Payment Transformation: Essentials of Patient Attribution An Introduction for Internal Staff

Transcription

1 Payment Transformation: Essentials of Patient Attribution An Introduction for Internal Staff May 6, 2016

2 Payment Transformation Will Address Key Goals In Pursuit of Māhie Maximize Value to Members, Providers, and Employers Improve member experience and quality of care better health and well-being Allow doctors to practice medicine the way they think it should be practiced Achieve Triple Aim: Access, Cost, and Quality (Health and well-being) build a new value-based sustainable model of care

3 A Comprehensive Approach to Payment Transformation Increased accountability for quality, cost, access, health Effective communication with members, providers, and POs More supportive ecosystem of health Improved provider satisfaction Better data analytics infrastructure Growth in MD membership - recruiting / marketing Payment Transformation will ensure the sustainability of independent providers in a free choice system

4 Recap of Primary Care Payment Model

5 Transitioning to a New Primary Care Payment Model Member attribution directly affects Base Payment, Engagement Measures, and Performance Measures Health care costs of attributed members will also influence Total Cost of Care

6 Base PMPM Payment 2016/2017 Global, bundled payment called Base PMPM is paid monthly 80% is based on previous FFS reimbursement ( ) Includes PCMH dollars in base in Year 1 to reward providers who have transformed their practices Desire to keep providers close to whole in Year 1 during transition to new payment model Going forward (in Year 2), 20% will be scored as foundational Engagement measures and will affect the Base PMPM High variation in PMPM bands (distribution) reflect variation created under FFS Medical group members paid based on group PMPM band New providers receive network average PMPM band 80% 20%

7 Engagement to Encourage Active Participation For 2018, 20% of the PMPM payment will be at risk, meaning PCP will be scored on work done in These will be 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, , text or 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 ) 20%

8 Engagement: Details Measure Commercial Akamai Advantage PCP/staff log into Cozeva at least once a month [pass = 100%] Check on well-being of all patients in panel [patient survey; pass = 75% of respondents report contact] Refer patients to health programs [Cozeva attestation; pass/fail] QUEST Integration 6.67% 6.67% 5% 6.67% 6.67% 5% 6.67% 6.67% 5% Submit EPSDT forms [audit] 5% TOTAL 20% 20% 20% 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. 12

9 Performance (Quality) Measures & Incentives Thoughtful, clinically meaningful measure set based on providers input and HMSA priorities (Akamai Advantage STARS, HEDIS, QUEST Integration) New goals for patient care, including prevention, well-being, access, patient-centeredness, and population health management Meaningful to patients and providers Financial rewards both at individual physician and PO levels One set of measures for all lines of business Build on progress made by providers on PCMH principles and P4Q measures Includes all HMSA members 15% to 25%

10 Performance: Scoring Methodology What s familiar Maximum potential: Performance (quality) budget based on PCP s attributed members multiplied by the PMPM for each line of business PMPM for 2017: Maximum PMPM Commercial $4.50 Akamai Advantage $8.00 QUEST Integration $3.00 Measures are weighted 1 or Can earn up to 110% of max potential for each measure 14

11 Patient Attribution

12 Agenda Importance of Member Attribution Choosing PCP Upon Enrollment New Process for Changing PCPs HMSA s Claims Attribution Logic Using Cozeva for Panel Management Questions & Answers on Attribution Pilot Project Updates 16

13 Importance of Member Attribution Patient attribution part of Pay for Quality and Patient-Centered Medical Home from the beginning Greater importance Monthly Payment Transformation payment = Base PMPM Rate X Attributed Members Performance (quality) max potential = Performance PMPM X Attributed Members each month (or member-months ) Reminder: Payment Transformation global payment is paid based on Member Attribution from two months earlier (April payment is for February member attribution), making reconciliation challenging 17

14 Choosing PCP Upon Enrollment For three plans, HMSA members select a PCP upon enrollment HMSA s HMO plans: Select an HMO health center and a PCP within the health center HMSA s QUEST Integration: Select a PCP or clinic HMSA s Akamai Advantage: Encouraged to select a PCP The name of the member s PCP is stored in HMSA s member data base and printed on their ID card Current process: To change PCPs, these members are asked to call HMSA/QUEST Integration customer service departments. PCP is changed on system; new member ID cards issued. 18

15 New Process for Changing PCP Please ensure patients are informed and agree they want you as their primary care provider. Explain your role as their PCP. Explain purpose of Patient Attestation Form Member completes form and signs. Follow instructions on form so change is documented: HMO members: must fax form to HMSA Akamai Advantage members: must fax form to HMSA QUEST Integration members: must fax form to HMSA QUEST PPO members, including Fed 87: file in your medical record In Cozeva, select Add the patient to the P4Q program or Payment Transformation Program to affect member count for Payment Transformation and Performance measures 19

16 New Patient Attestation Form Initial form sent in PCP toolkit Effective in May, please use revised form with fax numbers when it is distributed to pilot PCPs Form is only for Payment Transformation pilot PCPs 20

17 Cozeva Changes vs. HMSA Attribution PCP changes made through Cozeva will trump HMSA member enrollment selections and claims logic attribution. Considered active confirmation of the PCP-patient relationship. That s why informed patient consent and the Patient Attestation Form are important It s also critical that the form be faxed back to HMSA so our systems and member ID card can be updated. Claims processing and continuity of care can be affected by HMO health center and PCP data 21

18 HMSA s Attribution Logic Step 1: For all lines of business, attribute member to PCP who most recently added that patient to panel in Cozeva. Patient must sign attestation form to confirm relationship with PCP. Step 2: Attribute member to the PCP the member selected upon enrollment (should match HHIN and member ID card) Step 3: If no member selection (e.g., PPO members), HMSA looks at claims for face-to-face encounters over 16 months and attributes the member to the PCP: Seen most frequently; or, In case of a tie, seen most recently. Step 4: If no member selection and no claims history at all, patient is not attributed to any PCP 22

19 Examples of Claims Attribution Logic (no form, patient NOT added in Cozeva) Bob, a PPO member, had 3 visits with Dr. A in early 2016, then starts to see Dr. B in June Bob is attributed to Dr. A until he has 3 visits with Dr. B in the 16-month period, then the most recent visit becomes the tie-breaker. He then is attributed to Dr. B. Jane, a PPO member, has seen Dr. A twice in 2015, but needs care right away and can t get an appointment with Dr. A. She sees Dr. B. If she has no other visits with Dr. A, those 2015 visits roll off. She is then attributed to Dr. B. Chris is a new HMSA PPO member and sees Dr. A. He will remain attributed to Dr. A until an event triggers an attribution change. 23

20 Member Attribution A Fluid Process Feb. 10: Cozeva uploads HMSA s January member attribution file. PCPs add new members and delete others. Attribution depends on updates in two systems -- Cozeva and HMSA claims logic. As a result, list of members in Cozeva is close but does not exactly match attribution. March 1: Cozeva collects PCPs changes made in February and sends file to HMSA. March 3: HMSA applies changes and finalizes February member attribution count for April payment 24

21 Adding Patients: Be Patient Feb. 15: Dr. A submits Add Patient request on Cozeva for Harry, a PPO member, who signs Patient Attestation form Harry shows on All Patients registry as Added (in about 24 hours) Dr. A can see patient profile and care gaps Harry is added to Dr. A s Performance measures March 1: Cozeva sends file to HMSA that shows Dr. A added Harry to his panel March 3: HMSA runs attribution for February Harry is considered attributed to Dr. A for February March 12: Cozeva loads HMSA attribution file for February Harry s status changes from Added to Current 25

22 Using Cozeva for Panel Management

23 Panel Management Current = PT or P4Q patient count Added = Patient added by PCP after affirming PCP selection; patient transferred and accepted New = Member added through enrollment or claims logic Declined = PCP declined member Left = Member removed because coverage ended; patient died; patient added by another PCP or attributed to another PCP by claims logic 27

24 Panel Management Other Member for whom the provider is NOT the member s PCP (not included in that PCP s member count for Base PMPM, Performance or Engagement measures) Patient recently seen for urgent care or consult Provider is not claiming to be the PCP. Provider did not check the box, Add the patient to P4Q program or Payment Transformation program 28

25 Adding Patients Once a member is added to a PCP s panel via Cozeva, HMSA will not allow claims logic to reassign the member to another provider If one PCP has already submitted an Add Patient request for a member for that month, no other provider will be able to add the member in the same month Attribution to the new PCP stays until another PCP adds the member to his panel through Cozeva Please be professional in adding patients. Adding patients = adding to denominators for quality (Performance) measures 29

26 Using Cozeva for Panel Management

27 Number of Attributed HMSA Patients

28 Number of Attributed HMSA Patients

29 Number of Attributed HMSA Patients

30 How to Add a Patient

31 How to Add a Patient Fill out all necessary information in the form and click Search Click the circle next to the member s name to confirm the system found the correct member Click the first box to confirm the medical need to access the member s information Click the second box only if you are claiming to be the member s PCP

32 How to Add a Patient Reporting Member s Subscriber ID number on Cozeva, using the member ID card For HMSA PPO, HMO, and Akamai Advantage members: Use one letter followed by 12 digits. Include all leading zeroes. Do not include the BlueCard prefix of the first three letters. Example: If the card says XLHR , enter R For HMSA QUEST Integration: Use 10 digits. Include all leading zeroes. Do not include the BlueCard prefix of the first three letters. Example: If the card says XLQ , enter

33 How to Decline/Transfer a Patient

34 How to Decline/Transfer a Patient 38

35 How to Decline/Transfer a Patient Reason for declining patient (select one): Patient is deceased Patient moved off island and/or lives permanently out of state Patient was seen by me for consultation or second opinion Patient has been discharged from my practice Patient is being cared for by another primary care provider 39

36 How to Decline/Transfer a Patient 40

37 Patient Attribution Q&As Q. What happens if a PPO patient sees PCP #1 and signs form, then decides to see PCP #2 next month and signs form again? A. If both doctors have signed Patient Attestation Forms and both have done the Add Patient in Cozeva, the latest attribution will govern the member s PCP assignment. Q. If a PPO patient sees us once and we add him to our panel through the form and Add Patient on Cozeva, then sees another PCP who is not part of Payment Transformation several times, whom will the member be attributed to? A. A PPO member who signs the form and is added to Cozeva will remain attributed to that PCP. The attribution will change only if the PPO member signs another form and is added to that PCP s Cozeva panel. Adding a patient on Cozeva trumps claims logic. 41

38 Patient Attribution Q&As Q. When PT was introduced, we went through our panel and added patients from Cozeva s Other listing. What happens now? A. In the future, please use the Patient Attestation Form to tie the patient to your panel and notify HMSA about HMO, QUEST and AA members. Q. I have 500 PPO patients on my panel. Should I make all of them sign Patient Attestation forms? Is this necessary so they will remain attributed to me? A. If you are seeing your patients on an ongoing basis because of their health care needs, there is no need to have them sign Patient Attestation Forms, unless you would like to reinforce with them your role as their primary care physician. For PPO members, do not submit to HMSA; simply file the form in your medical records. 42

39 Pilot Project Updates

40 Concerns Payment Transformation pilot physicians continue to ask about payment if they are asked to see patients attributed to another PCP Coverage should continue as a shared, cooperative arrangement Reminder that your global payment took into consideration all FFS payments, including services to patients who weren t necessarily attributed to you in the three-year look-back period. Payment Transformation is to improve patient access to care, not block it 44

41 Updates Question #4 about how long did you wait for an appointment has been confusing for patients. Being rewritten. Aware of issue when survey is generated by patient changes appointment date Translations in progress for Ilocano, Japanese, Korean, Vietnamese, and Traditional Chinese (Formosa) This is the ONLY survey to be returned to HMSA. Code 45

42 Performance: Adult Measures Cancer screenings Breast cancer Cervical cancer Colorectal cancer Diabetes measures HbA1c in control Eye exam Attention for nephropathy Blood pressure control Advance care planning 2017 Trigger Yes Yes Yes Includes members 65+ Patient age 2 visits with diabetes as DX Patient age BMI assessment for adults Yes Any outpatient visit with PCP, specialists Review of Chronic Conditions for Akamai Advantage members Controlling Blood Pressure Yes Yes PO Performance measure 46 Patient age and DX 1 visit with hypertension as DX

43 New Adult Measures Screening for depression and anxiety (age 18 and older) [Patient Health Questionnaire-4] Tobacco cessation and followup Pilot/2017 Yes Yes Trigger Outpatient visit with an eligible PCP type * Outpatient visit with an eligible PCP type * Flu shots Yes Patient age Well-Being 5 (health risk assessment) completion Yes Patient age Patient Experience (survey) Yes Visit with attributed PCP * Eligible PCP type: GP, FP, IM, geriatrician, Peds, Ob/Gyn, APRN, PA 47

44 Performance: Adult Measures Measure Procedure Code ICD-10 Code Flu vaccine (ages 18 and older). Does not have to be administered by PCP Screening for symptoms of clinical depression and anxiety (ages 18 and older) Influenza vaccine CPT codes --Standard trivalent flu vaccine Preservative-free flu vaccine 90654, 90656, 90661, Nasal spray flu vaccine Quadrivalent flu vaccine 90686, New codes added: Q2034-Q Brief emotional/behavioral assessment (e.g., depression inventory, ADHD scale), with scoring and documentation, per standardized instrument 48 (suggested) Z23 Encounter for immunization (suggested *) Z13.89 Encounter for screening for other disorder *No copayment when code combination used with ACA-compliant plans

45 Performance: Adult Measures Measure Procedure Code ICD-10 Code Tobacco cessation and followup (ages 18 and older) Non-tobacco user: G9459 Currently a tobacco non-user or G9275 Documentation that patient is a current non-tobacco user New code added: 1036F Current tobacco non-user 49

46 Performance: Adult Measures Measure Procedure Code ICD-10 Code Tobacco cessation and followup Option 1: 1 proc code Tobacco user: G9458 Patient documented as tobacco user and received tobacco cessation intervention (must include at least one of the following: advice given to quit smoking or tobacco use, counseling on the benefits of quitting smoking or tobacco use, assistance with or referral to external smoking or tobacco cessation support programs, or current enrollment in smoking or tobacco cessation program) if identified as a tobacco user (suggested*) Z72.0 Tobacco use or Z Personal history of nicotine dependence *Credit will be given based on the G9458. These ICD-10 codes are optional. 50

47 Performance: Adult Measures Measure ICD-10 Code Tobacco cessation and followup Option 2: 1 proc code + 1 DX code Tobacco user: G0436 Smoking and cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes G0437 Smoking and cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes Smoking and cessation counseling visit; intermediate, greater than 3 minutes, up to 10 minutes Smoking and cessation counseling visit; intensive, greater than 10 minutes + Z72.0 Tobacco use Z Personal history of nicotine dependence New codes added: F Nicotine dependence, unspecified, uncomplicated F Nicotine dependence, cigarettes, uncomplicated 51

48 Performance: Adult Measures Measure Tobacco cessation and followup Option 3: 2 DX codes Procedure Code ICD-10 Tobacco user: Z72.0 Tobacco use or Z Personal history of nicotine dependence + Z71.6 Tobacco abuse counseling 52

49 Performance: Pediatric Measures Pilot/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 an eligible PCP type * * Eligible PCP type: Peds, FP, GP, IM, Ob/Gyn, APRN, PA, geriatrician 53

50 New Pediatric Measures Developmental screening in child s first 3 years (annually) Pilot/2017 Yes Trigger 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 * Patient Experience (survey) Yes Visit with attributed PCP CSHCN Screener completion (ages 3 to 21, every 3 years) Yes PO Performance Measure * Eligible PCP type: Peds, FP, GP, IM, Ob/Gyn, APRN, PA, geriatrician 54 Patient age

51 Performance: Pediatric Measures Measure Procedure Code ICD-10 Code Developmental screening in 12 months before child s 1 st, 2 nd, and 3 rd birthdays CSHCN Screener (ages 3-21, done every 3 years) HA modifier Developmental screening (e.g., developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument Screening done; positive finding for chronic or special health care needs: E/M CPT code + HA modifier * + Z Screening done; negative finding: E/M CPT code + HA modifier * HA HCPCS code modifier = Child/adolescent program * No copayment when code combination used with ACA-compliant plans (suggested *) Z Encounter for routine child health examination without abnormal findings Z Encounter for routine child health examination with abnormal findings Z Personal history of other specified conditions 55

52 Performance: Pediatric Measures Measure Procedure Code ICD-10 Code Screening for symptoms of clinical depression and anxiety (ages 12-17) Brief emotional/behavioral assessment (e.g., depression inventory, ADHD scale), with scoring and documentation, per standardized instrument or G0444 Annual depression screening, 15 minutes or 3725F Screening for depression performed (suggested*) Z13.89 Encounter for screening for other disorder *No copayment when code combination and Z13.89 used with ACAcompliant plans 56