Goals & Challenges for Outpatient Quality Directors Quality HealthCare Consulting, LLC CEO: Jennifer O'Donnell, MHA, PCMH-CCE
Objectives Learn a practical way for Quality Directors to align Quality Measures in order to set priorities, maximize efforts, and establish organization level strategies Risk vs. Reward- understand how annual wellness visits and coding to the highest level of specificity impacts the bottom line and future success in multiple CMS programs.
Overview Challenges Goals Strategies Best Practice Examples
Challenges Director of Quality and Outcomes at a Physician Hospital Organization Clinically and Financially Integrated 3 Hospitals >630 Physicians (half employed by the hospital) 3 Surgery Centers, LTAC, Home Health, Hospice, etc. >27 EMRs Joining at Super Clinically Integrated Network (SCIN) in 2017 Starting MSSP Track 1 in 2017 Employed Physicians and Hospital moved to EPIC 2016 Fragmented Data- Minimal IT Resources Multiple Incentive Programs- not aligned
Challenges Communication Concerns Two more quality directors one for the employed physicians one for the hospital one hand doesn't know what the other is doing Bureaucracy Independent Physicians think of the hospital as the Dark Side MACRA Proposed/Final Rules Published in 2016 Quality Measures - What gets measured gets managed? 2015 ~ 230 Measures 2016 ~ 180 Measures NCQA pushes PCMH Recognized practices on 2011 Standards to move to 2014 or 2017 Standards 6-9 months early PQRS-Multiple Submission Methods 2015 Denials/Informal Reviews 2016 Submission
CMS PAYERS Physician Quality PHYSICIANS CONCERNS NCQA
CMS Programs Triple Aim Physician Quality Reporting System (PQRS) Meaningful Use (MU) Value Based Payment Modifier (VBPM) Improvement Activities Medicare Access and CHIP Reauthorization Act (MACRA) Merit Based Incentive Payment Program (MIPS) Alternative Payment Model (APM) Partially Qualified APM Advanced APM CAHPS (PQRS, ACO, MIPS, Payer, Hospital) Physician Compare Center for Medicare and Medicaid Innovations (CMMI) Medicare Shared Savings Program (MSSP) CPC+ Pioneer/Tracks 1-3/Next Gen/Track 1+ Practice Transformation Network (PTN) Quality Advancing Care Information Cost Quality Payment Program (QPP) MIPS APM Coding: ICD 10 Annual Wellness Visits (AWV) Transitions of Care (TCM) Chronic Care Management (CCM) Hierarchical Condition Category (HCC) Codes
Payer Requests Quality Measures 2016 ~ 230 Measures 2017 ~ 180 Measures Includes: Preventative Chronic Utilization Medication Adherence Lower Costs Risk Scores Payment Pay for Performance Gain-Share Care Coordination Varying Definitions (NQF, PQRS, STAR, HEDIS) HEDIS Measures Medicare Advantage STAR Measures Varying Targets
Physician Concerns Quadruple Aim EMR Transition/Training/Data Compensation Benchmarks/Targets Productivity Patient Centered Medical Home Care Plans Huddles Standing Orders Quality Access/Wait-times Outreach Lower Costs/Control Utilization Patient Satisfaction/CAHPS Changing CMS Rules Quality Measures Outpatient Quality Measures 2016 ~ 230 Measures 2017 ~ 180 Measures Inpatient Quality Measures Coding ICD 10 Changes Annual Wellness Visits Care Transitions HCC Risk Coding Resource limitations Communication/Bureaucracy
NCQA Healthcare Effectiveness Data and Information Set (HEDIS) Patient Centered Medical Home (PCMH) Diabetes Recognition Program (DRP) Heart Stroke Recognition Program (HSRP) Patient Centered Specialty Practice (PCSP) Patient Centered Connected Care (PCCC)
Challenges
Goals 90% of the time Quality Directors want to do all tasks that improve outcomes for patients, resource limitations stop us Our Actions are Driven by the Goal to: Align measures- the more programs a measure impacts, the more likely we are to work on it Improve Quality Outcomes Have a Smooth and Easy Implementation of any new initiatives Reduce Resource Use (especially time) Save Money Eat the Elephant one bite at a time.
Strategies Determine organization goals by: Selecting the most important CMS and payer programs quality measures For example, this could include quality measures incorporated in the following programs: MSSP, MACRA, BCBS P4P Contract, Medicare Advantage P4P Prioritize this list and create a Goal Alignment Spreadsheet i.e. Preventative services, diabetes, medication adherence, readmissions, etc. Once you ve identified the areas of focus, align financial incentives to the organization and physicians (ideally cascading goals through the system) i.e. Bonuses/compensation tied to outcomes Focus PCMH interventions on these measures
Goal Alignment Spreadsheet RHP Outpatient Organization Level Adult Dashboard MEASURES TITLE MEASURE DESCRIPTION 2017 MSSP/ ACO TOTAL PREVENTATIVE Breast Cancer Screening Assesses women 50 74 years of age who had at least one mammogram to screen for breast cancer in the past two years. (HEDIS Definition) The percentage of women 50-74 years of age who had a mammogram to screen for breast cancer. (NQF 2372-MSSP Definition) YES 11 Preventive Care and Screening: Body Mass Index (BMI) Colorectal Cancer Screening Percentage of patients aged 18 years and older with a documented BMI during the current encounter or during the previous six months AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the encounter. Normal Parameters: Age 65 years and older BMI > or = 23 and < 30 Age 18 64 years BMI > or = 18.5 and < 25 (NQF 0421- MSSP Definition) Percentage of members 50 to 75 years old who had appropriate screening for colorectal cancer. Appropriate screenings are defined as: Fecal occult blood test (FOBT) during the measurement year Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year Colonoscopy during the measurement year or the nine years prior to the measurement year (NQF 0034-MSSP Definition) YES 6 YES 9 Influenza Immunization The percentage of members 6 months and older seen between October 1 and March 31 (during the measurement year) who received an influenza immunization OR who reported previous receipt of an influenza immunization. (NCF 0041-MSSP Definition) Flu Vaccinations for Adults Ages 18 64: The percentage of adults 18 64 years of age in commercial and Medicaid plans who report receiving an influenza vaccination between July 1 of the measurement year and the date when the commercial CAHPS 5.0H survey was completed. Flu Vaccinations for Adults Ages 65 and Older: The percentage of Medicare beneficiaries 65 years of age and older who report receiving an influenza vaccination between July 1 of the measurement year and the date when the Medicare CAHPS survey was completed. (HEDIS Definition) YES 6 Pneumonia Vaccination Status for Older Adults Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination. (NQF 0043-MSSP Definition) YES 5
Establish the Proactive Fundamental Infrastructure PCMH Best Practice Example 1. Measure Baseline Rate for the two immunizations (6A) 2. Set Goals for improvement of the two immunizations (6D- MUST PASS) 3. Setup Standing Orders (2D- MUST PASS) 4. Setup Huddle Reports to include Immunizations (2D- MUST PASS) 5. Setup Outreach Reports (3D- MUST PASS) 6. Educate the care team on: (2D- MUST PASS) The outreach plan Standing orders Plan to improve outcomes for immunizations What to say to help education the patients/motivational Interviewing Training 7. Extend hours, setup vaccine clinics, and allow for open access to nurse only appointments. (1A- MUST PASS) [Note: For chronic conditions #7 would be replaced with care plans and goal setting.] 8. Begin outreach- start with the patient portal, and move on to other outreach methods. (3D- MUST PASS) 9. Re-measure two immunizations rates to check for improvements (6E)
Proactive Examples Close Care Gaps and Manage Care while the Patient is at the Office Two Remarkably Effective Ways to Improve Outcomes: 1. Huddle Reports 2. Annual Wellness Visits In 2012 Medicare was 42% of the payer mix, by 2022 it will be 58% 1 Medicare Advantage plans are projected to nearly double between 2015 and 2025 (from 17.3M to 30M respectively) 2
Example 1: Huddle Report (Based on 2012 DRP + Aligned Preventative Goals) Huddle Report for Dr. Seuss on 01/14/2016 <7 - < 140/90 - <100-7 - 9 - Out of Range 140/90-145/95 - Out of Range 100-130 - Out of Range BMI > 30 w/ Counseling - > 9 Poor Control > 145/95 - Poor Control > 130 - Poor Controlled BMI > 30 w/o Counseling - * Not Found Within 1 YR - Missing Not Found Within 1 YR - Missing Not Found Within 1 YR - Missing Account Patient Name Appt Time DM HTN A1C BP LDL Foot Exam Eye Exam MAB ACE/ ARB Therapy Smoker w/o Cessation Not Found Within 1 YR - Missing BMI > 30 no MU Documentation for Weight Counseling Mammo Last 27 Months 11111 A, Test 07:30 AM Y 135/80 (05/02/2015) None 12/05/2010 22222 B, Test 08:00 AM Y Y 6.0 (05/22/2015) 115/84 (05/22/2015) 76.0 (05/22/2015) No No 11/05/2010 33333 C, Test 08:15 AM Y 125/78 (09/17/2015) 110.0 (09/17/2015) * 09/19/2015 03/05/2010 44444 D, Test 09:30 AM Y 150/97 (7/21/2015) 120.0 (7/21/2015) 04/05/2010 55555 E, Test 10:00 AM Y 9.7 (12/05/2015) 136/84 (12/05/2015) 110.0 (07/22/2015) None 05/05/2010 66666 F, Test 11:00 AM Y 111/62 (8/03/2015) 114.0 (06/24/2015) * 12/05/2015 06/05/2010 Colorectal Cancer Screening 77777 G, Test 12:00 PM Missing 07/05/2010 88888 H, Test 1:00 PM 135/68 (11/20/2015) 128.0 (11/10/2015) 99999 I, Test 2:00 PM Y 6.9 (11/11/2015) 127/70 (11/11/2015) 150.0 (11/10/2015) No 101010 J, Test 3:00 PM Y 125/68 (03/18/2015) 74.0 (02/24/2015) 04/05/2015 08/05/2010 111110 K, Test 4:00 PM Y 165/90 (12/15/2015) 140.0 (12/15/2015) * 222220 L, Test 5:00 PM Y 123/56 (01/12/2016) 101.0 (01/12/2016) 333330 M, Test 5:30 PM Y 95/60 (12/15/2015) 145.0 (12/12/2015) Most groups are leanly staffed and need more time- efficiency and delegation are key Work to the Highest Level of your License!
Example 1: Huddle Report - Outcomes Site A: Change Over Time 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Blood Pressure Control (<140/90 mm Hg) LDL Control (<100mg/dL) A1c <8 A1C>9 Smoking Status Documented Smoking Cessation Documentation DM Eye Exam Nephropathy Assessment DM Foot Exam Baseline 6 month 9 month
Example 1: Huddle Report - Lessons Learned 9 months post-huddle we began to see improved outcomes on our contracts. The groups performed better than the market and the nation in 3/5 DM measures. 12 months post-huddle- the groups began to see improvement on the preventative services that were added at 9 months. Outcomes peaked at 6 months Recommend re-training at 6months and also providing public positive feedback to the group about the achievements they made to date
Example 2: Annual Wellness Visits Annual Wellness Visits (AWV) have very long and comprehensive templates that cover: Gaps in care (preventative and chronic) Quality of life concerns (fall risks, depression screenings, etc) Risks levels AWVs typically take longer to complete, leading to physician complaints There are many benefits to developing a AWV strategy: Many insurance companies offer incentives to perform AWVs. In the case of Medicare Advantage and Health Exchange plans, CMS and HSS respectively pay the plan a premium to cover the costs associated with caring for patients based on their risk adjustment factors. In gain-share arrangements- the profit generated from more accurate coding maybe be shared with the practices. By collecting AWV info you can determining the patients risk levels and prioritize care within PCMH, Chronic Care Management, CPC+, and MSSP models.
Reactive Example Close Care Gaps and Manage Care after the Patient left the Office Not as efficient- The horse is already out of the barn Can be very effective Focus on risk levels- which may be determined by the payer, the EMR, or the disease registry Health Care Costs Concentrated in Sick Few: Sickest 5% Account for 50% of Expenses 1% 5% 10% 22% 50% 50% 65% 97% Source: Agency for Healthcare Research and Quality analysis of 2009 Medical Expenditure Panel Survey.
Reactive Example Care Coordination Low Risk Patients Assigned to a Care Coordinator Medium Risk Patients Assigned to a Wellness Coach High Risk Patients Assigned to a RN
Questions