Quality: Finish Strong in 2016. Get Ready for 2017 October 28, 2016
Agenda Stars: Medicare Advantage Quality Changes for 2017 Pay for Quality and PCMH Programs Important Announcements! 7
Stars: Medicare Advantage Quality
Topics Diabetes Incentive Program High Performer Program Dual Special Needs Metrics Medication Management Medication Reconciliation Post Discharge Medication Therapy Management Medication Review Blood Pressure Control 9
CMS Asks: How Good is Your Medicare Advantage Plan? CMS wants to: Inform beneficiaries as they choose a plan Encourage best evidence-based practices Improve/maintain health and well-being Payments for VALUE rather than volume 10
What Gets Scored? Preventive Screenings Breast Cancer Colorectal Cancer Chronic Disease Monitoring and Control Diabetes Hypertension Rheumatoid Arthritis Osteoporosis Medication Oversight Medication Adherence Medication Reconciliation Post Discharge Medication Therapy Management 11
Diabetes Incentive Program
Akamai Advantage Diabetes Incentive Program 741 members participating (out of 8,700 with diabetes) Potential to earn $100 in gift cards Services during 2016 HbA1c Testing PCP Visit for Diabetes Eye Exam Diabetes Education It s not too late to sign up! 13
High Performer Program
What is the program? You have patients who struggle with preventive services, so you were invited to participate We selected members who need the most assistance with gaps in care The program aligns bonus payments with the extra effort from your team 15
High Performer Program Update 527 Providers invited Packets mailed early September Initial gap for each member: $20 Additional gaps for each member: $5 Office incentives: gift cards 40 gaps = $100 Each additional 20 gaps = $50 more in gift cards 10 Offices with the most gaps closed = additional $100 Questions? Call 952-7822 16
Dual Special Needs
DSNP: What Gets Measured? Members who are eligible for BOTH Medicare and Medicaid All standard Medicare Quality Metrics Preventive Screenings Diabetes/Chronic Disease Measures Medication Management Four DSNP specific measures Health Risk Assessment Care for Older Adults 18
Care for Older Adults: Dual Special Needs Once per calendar year Four-part assessment: Medication Review Functional Status Assessment Pain Assessment Advance Care Planning COA form available with coding and checklist assessments Complete the assessments Add completed form to your medical record File a claim 19
Medication Management
CMS Emphasis: Medication Oversight Medication Reconciliation Post Discharge All Akamai Advantage Members Medication Therapy Management (MTM) 3 Chronic Conditions 8 or more Medications Medication Review Dual Special Needs (DSNP) Enrollees Within 30 days of hospital discharge Refer to Pharmacy Vendor Once per calendar year 21
Medication Reconciliation Post Discharge Hospital Discharge 30-day window Medication Reconciliation Document on claim 22
The Quick Version of Documentation MRP: Medication Reconciliation Post-Discharge (Medicare) The percentage of discharges from 1/1-12/1 of the measurement year for members 18+ for whom medications were reconciled on or within 30 days of discharge. Documentation needed: Medication reconciliation completed by the prescribing practitioner, clinical pharmacist, or registered nurse on or within 30 days of discharge. Need documentation that it was completed and the date that it was done in the outpatient chart. Any of the following evidence meets criteria: Notation that, I have reviewed patient s discharge medications and reconciled against pre-admit medications -or- Notation that no medications were prescribed upon discharge Submit CPT II Code: 1111F 23
Medication Therapy Management Patient receives a free comprehensive medication review by a pharmacist Help for your most complex patients 3+ chronic diseases 8+ maintenance medications spend >$ 876.75/quarter on medications Refer patient to HMSA s vendor: Mirixa (866) 208-1223 24
Cozeva Medication Tracking 25
Take Home Thoughts Diabetes Incentives High Performer Program (including office bonuses) Dual Care: COA forms Medication Measures Med Recon help from Pharmacare Med Management help from Mirixa Blood Pressure last chance for in-control values! 26
Akamai Advantage Review of Chronic Conditions (RCC) Deadline for RCC and supplemental reporting is December 31, 2016. Plan aiming for highest possible completion 74.5% Pay for Quality PCPs: Best strategy: work to achieve 4 to 5 stars (90%-95%) on RCC! Payment Transformation PCPs: Goal is 95% or higher for Maximum RCC rate as of 10/24/16 27
RCC Supplemental Reporting Most supplemental reporting for RCC requires upload of medical record into Cozeva. Deadline is December 31. Disconfirm Condition has improved; medical record required Disconfirm Condition has resolved; medical record required Disconfirm -- Insufficient evidence of this condition. Medical record is NOT required. Be sure to submit your complete attestation in the Cozeva comment box, or upload a document that contains the attestation. 28
Disconfirm - Insufficient Evidence PCP may choose to allow office staff (e.g., Cozeva Delegates) to complete attestation and submit supplemental data for disconfirmation on the PCP s behalf Sample: I, [staff member name], report that Dr. Aloha Lee, attests that this patient does not have the diagnosis of chronic renal disease. Dr. Lee has reviewed the pertinent medical information and finds that the patient has had normal creatinine levels over the past two years. PCPs will be held accountable for all submissions by Cozeva Delegate users. 29
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Changes for 2017 Pay for Quality and PCMH Programs October 28, 2016
2017: A Transition Year Staggered starts for Payment Transformation January 1, 2017 PCPs in identified Physician Organizations will move fully into Payment Transformation (global monthly payment + new measures), joining the 2016 pilot April 1, 2017 Some PCPs begin global monthly payment, but remain on Pay for Quality measures through 2017 July 1, 2017 Last group of PCPs begins global monthly payment, but remain on Pay for Quality measures through 2017 Expectation that most PCPs will move to Payment Transformation payment and metrics by 2018 32
PCPs in Transition to Payment Transformation Payment Transformation (Pilot, April 2016) Payment Transformation (January 2017) Payment Transformation (April 2017) Payment Transformation (July 2017) 33
Important Announcements In 2017, global monthly payment will be made on or about the 15 th of the month, with patient attribution from one month earlier New! Engagement measure to build PCP s profile on Sharecare find-a-provider application New! Performance measure Well-Being 5 being replaced by Sharecare RealAge Assessment Report to Provider will give more information about processing of each claim; will make account reconciliation easier Cozeva view will be reset in January 2017 Coming! PO training sessions and webinars 34
Important Announcements Supplemental data (commercial, QUEST Integration and Akamai Advantage) for January 2017 class ONLY must be entered into Cozeva by Dec. 31, 2016 Cozeva Pay for Quality view will be locked down for transition to Payment Transformation-only view for January 2017 All other PCPs have regular deadlines for submitting supplemental data: Jan. 31, 2017 for commercial, QUEST Integration and Akamai Advantage measures Dec. 31. 2016 for Review of Chronic Conditions 35
Payment Transformation Transition PCPs starting in April or July will remain on Pay for Quality program (rolling 12 months, quarterly payment). Will use familiar Cozeva dashboard Will also have sneak peek of Payment Transformation Cozeva dashboard All PCPs will work on 2 Physician Organization quality measures on the Payment Transformation dashboard Starting Date January 2017 April 2017 July 2017 Cozeva View Only Payment Transformation view Pay for Quality and Payment Transformation views; Will be scored on Pay for Quality measures 36
Pay for Quality View of Cozeva 37
Payment Transformation View Colored chiclets and stars replaced by bars Red = below 50th percentile Yellow = Minimum (earning 40% ) Green = Target (earning 100%) 38
Quality Measures Changes for 2017 Being dropped for P4Q because of small denominators; already dropped for Payment Transformation Appropriate testing for children with pharyngitis Appropriate treatment for children with upper respiratory infection Avoidance of antibiotic treatment in adults with acute bronchitis 39
Quality Measures Changes for 2017 Being dropped as a scored PCP measure, will remain as a Physician Organization measure that depends on PCP s performance Controlling high blood pressure Physician Organization measure Children with Special Health Care Needs Screener 40
Reporting Blood Pressure Report both systolic AND diastolic values on claims CPT codes 3074F 3075F 3078F 3079F Description Most recent systolic BP less than 130 mm Hg Most recent systolic BP 130-139 mm Hg Most recent diastolic BP less than 80 mm Hg Most recent diastolic BP 80-89 mm Hg For patients age 60 to 85 with hypertension, BP is considered adequately controlled when BP is below 150/90 mm Hg. Report compliant blood pressure values using Cozeva supplemental data. For patients age 60 to 85 with diabetes, BP considered in control if the blood pressure is below 140/90 mm Hg. For patients with Medicare primary/hmsa secondary, report using supplemental data on Cozeva or submit secondary claim to HMSA 41
Reporting CSHCN Screener Measure Procedure Code ICD-10 Code CSHCN Screener (NEW: ages 3-17, done every 3 years) Screening done; positive finding for chronic or special health care needs: E/M CPT code + HA modifier + Z87.898 Screening done; negative finding: E/M CPT code + HA modifier HA HCPCS code modifier = Child/adolescent program Z87.898 Personal history of other specified conditions For screener tool: http://www.cahmi.org/wp-content/uploads/2014/06/cshcns-surveyand-scoring.pdf 42
PCMH for 2017 Monthly PCMH payments continue until PCP moves to Payment Transformation global payment in January, April or July At that time, PCMH payment is wrapped into monthly global payment Old PCMH requirements dropped. Regardless of global payment start date, all PCPs work on PCP Engagement measures PCMH level advancement discontinued in 2017 43
Engagement to Encourage Active Participation These are foundational, relatively easy-to-achieve engagement steps Ensures providers are engaged in the systems to succeed in the new payment model Examples: Use of Cozeva Engage all attributed members annually through visit, call, email, mail, text, online care Referring patients to ecosystem programs (e.g.,hmsa Care Model, HMSA health education workshops, Dr. Dean Ornish Program for Reversing Heart Disease, community programs ) New! Sharecare Engagement build provider profile and upload PCP s photo for find-a-provider application 44
Engagement to Encourage Active Participation Will be displayed on Cozeva for ALL PCPs in 2017 Payment Transformation Pilot will be scored in 2018 Payment Transformation January 2017 will be scored in 2018 Payment Transformation April and July 2017 will be scored in 2018 45
Engagement: Details Measure Commercial Akamai Advantage QUEST Integration PCP/staff log into Cozeva at least once a month [pass = 100%] Check on well-being of all patients in panel [patient survey; pass = 75% of respondents report contact] Refer patients to health programs [Cozeva attestation; pass/fail] 5% 5% 4% 5% 5% 4% 5% 5% 4% New! Sharecare Engagement 5% 5% 4% Submit EPSDT forms [audit] 4% TOTAL 20% 20% 20% In Payment Transformation, each measure is all-or-nothing across all plans. Performing well adds up to 20 pct. points to the 80% base PMPM the following year. Doing poorly could result in loss of up to 20 pct. points. 46
PCMH Meets Payment Transformation To calculate global payment PMPMs for 2017, HMSA will use FFS data for 2013-2015 + your PCMH level (Level 1, 2 or 3) as of December 1, 2016 PCMH Level Level 1 Level 2 Level 3 Credited for PMPM $1 PMPM $3 PMPM $3.50 PMPM To advance to PCMH level 2 or 3, request and documentation needs to be submitted to HMSA by November 4 for review and approval in time for a Dec. 1 effective date to affect global payment for 2017 47
PCP Affiliation with Physician Organization If you are joining or switching to a new Physician Organization, PO must notify HMSA by Dec.15 Be mindful of PO s Payment Transformation transition date (Jan, April, or July 2017). Affects your quality/performance measures January 2017 Payment Transformation performance measures April 2017 and July 2017 Remain on Pay for Quality measures through 2017 Switch to Payment Transformation measures in Jan 2018 48
Adult Measures Cancer screenings Breast cancer Cervical cancer Colorectal cancer Diabetes measures HbA1c in control Eye exam Attention for nephropathy Blood pressure control Advance care planning 2017 Trigger Yes Yes Yes Includes 65+ Patient age 2 visits with diabetes as DX Patient age BMI assessment for adults Yes Any outpatient visit with PCP, specialists Review of Chronic Conditions for Akamai Advantage members Controlling Blood Pressure Yes Yes PO measure Patient age and DX 1 visit with hypertension as DX 49
Payment Transformation: Adult Measures Screening for depression and anxiety (age 18 and older) [Patient Health Questionnaire-4] Tobacco cessation and followup 2017 Trigger Yes Yes Outpatient visit with an eligible PCP type * Outpatient visit with an eligible PCP type * Influenza shots Yes Patient age New! Sharecare RealAge Assessment Yes Patient age Patient Experience (survey) N/A [Not a measure in 2017] * Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths 50
Pediatric Measures 2017 Trigger Well-child visits in first 15 months Yes Patient age Well-child visits, 3 to 6 years Yes Patient age Childhood immunizations by age 2 Yes Patient age Immunizations for adolescents Yes Patient age Weight assessment and counseling for nutrition and physical activity Yes Outpatient visit with PCP or ob/gyn* * Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths 51
Payment Transformation: Pediatric Measures Developmental screening in child s first 3 years (annually) 2017 Trigger Yes Patient age Adolescent well-care visit (ages 12 to 21) Yes Patient age Screening for symptoms of clinical depression and anxiety (ages 12 to 17) [Patient Health Questionnaire-2, -4, -9, -Adolescents] CSHCN Screener completion (ages 3 to 17, every 3 years) Yes Yes PO Measure Outpatient visit with an eligible PCP type * Patient age Patient Experience (survey) N/A [Not a measure in 2017] * Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths 52
Sharecare RealAge Assessment New! Commercial members 18 and older who complete Sharecare RealAge assessment at least once during the measurement year. Gauges how fast you re aging based on lifestyle and medical history. Replaces Well-Being 5 More information to be provided. Explore at https://www.sharecare.com/static/realage-test 53
Support for PCPs Your Physician Organization is your quality and transformation leader Call Cozeva at 1-888-448-5879 for questions or training about Cozeva display Call HMSA at 948-6820 on Oahu or 1 (877) 304-4672, toll-free or email psinquiries@hmsa.com: Need training/support from HMSA s Training Unit for you and your practice team 54