MD, MBA, FACHE, FAAPL

Transcription

1 Washington Association of Medical Staff Services Vancouver, Washington Ambulatory Credentialing and Privileging Jon Burroughs, MD, MBA, FACHE, FAAPL April 20, 2018 The Healthcare Transformation Journey: Moving from a. Sickness to a healthcare industry Fee for service to a risk based capitation business model Cottage to a standardized industry Hospital/physician office to healthcare system (CIN) Your New Healthcare System! 3 1

2 The New 21 st Century Reality 1. Being competent is no longer good enough (the bar is being raised throughout the country-and beyond) 2. Bottom decile performers will subsidize top decile performers 3. Top decile performers will earn disproportionate market share 4. Physicians and management now need to work together and share both quality and business information 5. Will healthcare contracts increasingly be based upon inpatient or total care across the continuum? Value-Based Purchasing Roadmap: What is your total Medicare Part A Revenue? CMS quality-based payment initiatives will put more than 12% of payment at risk REPORTING HOSPITAL QUALITY DATA FOR ANNUAL PAYMENT UPDATE 2% of APU VALUE-BASED PURCHASING 1% 1.25% 1.5% 1.75% 2% READMISSIONS 2% 3% 1% 2% 3% 3% 3% HOSPITAL-ACQUIRED CONDITIONS 1% MEANINGFUL USE 5% 1% 2% 3% 4% 5% Value Based Purchasing (VBP) is a Moving Target (and always will be) Domain FY 2017 FY 2018 Core Measures 5% (clinical processes) (was 70% in 2013) HCAPHS (patient experience) Outcomes (infections and mortality) 0% 25% 25% 25% 25% Efficiency (cost 25% 25% per episode of care) Safety 20% 25% 2

3 CMS is moving forward: MACRA (Medicare Part B) FFS Advanced Alternative Payment Models % 0.5% % % merit 5% % merit 2019 differential: 5% between highest and lowest More MACRA! MIPS = Measures for Quality, Resource Use, Clinical Practice Improvement, and Advancing Care Information FFS Merit Based Incentive Payment System % 0.5% % to +4% (up to 8%) % to +5% (up to 10%) % to +7% (up to 14%) % to +9% (up to 18%) Note: 2019 data based upon 2017 performance! What is your total Medicare Part B revenue? More MACRA! MIPS (Merit Based Incentive Performance System)-Are your physicians on board? I. Quality (50% weight): six customized measures for each practice/specialty that include one outcome measure and one crosscutting measure (applies to more than one measure) (80-90 points) II. Advancing Care Information (25% weight): security, e-prescribing, patient electronic access, coordination of care, HIE, clinical data registry (100 points) III.Clinical Practice Improvement Activities (15% weight): one of 90 activities to choose from (60 points) IV.Cost (10% weight): based on aggregate Medicare cost report for each clinician or group (prorated based upon all costs) 3

4 Key Metrics/Analytics that are utilized by Payers to determine Provider Inclusion into Narrow Networks: I. Cost efficiency Index (actual/expected costs) II. Quality Index (actual/expected outcomes for a roster of chronic diseases) III. Rate of non-service up coding Endorsed physicians (85%) have 40% lower costs than nonendorsed physicians (15%) and non-endorsed physicians are responsible for 10% excess cost to health plans How do Payers and Health Plans Define Quality in an Ambulatory Based Setting? Healthcare Effectiveness Data and Information Set (HEDIS MEASURES) developed by NCQA for CMS, Commercial Payers, and used by >90% of Health Plans: 91 measures across seven domains of care 1.Effectiveness of Care (52 measures) 2.Access/Availability of Care (6 measures) 3.Experience of Care (4 measures) 4.Utilization and Risk Adjusted Utilization (15 measures) 5.Relative Resource Use (5 measures) 6.Health Plan Descriptive Information (7 measures) 7.Measures Collected using Electronic Clinical Data Systems (2 measures) Types of Effectiveness of Care Measures: Immunizations Screenings Appropriate testing and medication management Appropriate follow up and monitoring Good compliance with recommended treatments Avoidance of non-recommended diagnostic testing or treatment (excessive testing or procedures) Avoidance of potentially harmful medications Core measures (outside of inpatient settings) Smoking cessation 4

5 Types of Access and Availability of Care Measures: Primary care Dental care Alcohol and Drug rehabilitation Pre and Post-natal care Call answer timeliness Types of Experience of Care Measures: Consumer Assessment of Healthcare Providers and Systems (CAHPS) measures for both adults and children developed by AHRQ for CMS, NCQA, and Payers/Health Plans for: Hospitals Clinician groups Hospice Ambulatory surgery Types of Utilization and Risk-Adjusted Utilization Measures: Frequency of pre/post natal, well child, health maintenance visits Frequency of ED and inpatient visits/care Mental health Drug and alcohol rehabilitation Antibiotic use Hospitalization for preventable complications 5

6 Types of Relative Resource Use Measures: Excessive use of ED and inpatient setting for individuals with: Diabetes Cardiovascular conditions Hypertension COPD Asthma Types of Health Plan Descriptive Measures: Board certification of physicians and practitioners Diversity of membership, language, cultural background Weeks of pregnancy at the time of enrollment Membership by State, service line, and totals Types of Electronic Clinical Data Measures: Use of PHQ-9 to monitor for depression (relapse and remission in adolescents and adults) PHQ-9 is an instrument for screening, diagnosing, measuring monitoring the severity of depression utilizing DSM-IV diagnostic criteria 6

7 Commercial Payers are Committed to Value: Aetna: 50% shared savings/risk by 2018 (e.g. total joints) Anthem: 50% shared savings/risk by 2018 Cigna: 50% shared savings/risk by 2018 Humana: 75% of Medicare advantage value based (with and without shared risk) by 2017 United: commitment to value based purchasing with capitated payment models How do Commercial Payers Incentivize Practices and Organizations based upon these measures? Blue Cross and Blue Shield of Tennessee Value Based Managed Care Plans: 1. Metrics are collaboratively chosen by practitioners, management and payers based upon practice profile 2. Metrics are scored from 1-5 stars based upon negotiated benchmarks 3. Each star is valued at $2 per member per month 4. Impact on each practice is potentially $250,000-$500,000 (assuming a 2,500-5,000 panel) What is regulatory quality? Core measures SCIP measures Specialty specific measures (e.g. STS, ACC etc.) NQF never events Patient safety measures HEDIS measures Why are these important and what do you want to do with them? 7

8 Hardwire regulatory quality! Clinical and functional pathways Standardize communications (e.g. SBAR) in high risk situations Manual checklists (pre-software) Decision support software and default functions Clinical and business analytics to monitor for variance (audit!) Many organizations are hitting 100% all of the time! Improve data capture (Tool: Ambulatory Summary) Condition Summary LINK 8

9 Population Reporting (Tool: Discern Analytics) What is Strategic Quality? The vital few (Pareto Principles) based upon what is most important to patients/customers, physicians, payers, management etc. Should be clinical and business measures! Monetize all measures before determining what the vital few are (each has a financial value now!) A small number of measures are responsible for most of your potential success (or lack thereof) Calculations from my new ACHE Course on Monetizing Quality: Decrease LOS by 1 day = $500 costs X $80,000 patients = $40,000,000 cost savings Increase CMI by 0.2 = $7,000 Medicare payment X 40,000 Medicare patients = $280,000,000; (1.9/1.7) X $280,000,000 = $312,941,176 or $32,941,176 incremental revenue Increase VBP by 1% = $500,000,000 Medicare part A revenue X 1.01 = $5,000,000 incremental revenue Increase MIPS by 4% = $100,000,000 Medicare part B revenue X 1.04 = $4,000,000 incremental revenue Decrease your labor ratio 5% = $40,000,000 (net operating margin) + $50,000,000 (5% of 1 billion) = $90,000,000 or $50,000,000 new incremental revenue Decrease your supply chain ratio 3% = $30,000,000 incremental revenue (same calculation as labor ratio) Reduce your cost per case by 10% = $500 (10% of $5,000) X 80,000 patients = $40,000,000 cost savings 27 9

10 Pareto Chart to Prioritize (first five make up > 96% of total): 1. Decrease your labor ratio 5% = $40,000,000 (net operating margin) + $50,000,000 (incremental revenue) = $50,000, Reduce your cost per case by 10% = $500 (10% of $5,000) X 80,000 patients = $40,000,000 cost savings 3. Decrease LOS by 1 day = $500 costs X $80,000 patients = $40,000,000 cost savings 4. Increase CMI by 0.2 = $7,000 Medicare payment X 40,000 Medicare patients = $280,000,000; (1.9/1.7) X $280,000,000 = $312,941,176 or $32,941,176 incremental revenue 5. Decrease your supply chain ratio 3% = $30,000,000 incremental revenue 6. Increase VBP by 1% = $500,000,000 Medicare part A revenue X 1.01 = $5,000,000 incremental revenue 7. Increase MIPS by 4% = $100,000,000 Medicare part B revenue X 1.04 = $4,000,000 incremental revenue 28 Don t forget to Align with Physicians and APPs!: Example of a comanagement contract (Ambulatory Practitioner): 50% base pay (10%tile MGMA compensation) 10% aligned HEDIS measures based upon payer contracts (2% bonus for every 20% departmental compliance with agreed upon quality targets) 10% patient experience (2% for each 10%tile above 30%tile PRC departmental scores) 10% access and availability (2% for each 10%tile above 40%tile for hospital survey of physicians and stakeholders) 10% oversight of clinical documentation (e.g. medical records) (2% for every 10% compliance over 50%tile) 10% working within budget of ambulatory practice as determined by physician and management leadership (top potential pay (90%tile MGMA compensation) Economic Credentialing: The use of non-competence related criteria for membership on a medical staff or in a healthcare organization Point of contention with AMA, physician groups, attorneys, and healthcare organizations (e.g. Murphy v. Baptist Health and Rosenblum v. Tallahassee Memorial Regional Medical Center, Friedman v. Delaware County Memorial Hospital-2009) Growing necessity due to evolution of at-risk reimbursement methodologies (e.g. shared savings) Best approach is to always link economic criteria to quality (e.g. utilization management), community need and maintain a clear moral compass with regard to patient and community interests 10

11 Sample economic credentialing and privileging criteria Family Physician: Complete an accredited residency in family medicine Board certified in family medicine Employed by hospital based patient centered medical home and integrated practice Willing to adopt and utilize evolving evidence based clinical, safety, service, and cost-effective practices as determined by the PCMH and integrated practice Willing to agree to participate in unblinded clinical and business analytics as determined by physician and management leadership and be held accountable for aligned outcomes Sample economic credentialing and privileging criteria Pediatric Advanced Nurse Practitioner: Successful completion of a master's, post-master's, or doctorate from a pediatric nurse practitioner program accredited by the Commission on the Collegiate of Nursing Education (CCNE) or the National League for Nursing Accrediting Commission (NLNAC), Board certified as a pediatric nurse practitioner Employed by hospital based patient centered medical home and integrated practice Willing to adopt and utilize evolving evidence based clinical, safety, service, and cost-effective practices as determined by the PCMH and integrated practice Willing to agree to participate in unblinded clinical and business analytics as determined by physician/app advisory committee and management leadership and be held accountable for aligned outcomes Traditional and Contemporary Privileging Criteria I. Traditional: CMS: individual character, competence, training, experience, and judgment TJC: medical/clinical knowledge, technical/clinical skills, clinical judgment, interpersonal skills, communication skills, professionalism II. Contemporary: economic relationship to the organization, willingness to comply with evidence based practices and strategic goals/objectives, willing to comply with value analysis process, health plan rating, comply with conflict of interest policies 11

12 Key Components of At Risk Contracts with Physicians (Intermountain Health): Be willing to participate in at risk contracts based upon strategic goals/objectives developed and approved by physicians and management Comply with clinical and business best practices as determined by peer group/management (and be willing to be peer audited for exceptions) Agree to un-blinded transparency of all clinical and financial data/analytics Be willing to comply with value analysis process Disclose all potential conflicts of interest and accept determination of deliberative physician bodies The New World of Ambulatory Credentialing and Privileging : Your health organization is becoming a healthcare delivery system and you will be increasingly held accountable for the entire continuum of care The medical staff is now system and not hospital based You will need to align medical staff performance with at risk payer contracts! You will need to align with all qualified members of the medical staff to do at risk contracts with them! Focus on strategic outcomes (clinical and business) that matter to your staff, your payers, your patients, and your management team! Questions, Discussion, and Wrap Up 12

13 Thank You for Joining Us! Jon Burroughs, MD, MBA, FACHE, FAAPL