HOT TOPICS IN HEALTH CARE A - Z Update for Quarterly Office Managers Meeting 06/23/2016
ACO
ACO ACCOUNTABLE CARE ORGANIZATION What is an ACO: An organized, legal entity comprised of providers from multiple practices, contracted with each other and CMS. Provides tools and information for those providers to identify and manage their high risk & complex patients and with ways to work together with other providers across all specialties. Employs nurses and support staff to provide population management, and complex and transitional care coordination. Shared savings dollars are available from CMS to organizations that demonstrate reduced cost and quality care.
VALLEY S ACO STATUS VMG and other (non-employed) Valley physicians were a part of Atlantic ACO for 3 years. Contract expired 12/31/15. Effective 01/01/16, Valley partnered with Holy Name Medical Center to form the North Jersey ACO. Comprised of physicians employed by HNH and VMG, as well as other nonemployed physicians affiliated with our hospitals. Anticipated number of covered lives attributed to Valley = 15,000+
Population Health
POPULATION HEALTH Generally, there are three goals for an organization implementing a Population Health program: 1. Improve quality 2. Improve patient satisfaction 3. Decrease costs across the practice.
POPULATION HEALTH IMPLEMENTATION: Identify the practice s patient populations by risk or complexity. Identify & focus on rising-risk and complex patients. Establish a multidisciplinary patient-centered team of providers, practice based staff, and Population Care Coordinators (PCCs) or Population Health Managers (PHMs) (which are generally RNs) and other health care professionals as appropriate pharmacists, social workers, clinical psychologists, etc. Develop processes to manage the practice s population appropriately. P t th i i l f ti t t d
VALLEY HEALTH SYSTEM POPULATION HEALTH DEPARTMENT Located at 579 Franklin Turnpike, Ridgewood, NJ Brings together complex care nurses, discharge nurses, and support staff from the TVH, VHC, and VMG under one roof. Works closely with the ACO and large managed care contracts To assure seamless care for our more complex patients To implement processes with the practices to close gaps in care for our healthy and rising risk populations
POPULATION HEALTH COMPLEX CARE NURSES Meg Borders Anne Fleming Jo-Anne Zimmerman Sheila Minnich
POPULATION HEALTH STAFF Shavon Adams Population Health Support Specialist Jean Lindquist Population Health Support Specialist
POPULATION HEALTH STAFF Joanna Vogel Transitions of Care Administrativ e Coordinator Dana Strauss Population Health Post-Acute Care Navigator
CURRENT POPULATION HEALTH INITIATIVES AT VALLEY HEALTH SYSTEM UnitedHealthcare Medicare Advantage Primary Care Incentive Program: 1200 covered lives as of 01/01/16 Horizon PCMH: 20,000+ covered lives as of 01/01/16 Cigna for Valley Health System insured employees: 7,500 covered lives North Jersey Accountable Care Organization (NJACO): 15,000+ covered lives attributed to Valley
PCMH
PCMH PATIENT CENTERED MEDICAL HOME Qualities of practices that are recognized as a PCMH: PATIENT-CENTERED PROVIDE COMPREHENSIVE, TEAM- BASED CARE OFFER ACCESSIBILITY PROVIDE CARE COORDINATION TRACK AND FOLLOW UP ON REFERRALS ARE COMMITTED TO PATIENT SAFETY AND QUALITY IMPROVEMENT
HOW DO YOU BECOME A PCMH? Choose a recognition body: JCAHO, NCQA, etc. Engage a consulting group to assess the practice for readiness, identify gaps in meeting the requirements, and walk you through the process to recognition. You must be able to demonstrate how the practice meets each measure/requirement as per the accrediting body s requirements.
HOW DO YOU BECOME A PCMH For JCAHO, You must first attain JCAHO Ambulatory Care Certification, then you can add on their PCMH Certification. The practice will have a comprehensive on-site inspection to determine if they meet the criteria. For NCQA, you will complete an on-line survey and upload your back up documentation. Your survey is reviewed and scored by a panel at NCQA. Based on score, the practice attains a level 1, 2 or 3 status. Recognition is awarded for a three-year period.
PATIENT CENTERED MEDICAL HOME 17 of Valley Medical Group s primary care practices have achieved recognition as Patient Centered Medical Homes by the National Committee for Quality Assurance (NCQA).
MU
MEANINGFUL USE = CMS EHR INCENTIVE PROGRAM CMS EHR Incentive Program commonly referred to as Meaningful Use. CMS awarded money to physicians/groups who adapted an EHR and successfully demonstrated that they are meaningful users of their EHR. Maximum incentive for those who started in 2011 and 2012 was $44,000.00 per provider over 5 years. Providers who did not adapt an EHR and attest by 2014 are not eligible for any monetary incentive awards and in fact have incurred a payment reduction from CMS in 2015 and beyond.
WHAT IS MEANINGFUL USE? Physician certifies that he is using a qualified EHR. Physician provides data to CMS showing that he/she: Used computerized order entry Transmitted electronic prescriptions Provided a clinical visit summary to the patients Performed medication reconciliation In addition, physician provides quality data for certain measures such as: patients smoking status and cessation counselling HgbA1c in diabetics BP control in hypertensives and more
MU PAYMENT SCHEDULE FOR PHYSICIANS WHO FIRST ATTESTED IN 2011:
MU PAYMENT SCHEDULE FOR PHYSICIANS WHO FIRST ATTESTED IN 2012:
MU PAYMENT SCHEDULE FOR PHYSICIANS WHO FIRST ATTESTED IN 2013:
MU PAYMENT SCHEDULE FOR PHYSICIANS WHO FIRST ATTESTED IN 2014:
MEANINGFUL USE MEASURES HAVE EVOLVED. MEASURES THAT WE NO LONGER ARE REQUIRED TO REPORT ON: Maintain UTD Problem List Maintain active Med List Record Demographics Record Vital Signs Record smoking status Send reminders for preventive/follow-up care
MEANINGFUL USE MEASURES THAT HAVE REMAINED THE SAME SINCE INCEPTION: CPOE Provide electronic copy of health info to patient Transmit Rxs electronically Med reconciliation Drug formulary checks Drug-drug and drug-allergy interaction checks in place
MEANINGFUL USE MEASURES THAT HAVE EVOLVED: THEN One clinical decision support rule in place Test capacity to transmit data to (one) immunization registry Report on 6 clinical quality measures Provide clinical summary to patient after each visit NOW Five clinical decision support rules in place Report data to 2 public health registries Report on 9 clinical quality measures across 3 domains Provide patient electronic access to that summary info plus additional information from their record
MEANINGFUL USE TRACKING & ATTESTATION Sample MU Dashboard in the EMR:
PQRS
PQRS Physician Quality Reporting System, began in 2007 Physicians are required to report certain quality measures to Medicare via: Claims, Registry, EHR, GPRO, CGCAPHS survey 2007 2014: Physicians were incentivized (paid additional money) for reporting quality data. Incentive amount changed from 1.5% - 2% - 1% -0.5%. 2015 present: Incentive payments no longer available. But physicians must report in order to not be penalized with reduced Medicare payments. ACO membership and participation eliminates the need to do PQRS reporting.
WHAT S GOING AWAY AS WE KNOW IT??? Meaningful Use PQRS Value Modifier Program (Physician Value-Based Modifier Program)
WHAT S NEXT? MACRA QPPs
WHAT S NEXT? MACRA QPPs Medicare Access & CHIP Reauthorization Act of 2015 Quality Payment Programs: MIPS = Merit Based Incentive Payment System APMs = Alternative Payment Models
MIPS--MERIT BASED INCENTIVE PAYMENT SYSTEM Eliminates the old programs (PQRS, MU, VM). New program that will measure providers on: Quality Resource Use Clinical Practice Improvement Activities Meaningful use of certified EHR technology Providers will earn a composite score for criteria in each of the above categories which will determine their fee increase or decrease. MIPS Performance measurement will begin in 2017. Payment adjustment (+ or -) will become effective in 2019.
ALTERNATIVE PAYMENT MODELS (APMS) CMS will determine which groups are eligible for an APM in 2018 and will implement next generation payment models in 2019 2024 Additional plans being formulated to start in 2026. ACOs, PCMH, Bundled payments
RESOURCES AT CMS.GOV QUALITY PAYMENT PROGRAM
CMS.GOV QUALITY PAYMENT PROGRAM
RESOURCES AVAILABLE AT CMS.GOV Medicare Learning Network