MDwise Pay-for-Performance (HEDIS)

Transcription

1 MDwise Pay-for-Performance (HEDIS) MDwise Quality Make it Count Exclusively serving Indiana families since HHW-HIPP0466 (8/16)

2 Who is MDwise? MDwise is a local, not-for-profit company serving Hoosier Healthwise, Hoosier Care Connect and Healthy Indiana Plan (HIP) members. MDwise believes that everyone deserves to have health coverage. MDwise serves Hoosier Healthwise and Healthy Indiana Plan members under a Delivery System Model as opposed to a model where the managed care entity contracts individually with Providers. The basis of this model is the localization of health care around a group of Providers. These organizations are called Delivery Systems within the MDwise Network and are typically comprised of hospital, primary care, specialty care, and ancillary providers who are closely related either in ownership or shared missions. 3

3 MDwise Delivery Systems

4 What is Risk Based Medicaid? MCEs are paid a per member per month fee; this is called a capitated rate The capitated premium covers the cost of care for all covered services for the patients. The MCE assumes financial risk for services of members; thus the name Risk-Based does not mean the patients are high risk. 5

5 Hoosier Healthwise Package A: Standard Plan Package C: Children s Health Plan Children 19 And Under And Family Must Be Between 158 and 250 Percent Of Federal Poverty Level The child must not have creditable health coverage or have creditable health coverage at any time during a waiting lasting no longer than 90 days. Family Must Pay Monthly Premium For Insurance Coverage Presumptive Eligibility: period Temporary Coverage For Those Whose Applications For Medicaid Are Pending Must Not Be A Current Medicaid Member Must Be Indiana Resident And U.S. Citizen Must Have Gross Income Of 200 Percent of FPL

6 Healthy Indiana Plan(HIP) Who Is Eligible? Individuals 19 To 64 Years Of Age Uninsured Hoosiers Without Access To Employer Sponsored Health Insurance How It Works A Power Account Valued At $2,500 Per Adult To Pay For Medical Costs. 2% Of Family Income And Money From The State Make Up The Power Account Income Must Be Between Percent Of Federal Poverty

7 Hoosier Care Connect Who Is Eligible? Individuals That Are Blind, Disabled, or Aged 65+ Individuals Receiving SSI Medicaid For Employees With Disabilities Enrollees Wards Of The Court Or Foster Children Children Receiving Adoptive Services

8 NCQA Mission Vision To improve the quality of health care. To transform health care quality through measurement, transparency and accountability. Values Our passion is improving the quality of health care. We stand for accountability throughout the health care system. 10

9 NCQA Created HEDIS Healthcare Effectiveness Data & Information Set A set of standardized performance measures that: Ensures that consumers have reliable information on the performance of MCEs. >90% of health plans use HEDIS to measure performance on important dimensions of care and service. 11

10 HEDIS Overview What is HEDIS? HEDIS Healthcare Effectiveness Data and Information Set National Committee for Quality Assurance (NCQA) uses these performance measures for commercial insurance, Medicare, and Medicaid. HEDIS is the most used set of performance measures in the Managed Care industry, developed and maintained by NCQA. Hoosier Healthwise 10

11 HEDIS Overview Majority of HEDIS is measures from administrative results-claims, but some of the measures are pulled from hybrid results-medical record review. Administrative data is calculated by a claim or an encounter submitted to the health plan. Hybrid reviews are a random sample of member medical records. Hybrid data can consist of administrative data and a sample of medical record data. Annual State mandated quality improvement initiative required of all Health plans. Retrospective review of medical care and services from the prior year. Hoosier Healthwise 11

12 HEDIS Overview Data is reported to NCQA in June of the reporting year. Data reflects events that occurred during the measurement year (calendar year). Example: HEDIS 2017 data is reported in June Data reflects events that occurred in January December 2016 (per specs) HEDIS 2017 = 2016 data Hoosier Healthwise 12

13 HEDIS Overview Denominator Eligible members of the population. Numerator Members that meet the criteria of the measure. Anchor Date The specific date the member is required to be enrolled to be eligible for the measure. Continuous Enrollment The minimum amount of time a member must be enrolled to be eligible for a measure. Provider Specialty Certain measures must be performed by a specified provider specialty. Hoosier Healthwise 13

14 HEDIS Score Barriers Claims not submitted due to members that have third party liability. Members that are assigned to the wrong Primary Medical Provider. Claims are submitted without the appropriate diagnosis or CPT codes that will count towards the measures. Claims submitted with diagnosis code in error to add members to a measure and denominator. The provider specialty does not count towards the measure. The member is not continuously enrolled. The services are not all documented in the members medical chart. All components of the required measure were not provided. New member and previous medical records are not obtained or transferred when a member changes PMPs. Appointment availability when a member tries to schedule preventive services. Appointment availability for new members on the PMP panel. Hoosier Healthwise 14

15 HEDIS Contains 81 Quality Measures Asthma Medication Use Persistence of Beta-Blocker Treatment after Heart Attack Controlling High Blood Pressure Comprehensive Diabetes Care Breast Cancer Screening Antidepressant Medication Management Childhood and Adolescent Immunization Status Well Child Care.and others 12

16 2016 Incentivized HEDIS Measures for HHW Adolescent Well Care Ages Well-Care for Children Ages 3 6 Well-Care for Children 0 15 months Emergency Room Utilization Timeliness of Postpartum Care (21 56 days after delivery) Frequency of Ongoing Prenatal Care Follow-up after Hospitalization from Mental Illness Within 7 days 13

17 HEDIS Measures/HHW Well Child Visits in the First 15 Months of Life W15 Members 0 15 months of age must receive 6 or more well child visits with a PMP that document in the medical record the following: health and developmental history (physical and mental) i.e. developmental questionnaires regarding sleep habits, feeding, motor skills, teething, interaction with others, walks alone, teething/chewing objects, and PCP observation. a physical exam i.e. general appearance, height, weight, heart, lungs, abdomen, head circumference, deformities, reflexes present, fontanels, and alertness. health education/anticipatory guidance i.e. injury prevention, circumcision care, thermometer use, choking prevention, bathing, car seat use, temper tantrums, and lead poisoning. The claim must have the appropriate coding and submitted with the appropriate provider specialty to count towards the measure. The following diagnosis codes or CPT codes make the member compliant for the well child measure: 99381,99382,99391,99392, Z0000,Z0001,Z00110,Z00111,Z00121,Z00129,Z005,Z008,Z020,Z021,Z0 22,Z023, Z024,Z025,Z026,Z0271,Z0279,Z0281,Z0282,Z0283, Z0289,Z029 Hoosier Healthwise 17

18 HEDIS Measures/HHW Well Child Visits in the Third, Fourth, Fifth and Sixth Years of Life W34 Members 3 6 years of age in the measurement year must receive one well child visit with a PMP each year that documents in the medical record the following: health and developmental history (physical and mental) i.e. developmental milestones, disposition, communication with others, vocabulary, independence with dressing, and toileting. a physical exam i.e. general appearance, height, weight, heart, lung, abdomen, BMI percentile, vision, hearing, abuse/neglect, eyes/strabismus, and alertness. health education/anticipatory guidance i.e. balance meals with snacks, limit sweets, caution with strangers, second hand smoke, childcare planning, bed time, friends, and limit setting. The claim must have the appropriate coding and submitted with the appropriate provider specialty to count towards the measure. The following diagnosis codes or CPT codes make the member compliant for the well child measure: 99382,99383, 99392, Z0000,Z0001,Z00110,Z00111,Z00121,Z00129,Z005,Z008,Z020,Z021,Z0 22,Z023, Z024,Z025,Z026,Z0271,Z0279,Z0281,Z0282,Z0283, Z0289,Z029 Hoosier Healthwise 18

19 HEDIS Measures/HHW Adolescent Well Care Visits AWC Members years of age in the measurement year must receive one well child visits with a PMP that document in the medical record the following (school physical, preventive care visits with a Pap, prenatal, or post partum visit): health and developmental history (physical and mental) i.e. developmental questionnaires regarding social and emotional development, school progress, physical activity, depression, menarche, and peer relationships. a physical exam i.e. general appearance, height, weight, heart. Lung, abdomen, tanner stage, BMI, head eyes, heart, ungs, acne, and pap smears. health education/anticipatory guidance i.e. balanced meals, sex education, safety, smoking, drug and ETOH avoidance, regular exercise, breast self exams, seat belt use, suicidal ideation, and partner selection. The claim must have the appropriate coding and submitted with the appropriate provider specialty to count towards the measure. The following diagnosis codes or CPT codes make the member compliant for the well child measure: 99383, 99384,99385, 99393,99394,99395 Z0000,Z0001,Z00110,Z00111,Z00121,Z00129,Z005,Z008,Z020,Z021,Z0 22,Z023, Z024,Z025,Z026,Z0271,Z0279,Z0281,Z0282,Z0283, Z0289,Z029 Hoosier Healthwise 19

20 HEDIS Measures/HHW Frequency of Ongoing Prenatal Care FPC Members who delivered a live birth on or between November 6 of prior year to November 5 of measurement year and were continuously enrolled 42 days prior to delivery. Documentation of all prenatal visits. 81 percent of expected visits. Hoosier Healthwise 20

21 HEDIS Measures/HHW Prenatal and Postpartum Care PPC Members who had a live birth in the measurement year who had their first prenatal visit within 42 days of enrollment or during the first trimester. Postpartum Care Members who had their postpartum visit on or within days of delivery. The claims must have the appropriate coding and submitted with the appropriate provider specialty to count towards these measures. Hoosier Healthwise 21

22 HEDIS Measures: Follow-up After Hospitalization for Mental Illness/HHW Follow up After Hospitalization for Mental Illness FUH Members 6 years of age and older as of the date of discharge from an acute inpatient stay must receive an outpatient visit with a mental health practitioner within 7 days after the discharge. Hoosier Healthwise 22

23 HEDIS Measures-Follow-up After Hospitalization for Mental Illness / HHW Follow up After Hospitalization for Mental Illness FUH MCEs currently working with the inpatient and outpatient providers on relationship building, education on the clinical practice guidelines and the measure, and Bridge Appointments. Providers can bill for bridge appointments in an outpatient setting with the 513 revenue code and procedure codes and Hoosier Healthwise 23

24 2016 Incentivized HEDIS Measures for HIP Adults Access to Preventive/Ambulatory Health Services (AAP) Follow Up After Hospitalization For Mental Illness (FUH) 14

25 HEDIS Measures/HIP Adult Access To Preventative Care/Ambulatory Health Services (AAP) Members must receive one annual preventative or ambulatory care visit for acute care, new patient consultation, or preventive care services: This measures a members access to primary care demonstrating their ability to obtain preventative services as needed. The claim must have the appropriate coding to count towards the measure. Hoosier Healthwise

26 HEDIS Measures/HIP Adult Access To Preventative Care/Ambulatory Health Services (AAP) The following diagnosis codes or CPT codes make the member compliant: 99201,99202,99203,99204,99205,99211,99212,99213,99214,9 9215, 99241,99242,99243,99244,99245,99341,99342,99343,99344,9 9345, 99347,99348,99349,99350,99381,99382,99383,99384,99385,9 9386, 99387,99391,99392,99393,99394,99395,99396,99397,99401,9 9402, 99403,99404,99411,99412,99420,99429, 92002,92004,92012,92014, 99304,99305,99306,99307,99308,99309,99310,99315,99316,9 9318, 99324,99325,99326,99327,99328,99334,99335,99336,99337 Z0000,Z0001,Z00121, Z00129,Z005,Z008,Z020,Z021,Z022,Z023, Z024,Z025,Z026,Z0271,Z0279,Z0281,Z0282,Z0283,Z0289, Z029

27 HEDIS Measures-Follow-up After Hospitalization for Mental Illness/HIP Follow up After Hospitalization for Mental Illness FUH Members 6 years of age and older as of the date of discharge from an acute inpatient stay must receive an outpatient visit with a mental health practitioner within 7 days after the discharge. Hoosier Healthwise 27

28 HEDIS Measures-Follow-up After Hospitalization for Mental Illness / HIP Follow up After Hospitalization for Mental Illness FUH MCEs currently working with the inpatient and outpatient providers on relationship building, education on the clinical practice guidelines and the measure, and Bridge Appointments. Providers can bill for bridge appointments in an outpatient setting with the 513 revenue code and procedure codes and Hoosier Healthwise 28

29 Pay for Outcome (P4O) Incentivized HEDIS Measures A contractual activity of MCEs P4O is an incentive for providers to meet quality measures in Hoosier Healthwise, Hoosier Care Connect, and the Healthy Indiana Plan A portion of the MDwise capitated payment is withheld, and paid to the MCE when quality goals are met 15

30 How We Promote Quality Care Provider and staff education Network Improvement Program (NIP) Team Billing and process audits Member education Member incentives Provider Incentives Case management services for members Case management for members receiving behavioral health services 19

31 How NIP Can Help NIP Team Responsibilities Created to take improvement efforts to a higher level Educating providers on HEDIS, NCQA, and OMPP standards Providing providers with information about their quality performance Diagnose office practices that may result in missed opportunities to provide care or cause services to not be billed correctly Creating and distributing reference/educational materials and tools Initiating programs and tools that assist the Plan in meeting quality targets Communicating to delivery systems and providers about areas of opportunity for improving efficient healthcare resource utilization 20

32 How NIP Can Help Create and implement pilot projects to improve quality of care in medical and behavioral health Maximize the opportunity for MDwise, Inc. to recoup as much of the State withhold on quality as possible in the targeted Pay for Outcomes measures Quality Reports Outreach Calls Online Reporting

33 NIP Reports Progress 2016 HEDIS COMPARISON REPORT AWC (Well-Care Ages 12-21) W34 (Well-Care Ages 3-6) W15 (Well-Care Ages 0-15 mo.) AAP (Adult Preventive Care) 50th %tile 75th %tile 90th %tile 50th %tile 75th %tile 90th %tile 50th %tile 75th %tile 90th %tile 50th %tile 75th %tile 90th %tile 49.15% 59.98% 66.58% 72.02% 78.46% 83.75% 59.76% 66.24% 74.47% 79.60% 83.87% 86.96% Eligible Meets % Meets Eligible Meets % Meets Eligible Meets % Meets Eligible Meets % Meets Members Criteria Criteria Members Criteria Criteria Members Criteria Criteria Members Criteria Criteria MDwise Total 75,580 24, % 47,798 21, % 13,530 8, % 103,070 70, % HEALTH CENTER INC 2,424 1, % 1, % % 2,497 1, % HEALTH CENTER A A % % % % HEALTH CENTER B B % % % % HEALTH CENTER C C % % HEALTH CENTER D D % % % % HEALTH CENTER E E % % % % HEALTH CENTER F F % % % % HEALTH CENTER G G % % % % HEALTH CENTER H H % % % % HEALTH CENTER I I % % % % P0738 (8/12) Hoosier Healthwise 33

34 NIP Reports Missed Opportunities ABC HEALTH CENTER 2016 MISSED OPPORTUNITIES REPORT Members to Achieve % Earning Threshold Members to Achieve % Earning Threshold Members to Achieve % Earning Threshold Measure Eligible Members Current Numerator Current % Meets % Earning Threshold % Earning Threshold % Earning Threshold Missed Opportunity Members* Potential % Meets W % 59.76% 66.24% 74.47% % W % 72.02% 78.46% 83.75% % AWC % 49.15% 59.98% 66.58% % Note: Data reflects eligibility as of 9/1/2016 with claims processed as of 8/23/2016. * Missed Opportunity Members had visits with their assigned PMP group during the measurement year but no qualifying services were billed % 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% W15 W34 AWC P0738 (8/12)

35 NIP Reports YTD Comparison ABC HEALTH CENTER 2015 VS 2016 YEAR TO DATE COMPARISON REPORT Measure 2015 Eligible Members (paid thru 8/27/2015) 2015 Numerator (paid thru 8/27/2015) 2015 Rate (paid thru 8/27/2015) 2016 Eligible Members (paid thru 8/23/2016) 2016 Numerator (paid thru 8/23/2016) 2016 Rate (paid thru 8/23/2016) % Earnings Threshold % Earnings Threshold % Earnings Threshold W % % 59.76% 66.24% 74.47% -0.21% W % % 72.02% 78.46% 83.75% -3.08% AWC % % 49.15% 59.98% 66.58% -9.09% AAP % 1, % 79.60% 83.87% 86.96% -0.84% 2015 vs 2016 Rate Diff YTD % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% W15 W34 AWC AAP P0738 (8/12)

36 EPSDT Coding Booklet 36

37 Well Child First Hoosier Healthwise 37

38 Opportunities For Improvement Maximize every member interaction to provide preventive and well-care Well care visits for children when they are in for acute care Schedule the 15 th month EPSDT visit prior to the 15 th month of life Staff who does scheduling can identify members that need services to schedule in a timely fashion Ensure proper billing for services rendered Be sure that the documentation is complete 21

39 Opportunities For Improvement A primary medical provider (PMP) office could take the opportunity to convert a sick visit into a well child visit when the member is in the office for acute care. If the PMP office has electronic medical records (EMR), implement alerts to reflect the non compliant members in the quality measures. If the PMP office receives a list of non compliant members, the office should reach out to the members and schedule preventive services. If a member contacts the PMPs office for a sore throat (acute visit) the office should take the opportunity to provide preventive care and schedule a well child visit if the member is due for services. 22

40 Opportunities For Improvement If a member is being seen for an initial prenatal visit or post partum visit, all the components of a preventive well care exam are provided. The appropriate preventive diagnosis code can be submitted as a secondary diagnosis code and count towards the AWC measure. If all components of the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services were provided, remember to submit the appropriate procedure codes or with the diagnosis code Z or Z as primary. 23

41 Opportunities For Improvement If all components of EPSDT were not provided, remember to submit the appropriate E&M code along with the appropriate preventive diagnosis code to ensure the services count towards the HEDIS measure. If EPSDT services were provided along with acute care, be sure to submit the appropriate EPSDT code along with the E&M code and the 25 modifier to ensure the services are counted towards the HEDIS measure. 24

42 Documentation For Well-Child Visits Developmental milestones Review diet and nutrition Previous problems addressed Address obesity and other chronic problems Ask about smoking, starting at age 10 yrs. Mental and physical assessment BMI record & discuss Unclothed exam Provide anticipatory guidance & counseling Do routine testing (lead, vision, hearing) 25

43 HealthWatch/EPSDT/Bright Futures Preventive healthcare program Emphasis is given to early detection For members from birth to 21 years old Required care for Medicaid recipients Assures availability and accessibility of required health care resources These components of care are a required part of the well-child assessment 26

44 Resources MDwise website: MDwise.org INcontrol Case managers American Academy of Pediatrics / Bright Futures Bright Futures Tool Kit Provider and Member Incentives Provider Quality Visits MDwiseREWARDS 27

45 NIP Resources NIP Resources below are available on: Providers/Quality/HEDIS: HEDIS Performance Poster (produced annually) Well Child Mini Poster Access to Care Guidelines Vaccine Schedule Fax Back Program (Tip Sheet and Form) Lead Screening Poster Periodicity Schedule CAHPS Poster EPSDT Billing Guide W-15 Tip Sheet Quit line Forms and Materials Well Child Form Pharmacy Documents IHCP EPSDT Manual at NOP Tip Sheet 45

46 NIP Resources Contact NIP Team Manager for additional outreach: Laura Trainor

47 Questions 31