Most Complex Patients: Highlights from NGA s Intensive Work with Seven States

NGA Paper. Using Data to Better Serve the Most Complex Patients: Highlights from NGA s Intensive Work with Seven States NGA Paper Using Data to Better Serve the Most Complex Patients: Highlights from NGA s Intensive Work with Seven States Executive Summary Across the country, health care systems continue to grapple with

More information

CMS Quality Initiatives: Past, Present, and Future

CMS Quality Initiatives: Past, Present, and Future CMS Quality Initiatives: Past, Present, and Future Jeff Flick Regional Administrator CMS, Region IX June 29, 2007 Slide -1 Learning Objectives Value Driven Health Care CMS Quality Initiatives Premiere

More information

Enhancing Outcomes with Quality Improvement (QI) October 29, 2015

Enhancing Outcomes with Quality Improvement (QI) October 29, 2015 Enhancing Outcomes with Quality Improvement (QI) October 29, 2015 Learning Objectives! Introduce Quality Improvement (QI)! Explain Clinical Performance Person-Centered Medical Home (PCMH) Measures! Implement

More information

Christi McCarren, SVP, Retail Health & Community Based Care Lynnell Hornbeck, Manager, Home Health

Christi McCarren, SVP, Retail Health & Community Based Care Lynnell Hornbeck, Manager, Home Health Christi McCarren, SVP, Retail Health & Community Based Care Lynnell Hornbeck, Manager, Home Health Webinar: Northwest Regional Telehealth Resource Center October 27, 2016 1 MultiCare Health System MultiCare

More information

2015 Quality Improvement Work Plan Summary

2015 Quality Improvement Work Plan Summary 2015 Quality Improvement Project Member Service and Satisfaction Commercial Products: Commercial Project Description: To improve member service and satisfaction and increase member understanding of how

More information