Payment Transformation 2018 Measure Changes and Updates. April 4, 2018

Transcription

1 Payment Transformation 2018 Measure Changes and Updates April 4, 2018

2 Performance Measures Engagement Measures 3. Patient Attribution & Panel Management Cozeva 4. Coreo 1. Effectively Manage Your Panel in Coreo 2. Supplemental Data Reporting 5. Toolkit and Resources 2

3 Performance Measures 3

4 Performance Measures Carried Over From Pay For Quality Cancer Screenings: Breast Cervical Colorectal Diabetes Care: Eye Exam Nephropathy HbA1c Blood Pressure Advance Care Planning Body Mass Index Well Child: 15 Months 3 6 Years Immunizations: Childhood Adolescent Weight Assessment & Counseling Review of Chronic & Suspect Conditions 4

5 New Performance Measures 1. Tobacco Screening and Cessation Counseling 2. Screening for Symptoms of Depression and Anxiety 3. Influenza Vaccine 4. Adolescent Well Care 5. Developmental Screening in the First Three Years 6. Sharecare RealAge Assessment 5

6 Tobacco Screening and Cessation Counseling C Q M The percentage of attributed members 18 years of age and older who had an outpatient visit with an eligible PCP type during the measurement year, were screened for tobacco use, and had tobacco cessation if screened positive for tobacco use. 6

7 Screening For Symptoms of Depression and Anxiety C Q M Numerator criteria to allow a combination of an expanded set of depression and anxiety screener tools Claims reporting requirements are unchanged 7

8 Adolescent Well Care C Q The percentage of attributed members years of age who had at least one comprehensive well-care visit with a PCP or an ob-gyn during the measurement year. 8

9 Developmental Screening in the First Three Years C Q Percentage of attributed member children screened for risk of developmental, behavioral, and social delays using a standardized screening tool in the 12 months preceding their first, second, and third birthdays. 9

10 Updates to Existing Measures 10

11 Breast Cancer Screening Update C Q M Three new codes accepted for numerator credit: 1. CPT Digital breast tomosynthesis, unilateral 2. CPT Digital breast tomosynthesis, bilateral 3. HCPCS G Digital breast tomosynthesis, unilateral or bilateral (list separately in addition to G0204 or G0206) **not a covered benefit for some plans and may result in a member co-pay 11

12 Breast Cancer Screening Update C Q M Effective for claims with dates of service on or after January 1, 2018, the following HCPCS codes are being replaced: G0202, G0204, G0206 Replaced by these CPT codes: screening mammography, bilateral (2-view study of each breast), including CAD when performed diagnostic mammography, including (CAD) when performed; bilateral diagnostic mammography, including CAD when performed; unilateral 12

13 Diabetes Care Eye Exam C Q M The percentage of attributed members with diabetes years of age who received a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the current measurement year or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the prior measurement year. Numerator credit to include eye enucleations performed at any time during the patient s history through December 31,

14 Diabetes Care Medical Attention for Nephropathy C Q M The percentage of attributed members with diabetes years of age who had at least one test for microalbumin during the current measurement year or who had evidence of medical attention for existing nephropathy (diagnosis of nephropathy or documentation of microalbuminuria or albuminuria; ACE inhibitor/arb therapy during the measurement year is also acceptable evidence). Numerator credit to include sacubitril/valsartan as an allowable hypertensive combination 14

15 Diabetes Care Update C Q M Denominator criteria modified to include only outpatient encounters with a diagnosis of diabetes with the following provider types: Primary care APRN Endocrinologist Family Practice General Practice Internal Medicine Naturopathic Practice Nephrologist Pediatrics Pediatric Endocrinologist Pediatric Nephrologist Primary Care Physician Assistant Exclusion criteria to exclude patients with polycystic ovarian syndrome 15

16 Body Mass Index C Q M The percentage of attributed members years of age who had an outpatient visit and whose body mass index was documented during the measurement year. Denominator criteria to include only outpatient encounters with an eligible PCP Primary care APRN Family Practice General Practice Internal Medicine Pediatrics Naturopathic Practice Primary Care Physician Assistant 16

17 Immunizations For Adolescents C Q One meningococcal conjugate vaccine on or between their 7th and 13th birthdays. One Tdap on or between their seventh and 13th birthdays. HPV: Please note that Cozeva will display this measure in 2018, but PCPs will not be scored on their performance rate until

18 Influenza Vaccine C Q M Percentage of attributed members 18 years and older who received an influenza vaccine during the measurement year. 18

19 Sharecare RealAge C The percentage of members 18 years of age and older who completed the RealAge assessment at least once during the measurement period. Re-Instated for 2018 Minimum threshold 5% Target threshold 10% 19

20 Sharecare Materials 20

21 Weight Assessment and Counseling for Nutrition and Physical Activity New ICD-10 code for numerator credit: Z71.82 Exercise Counseling 21

22 Review of Chronic Conditions M Measurement period will be January 1 September 30, 2018 Supplemental data accepted through October 31,

23 PCP Performance Measures PATIENT EXCLUSION Applies to members living in long-term care facilities Patient institutionalized a least 6 months during the measurement year with supporting documentation Request for Reconsideration R4R required each year Exclusion requests accepted beginning Q

24 PO Performance Measures Access and Utilization: Hospitalization for Potentially Preventable Complications (HPC) Chronic Ambulatory Care Sensitive Conditions (ACSC) Avoidable Emergency Department Visits Controlling Blood Pressure Collaboration: Accountability for PCP Communication Population Health: CSHCNS 24

25 Engagement Measures 25

26 PCP Engagement Measures ENGAGEMENT MEASURE COMMERCIAL 2018 MEASURE WEIGHT AKAMAI ADVANTAGE QUEST INTEGRATION Access to and Use of Cozeva 6% 6% 5% Panel Management 7% 7% 5% Engagement with Ecosystem 7% 7% 5% EPSDT Completion Rate 5% TOTAL 20% 20% 20% **Sharecare Engagement REMOVED for 2018 F 26

27 PO Engagement Measures ENGAGEMENT MEASURE Access: Facilitating timely access for new members Access: Facilitating timely access for existing members Access: Facilitating timely access for members across all lines of business Access: Providing 24/7 coverage for attributed members Collaboration: Participation in HMSA PO meetings COMMERCIAL 2018 MEASURE WEIGHT QUEST INTEGRATION AKAMAI ADVANTAGE 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% TOTAL 100% 100% 100% **Population Health: Social Determinants of Health Data Collection - UNSCORED 27

28 Total Cost of Care PO must have an aggregate performance score (across all LOBs and all member PCPs in the PO) equivalent to earning at least 50% of the total maximum potential performance payments for the PCP performance measures during the measurement year. Calculations exclude drug costs associated with drug plan riders and behavioral health services. Performance will only be calculated on a PCP s medical spending trend for HMSA commercial plan members. There will be no other outlier exclusions applied to the calculation. 28

29 Total Cost of Care 29

30 Patient Attribution & Panel Management in Cozeva 30

31 Cozeva - Adding Patients to Your Panel HMO, QUEST Integration and Medicare Advantage members 1. Verify PCP information on HHIN 2. Member signs Patient Attestation Form 3. PCP adds member to panel on Cozeva 4. *PCP faxes form to Attn: HMSA Membership Services (Oahu) (Neighbor Islands) 5. PCP files form in the member s medical record 6. Member is attributed to the PCP in HMSA s enrollment database as of the end of the month 31

32 Verifying PCP Information on HHIN HMO, QUEST Integration and Medicare Advantage members ALOHA, KIMBERLY ALOHA PHYSICIANS GRP 1/1/2018 Medical Verify the name displayed under Primary Care Provider Name. If the provider s name is not displayed on HHIN: 1. Ensure patients are informed and agree that they want you as their PCP. 2. Explain your role as their PCP and the significance of the Patient Attestation Form. 3. Member signs the Patient Attestation Form. 4. Provider s office faxes the form to HMSA. Please allow 10 business days to process your request. Note: If you or your office do not have access to HHIN, please contact HHIN at (808) on Oahu or 1 (800) , ext toll-free Neighbor Islands 32 32

33 Updating or Changing PCPs PCP uses the PCP Selection Form This form is also called the Patient Attestation Form Available at: portal/provider/za v_pel.aa.pay.100. htm Available in several languages: English, Chinese, Japanese, Korean, Ilocano, Vietnamese 33 33

34 How to Add a Patient Using Cozeva 1. Complete necessary information and click Search 2. Click the circle next to the member s name to confirm member 3. Click the first box to confirm the medical need to access the member s information 4. Click second box, Add patient to P4Q or Payment Transformation program 34

35 Cozeva Display Dual Members Dual members can be easily identified on Cozeva, member coverage IDs are underlined as shown above.

36 Patient Attribution Dual Members HMO, QUEST Integration and Medicare Advantage members 1. When a member has dual membership with an HMO, QUEST, and/or Medicare Advantage plan, it is important to verify that the provider s name is displayed on HHIN. 2. The attributed provider is aligned with PCP assignments in HMSA s enrollment databases, which are also displayed on HHIN. PCP information is updated to reflect the provider s name. (e.g., dual PPO and HMO attribution will be aligned with the PCP displayed on HHIN for HMO) The PCP name displayed on HHIN match. (e.g., dual HMO and QUEST)

37 Transitioning to Coreo Coreo launches May 1 st, 2018 Effectively Manage Your Panel in Coreo Supplemental Data Reporting Request for Reconsideration 37

38 Panel Management Module: Overview Panel management consists of 3 sub-modules: All patients registry Transfer registry Attribution activity log

39 Panel Management: All Patients Registry The All Patients Registry displays all actively attributed patients 39

40 Panel Management: Member ID 40

41 41

42 42

43 43

44 Panel Management: Transfer Registry and Attribution Activity Log The Transfer Registry allows users to view pending additions and removals, as well as recently completed transfers. The Attribution Activity Log is a historical log of all attribution movement over time.

45 Tasking Module This module is designed to streamline communication between contracted care management service specialists and the providers. The Tasking module allows users to easily view all of their Care Gap Opportunities across lines of business, the Supplemental Data Log, the R4R Queue in process, and the Approved R4R list. After EMR integration has been completed, providers will have advanced functionality to print patient face sheets per the daily schedule to use for pre-visit planning/prep or at the point-of-care to close care gaps. 45

46 Tasking: Care Opportunities Pre-visit planning and managing care gaps 46

47 Tasking: Supplemental Data Entry Easily add supplemental data to meet quality measures by clicking the clipboard icon Upload supporting data Complete the process by filling out measure specific supplemental data entry forms

48 Tasking: Requests for Reconsideration (R4R) Easily submit R4R Requests for Reconsideration data 1. Prepare supplemental documentation file (PDF) 2. Click the silhouette icon 3. Record required data 4. Supply a statement of justification 5. Click the paperclip icon to upload supporting data 6. Click the Submit button

49 Toolkit and Resources 49

50 Provider Toolkit Understanding your PMPM band Patient attribution Patient Satisfaction survey samples Screening tools Performance measure codes and claims filing guidance Report to Provider samples and sample provider reports and cover letters Total Cost of Care overview Brochures for patients explaining Payment Transformation 50

51 Provider Resources hmsa.com 51

52 Provider Resources hmsa.com 52

53 Provider Resources - Contacts Your Physician Organization is your transformation leader Call Cozeva at for questions or training about Cozeva display Call HMSA at on Oahu or 1 (877) , toll-free or psinquiries@hmsa.com: Questions about global payment amount Questions about engagement or performance measures Need training/support from HMSA s Training Unit for you and your practice team 53

54 Payment Summary Reports on HHIN 54

55 Provider Resources - HHIN Payment Transformation Program Guide To request HHIN access, call on Oahu or 1 (800) , ext toll-free Neighbor Islands 55

56 QUESTIONS? 56

57 Adding Patients to Your Panel PPO members 1. Member signs Patient Attestation form 2. PCP adds member in Cozeva 3. PCP files form in the member s medical record The PCP assignments based on historic claims-based attribution for commercial PPO members will remain until a change is requested through Cozeva. 57