Playing to Win in MSSP FEBRUARY 16, 2016 HEALTH ENDEAVORS 2016 1-888-862-0366 1
CMS Portals Who is responsible? MFT, HPMS, ACO PORTLET, QNET, EIDM, CAHPS, PUBLIC REPORTING HEALTH ENDEAVORS 2016 1-888-862-0366 2
EUA Password Reset, Annual Certification https://eua.cms.gov/identityiq/login.jsf MFT CCLF, Assignment & Aggregate Reports https://eftp2.cms.hhs.gov:11443/cfcc/login/login.jsp HPMS - Participant (TIN, CCN, NPI) Management, Application https://hpms.cms.gov/app/login.aspx ACO Portlet - CMS Webinar Recordings, File Retrieval https://portal.cms.gov/wps/portal/unauthportal/home/ CMS UserID EUA, MFT, HPMS, ACO Portlet For help with Form CMS-20037 and CMS User ID: HPMS_Access@cms.hhs.gov or (800) 220-2028 EIDM/QNET PQRS/GPRO (September, 2016) (used to be IACS/QNET) https://portal.cms.gov/wps/portal/unauthportal/home/ CAHPS (Patient Surveys) (August, 2016) http://acocahps.cms.gov/content/approvedvendor.aspx Public Reporting Guidance (January, 2016) https://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/downloads/aco-public-reporting-guidance.pdf 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
Every ACO Is Different Primary Care Only Primary Care + Specialists Primary Care + Hospital Primary Care + Specialists + Hospital +Home Health Hospital Based Patient History & Demographics Geography Management/Governing Body Organizational Structure Single EMR Multiple EMRs 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
One Strategy Does NOT Fit All Best Practices + Unique Decisions =Your ACO Strategy 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
3 Components of Population Health Management Data Analysis Quality Program GPRO/PQRS Care Coordination & Case Management HEALTH ENDEAVORS 2016 1-888-862-0366 6
MSSP ACO Goals Physician Engagement Quality Improvement Program GPRO/PQRS CCM 99490 Annual Wellness Visit After Hours Program/ER Alternatives Specialist Outreach Clinics (Access to Care) Out-of-Network Spend Preventive Care Services (Gaps in Care) Missed Revenue Opportunities Control Out-of-Network Spend Triple Aim Better care for patients Better health for our communities Lower Costs through improvements for our health care system Achieve Shared Savings Targeted Spend Reduction Stop the Admit Visit Stop the ER Visit Preventive Care Services (Gaps in Care) Patient Case Management & Care Coordination Patient Follow-up & Education Utilization Trends MRI, CT, Home Health HEALTH ENDEAVORS 2016 1-888-862-0366 7
How does Shared Savings Work? 2 Primary Requirements to Earn Shared Savings: Successful Quality Measures Reporting and Benchmark Performance (GPRO) https://www.cms.gov/medicare/medicare-fee-for-service-payment/sharedsavingsprogram/downloads/mssp-qm-benchmarks-2016.pdf Reduce Spending at least 5% (or a % greater than the assigned Minimum Shared Savings % Rate) below the Historical Benchmark 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
How does our ACO know if we are on track to achieve Shared Savings? 2 Primary Data Analytics to determine your ACO Status: Year-round GPRO/PQRS Data Collection & Performance Scoring NPI Level Actual Benchmark vs. Goal Benchmark (based on Historical Spend) NPI Level 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
Quality Accountability Year-round GPRO/PQRS Data Collection & Performance Scoring NPI Level HEALTH ENDEAVORS 2016 1-888-862-0366 10
Quality of Care In order to be eligible to share in any savings generated: In the first performance year of their first agreement period, ACOs satisfy the quality performance standard when they completely and accurately report on all quality measures (pay-for-reporting). Complete and accurate reporting in the ACO s first performance year qualifies the ACO for the maximum sharing rate. In subsequent performance years, quality performance benchmarks are phased-in for performance measures and the quality performance standard requires ACOs to continue to completely and accurately report quality data on all measures but the ACO s final sharing rate is determined based on its performance compared to national benchmarks. In addition, ACO s must meet minimum attainment (30th percentile benchmark) on at least 1 pay-for-performance measure in each domain in order to be eligible to share in savings. Both attainment and improvement in performance are taken into account when calculating the final sharing rate for ACOs in their second and subsequent performance years. ACOs are rewarded up to four additional points in each domain, if they demonstrate quality improvement. In this way, the ACO becomes increasingly responsible for quality performance and improvement during the first agreement period. When an ACO renews its participation in the program for a second or subsequent agreement period, the quality performance of ACOs is assessed in the same manner as ACOs in the third performance year of their first agreement period. HEALTH ENDEAVORS 2016 1-888-862-0366 11
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Performance scoring HEALTH ENDEAVORS 2016 1-888-862-0366 21
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Financial Accountability Actual Benchmark vs. Goal Benchmark (based on Historical Spend) NPI Level HEALTH ENDEAVORS 2016 1-888-862-0366 23
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Data Analysis Action Items Phase I Assign every patient to an individual NPI Apply algorithms utilizing claims data and patient assign data Primary Care vs. Specialist Plurality of Visits TIN visits and associated NPI visits HCC Risk Score every patient Start HCC comparison 2015 vs. 2016 Identify Patient Disease & Wellness Gaps in Care Provider Patient Profile Care Coordination & Case Management HEALTH ENDEAVORS 2016 1-888-862-0366 29
Data Analysis Action Items Phase I Actual Benchmark vs. Goal Benchmark (based on Historical Spend) NPI Level Establish NPI goal benchmark based on historical spend Aggregate Expenditure & Utilization Map CCLF individual patient data back to CMS Aggregate Report Compare to National FFS Average and MSSP ACOs Patients Trending to be Costly Top 30% HCC Score ED visit and Hospitalization in last 12 months 2 or more chronic conditions HEALTH ENDEAVORS 2016 1-888-862-0366 30
Get your arms around Patient Population Who is sharing data? Who are they? Where are they? What is HCC Score? Use your Claims Data for GPRO! Who is Potentially Costly? What are their disease & wellness gaps in care? Who is treating them? 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
Assign every patient to an individual NPI Apply algorithms utilizing claims data and patient assign data Primary Care vs. Specialist Plurality of Visits TIN visits and associated NPI visits HEALTH ENDEAVORS 2016 1-888-862-0366 32
HCC Risk Score every patient Start HCC comparison 2015 vs. 2016 HEALTH ENDEAVORS 2016 1-888-862-0366 33
Identify Patient Disease & Wellness Gaps in Care Provider Patient Profile Care Coordination & Case Management HEALTH ENDEAVORS 2016 1-888-862-0366 34
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Actual Benchmark vs. Goal Benchmark (based on Historical Spend) NPI Level Establish NPI goal benchmark based on historical spend HEALTH ENDEAVORS 2016 1-888-862-0366 36
Aggregate Expenditure & Utilization Map CCLF individual patient data back to CMS Aggregate Report Compare to National FFS Average and MSSP ACOs HEALTH ENDEAVORS 2016 1-888-862-0366 37
Patients Trending to be Costly Top 30% HCC Score ED visit and Hospitalization in last 12 months 2 or more chronic conditions HEALTH ENDEAVORS 2016 1-888-862-0366 38
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Data Analysis Action Items Phase II Specialist Spend Out-of-Network Spend Admissions & Readmissions Spend HEALTH ENDEAVORS 2016 1-888-862-0366 42
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GPRO/PQRS Readiness Action Items Assign every patient to individual NPI Apply algorithms utilizing claims data and patient assign data Primary Care vs. Specialist Plurality of Visits TIN visits and associated NPI visits EMR Gap Analysis Incomplete, Non-performing responses Quality Measure Central Repository [EMR, CCLF, Manual Key, Lab] Provider Education on 2016 PQRS/GPRO QM 2016 Measure Requirements QM 2016 Audit Document Assess Performance Year Round Email Performance and Progress Scorecards to Providers HEALTH ENDEAVORS 2016 1-888-862-0366 50
Assign every patient to an individual NPI Apply algorithms utilizing claims data and patient assign data Primary Care vs. Specialist Plurality of Visits TIN visits and associated NPI visits HEALTH ENDEAVORS 2016 1-888-862-0366 51
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Quality Measures 2014 LEGEND Bottom of Screen March 1, 2014 1-888-862-0366/WWW.HEALTHENDEAVORS.COM 55
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Filters: Patient Claims = Claims Data Available for this patient to assist in answering the Quality Measure March 1, 2014 1-888-862-0366/WWW.HEALTHENDEAVORS.COM 58
Claims Data will display above the applicable question/module Click on the Pink Bar to Expand March 1, 2014 1-888-862-0366/WWW.HEALTHENDEAVORS.COM 59
Claims Summary for this Measure will display including CPT and ICD9 codes March 1, 2014 1-888-862-0366/WWW.HEALTHENDEAVORS.COM 60
Click on red plus button to view NPI information for Rendering Provider and Facility March 1, 2014 1-888-862-0366/WWW.HEALTHENDEAVORS.COM 61
EMR & Chart Gap Analysis Not on Chart (EMR) Can t Report March 1, 2014 1-888-862-0366/WWW.HEALTHENDEAVORS.COM 62
Work Flows/EMR Gap Analysis-- Who/What/Where/When/How --Quality Measure conducted and documented on a consistent basis? [What?] --Responsibility for conducting and documenting the Quality Measure assigned to staff or providers? [Who?] --Quality Measure conducted and documented in the hospital or physician setting [Where?] --Quality Measure documented in the EMR, paper chart or other method? [How?] --Staff aware of the timeframes for capturing each Quality Measure? [When?] 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
QM 2016 Import Chart --CCLF Imports --EMR Report Imports --Abstracted by Facility --Abstracted by Health Endeavors --EMR CCDA Imports --Abstracted by Facility --Abstracted by Health Endeavors --Manual Key --Preferences/Defaults --Carry-Over Pneumonia Module from 2014 --Lab Imports (Hemoglobin A1c) --Lab Displays 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
Scorecards Performance & Progress Quality & Financial By Patient By Facility (TIN) By NPI ACO (aggregate) 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
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GPRO/PQRS Data Abstraction & Integration to Central Repository HEALTH ENDEAVORS 2016 1-888-862-0366 71
Facility abstract EMR Report or CCDA Data to import into the Health Endeavors QM 2016 Reporting Tool to complete the GPRO Measures Facility abstract data from EMR into Electronic Report or CCDA Facility remit EMR Data (Electronic Report or CCDA) for Import using Submit a Request Health Endeavors import EMR Data into QM 2016 GPRO Tool 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
Health Endeavors imports CCLF data to complete QM 2016 responses based on CPT and ICD9 and ICD10 codes Health Endeavors import CCLF data (monthly) into QM 2016 Imported CCLF data completes QM 2016 Based on the CPT and ICD9 Codes 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
Preferences & Defaults QM 2016 Chart Default Applicable Modules/Responses to No or Not Done Complete QM 2016 Import Chart Preferences Health Endeavors applies your QM 2016 Import Chart Preferences to QM 2016 Tool 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
Manual Chart Abstraction Pull Charts and Key Data Health Endeavors QM 2016 Tool 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
Approaches to GPRO 1. Do nothing and hope for the best 2. 8 weeks of manual chart abstraction 3. Year Round Plan of Action Provider & Staff Education EMR Gap Analysis Central Repository of Data Distribution of Performance Scorecards to NPIs Patient Gaps in Care Readiness for Physician Compare Public Posting HEALTH ENDEAVORS 2016 1-888-862-0366 76
Out-of-Network Migration HEALTH ENDEAVORS 2016 1-888-862-0366 77
In-Network/Out-Network Migration Out-of-Network Leakage 2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015
ACO Distribution Model Example Distribution Criteria TIN Benchmark 2 met benchmark 1 did not meet benchmark Example Distribution Point System Quality Measures 2 successful reporting of quality measures to ACO 0 did not successfully reporting quality measures to ACO Patient Survey Results 2 Satisfied successful percentage per CMS Standards 0 Did not satisfy the percentage per CMS Standards. EMR Use and Integration Leadership and Participation 2 stage 2 MU attestation 1 stage 1 MU attestation 0 no stage 1 MU attestation 2 took on leadership role 1 participated on committee 0 no leadership or committee involvement HEALTH ENDEAVORS 2016 1-888-862-0366 79
CCM 99490 HEALTH ENDEAVORS 2016 1-888-862-0366 80
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Compliance 1. Do not use unsecure text or email of Patient Health Information 2. Do not send CMS TINs or NPIs in a non-secure email. 3. Conduct Conflict of Interest annually. 4. Prepare an ACO Compliance Plan and Medical Practice Compliance Plan. 5. Conduct HIPAA education. HEALTH ENDEAVORS 2016 1-888-862-0366 83
https://www.cms.gov/medicare/medicare-fee-for-service- Payment/sharedsavingsprogram/News-and-Updates.html Final & Proposed ACO Rules HEALTH ENDEAVORS 2016 1-888-862-0366 84
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Recap Beneficiary Assignment 1. Identify all beneficiaries that had at least 1 primary care service with a physician who is an ACO professional in the ACO and who is a primary care physician. 2/16/2016 86
Recap Beneficiary Assignment 2. Identify all primary care services furnished to beneficiaries identified by ACO professionals of that ACO who are primary care physicians, non-physician ACO professionals and physicians with specialty designations. 2/16/2016 87
Recap Beneficiary Assignment 3. Under First Step, a beneficiary identified is assigned to an ACO if the allowed charges for primary care services furnished to the beneficiary by primary care physicians who are ACO professionals and non-physician ACO professionals in the ACO are greater than the allowed charges for primary care services furnished by primary care physicians, nurse practitioners, physician assistants and clinical nurse specialists who are: ACO professionals in any other ACO; Not affiliated with any ACO and identified by a Medicare-enrolled billing TIN. 2/16/2016 88
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Recap Beneficiary Assignment 4. The second step considers the remainder of the beneficiaries identified who have not had a primary care service rendered by any primary care physician, nurse practitioner, physician assistant or clinical nurse specialist, either inside the ACO or outside the ACO. The beneficiary will be assigned to an ACO if the allowed charges for primary care services furnished to the beneficiary by physicians who are ACO professionals with specialty designations specified by CMS are greater than the allowed charges for primary care services furnished by physicians with specialty designations who are: ACO professionals in any other ACO; Not affiliated with any ACO and identified by a Medicare-enrolled billing TIN. 2/16/2016 91
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Non-Physician ACO Professional 1. CCN List 2. NPI List for Physicians and Non-Physician ACO Professional 2/16/2016 94
99495, 99496 Transitional Care Management (TCM) Services 99490 Chronic Care Management (CCM) Services 2/16/2016 95
Company Overview Recent Regional Contract Announcement: Greater New York Hospital Association (GNYHA) Contract: GNYHA-IT-054 Since 2008, Health Endeavors has been on the cutting edge of healthcare technology development and has quickly become the country s most reliable healthcare vendor from coast to coast. Our unique technology is why the nations largest healthcare providers rely on Health Endeavors year in and year out to keep them on the forefront of healthcare technology and challenges. With offices based in in Scottsdale, Arizona and Omaha, Nebraska since 2008, we are strategically located to be readily available to clients in any time zone. Our cloud-based Patient Health Integrated Tools (PHIT) and Hospital Admin Tools (HAT) technology are used on a daily basis by over 1.5 million users to improve the care of over 10 million patients. Click here to visit our website!
Kris Gates, J.D., CEO of Health Endeavors, is the primary architect of the Health Endeavors technology suite. Using her extensive experience gained in both the business, population health management and legal sectors, Health Endeavors developed a suite of technology solutions to assist healthcare providers with the management and utilization of administrative and clinical data. Currently, the Patient Integrated Health Tools (PHIT) and Healthcare Admin Tools (HAT) suites are used by over 1.5 million users. In addition, the PHIT Tools manage over 10 million patients on a daily basis. Kris worked in programming and SQL database service positions prior to law school for MidAmerican Energy and IBP, Inc. with a focus on patient health management and data analysis. In 2001, she earned her juris doctor from Creighton University School of Law with cum laude recognition. In addition to her technology development experience, Kris provided legal services in private practice and served as corporate counsel to several large nonprofit health systems, including Banner Health, Alegent Health and Norton Healthcare. HEALTH ENDEAVORS 2016 1-888-862-0366 97