Utilization of a Pay-for-Performance Program to Drive Quality and Reduce Cost Thomas M. Deas, Jr., MD Vice President, Physician Development Theresa A. Bissonnette, MBA/HCM, CPHQ Director of Risk Adjustment and Quality North Texas Specialty Physicians November 16, 2016
Objectives Upon completion of this activity, participants should be able to: Understand the value of aligning compensation with quality performance measures Identify innovative compensation models for independent primary care and specialist physicians Describe the evolutionary process that must be undertaken in a practice to move from reporting to outcome measures. Recognize the challenges that are encountered in moving from reporting to outcome measures Outline the process for collecting, validating, and reporting quality measures Develop reports documenting physician performance 2
North Texas Specialty Physicians Independent Physician Association 3
North Texas Specialty Physicians (NTSP) Emerged in 1995 (HMO era) to manage specialist risk Physician led Evolved to primary care and 22 specialty divisions managing Medicare Advantage global risk Health plans: United Healthcare, Humana, and Care N Care Innovations: Health-e-Care, Sandlot HIE, Silverback TPA & Care Management, North TX Respecting Choices 4
North Texas Specialty Physicians (NTSP) Indispensable partner for our physician network engaging our physicians around... Common purpose the health of our member patients and CMS Quality Star Ratings Respect of their peers reporting and transparency of quality and cost performance Organizational culture physician leadership, innovation, and medical management Self-interest compensation linked to both quality and cost-effectiveness incentives, PCP referral base, specialty network, practice support, MACRA education, risk-adjustment, quality measures 5
Physician-led Governance NTSP Physician Board (PCP & Specialists) Primary Care Executive Committee 6 primary care physicians Medical Executive Committee 23 division chiefs from primary care, hospitalist, medical, and surgical divisions Quality Council Medical Management Committee Credentialing Committee 6
Subsidiary companies
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Aligning compensation with quality and value Specialty division budgets, payout methodology, and cap surplus Specialty division Pay for Performance (P4P) Primary Care Physician (PCP) per member per month (PMPM) compensation Quality PMPM Risk-adjusted PMPM PCP gain-sharing incentives? 10
Medical and Surgical Specialty Division Compensation Q 6 month adjustment Budget $100,000/month Claims paid at 100% Medicare Budget =$100K x 6 = $600K Paid claims = $536,000 @ MC rates Adjust to 112% MC = $600,000 6 month adjustment = $64,000 End of Year PAY FOR PERFORMANCE(P4P) LEADERSHIP CAP SURPLUS 11
Primary Care Compensation (member > 18 months, patient panel > 50) Fixed % of premium PMPM RAF >1.0 % PMPM bonus >1.2 % PMPM bonus Closed panel STARS -1.00% (if <400 members total) >3.9 % PMPM bonus >4.5 % PMPM bonus 12
Developing Measures PQRS (CMS.gov) NQF (qualityforum.com) QPS Tool HEDIS measures Potential measures described in the Request for Comments and Draft Call Letters from CMS Internally Developed 13
Specialists Developing Measures More traditional P4P measures (PQRS, NQF) Apply HEDIS CMS 5 Star measures where applicable HEDIS measures follow member PCPs Use these physician members as training ground for CMS 5 Star potential measures Traditional HEDIS measures Display measures Pharmacy measures Have to consider applicability to their practice 14
Developing Measures Discuss Measures with Division Approve Measure and Set Thresholds Develop Technical Specifications Present Data to Division and Quality Council Mock the Data 15
Developing Measures Release Specifications and Compliance Expectations to Divisions 16
Reporting process and outcome measures Process measures: Screening BMI, medication documentation, cancer screening Outcome measures: BP control, HgA1C < 9, surgical site infection, re-operation, post-op DVT, 30-day readmission, ER visits/1000 members 17
Quality Measures: Clinical Outcomes 18
Collecting, Validating and Reporting Quality Measures Reporting Collecting Claims data Paper submission Physician Attestation Validating Data Hub Entry 50% Threshold Month over Month Comparison Internal Physician Facing Timing 19
Collecting, Validating and Reporting Quality Measures 20
Collecting, Validating and Reporting Quality Measures 21
Collecting, Validating and Reporting Quality Measures 22
Collecting, Validating and Reporting Quality Measures Date Action 1.1.2016 2016 P4P Measurement Period Begins 4.29.2016 Deadline to submit requests for alternate methods to demonstrate compliance with P4P measures 5.13.2016 NTSP will provide response to any requests for alternate methods to demonstrate compliance 12.31.2016 2016 P4P Measurement Period Ends 3.1.2017 Final 2016 P4P refresh report released for distribution 3.31.2017 Deadline for documentation submission to show compliance for 2016 P4P 6.30.2017 2016 P4P Bonus Checks Distributed 23
CRC Screening: Process measure, powerful impact Engage patients communicate/educate/remind Engage primary care physicians STAR rating and PMPM Quality Team support Timely reporting HealthFair 24
CRC Screening: Process measure, powerful impact 3 2 1 Colorectal Cancer Surgery/1000 Members CNC Health Plans 0 2009 2010 2011 2012 2013 2014 2015 25
PCP and Diabetes Case Study Initially PCPs participated in traditional P4P Switched to Star Rating bonus Year round chart chase strategy using QCs Attention to offices that collect their own labs 100% 90% 80% 70% 60% 50% 40% Diabetes HEDIS Measures 30% CDC Eye CDC A1c CDC Neph 2013 DOS 2014 DOS 2015 DOS 26
PCP and Diabetes Case Study Launched new HMO Product 1.1.2015: CDC Eye 63.64% CDC Neph 100% CDC A1c 100% 27
Conclusion/Summary Align compensation with quality performance Move physicians from process to outcome measures Collect accurate and reliable information Develop dependable reporting for physicians 28
Contact Information Thomas M. Deas, Jr., MD Vice President of Physician Development tdeas@ntsp.com 817.332.8847 Theresa A. Bissonnette, MBA/HCM, CPHQ Director of Risk Adjustment and Quality tbissonnette@ntsp.com 817.529.8255 North Texas Specialty Physicians 1701 River Run, Suite 902 Fort Worth, TX 76107 29