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Upcoming HMSA Provider Trainings Nov. 5 Pay for Quality and PCMH Changes for 2016 (The Queen s Conference Center and webinar) NIA Webinars on advance imaging. Email NIAwebinar@magellanhealth.com to register Nov. 5 and 12, noon to 1 p.m. Dec. 3, noon to 1 p.m. Nov. 3, 10, and 19, 8 to 9 a.m. Nov. 18 and Dec. 15 Well-Being Webinars Dec. 2 QUEST Integration Webinar 10/28/2015 4
Today s Presenters Victoria Mizumoto Educator, Provider Services Lara Adelberger STARS Clinical Coordinator 10/28/2015 5
Primary Care Pay-for-Quality and PCMH Program Changes for 2016 Oct. 29, 2015 and Nov. 5, 2015
Agenda Pay for Quality Changes for 2016 Payment Update for 2015 PCMH Changes for 2016 Akamai Advantage: Last Push for 2016 10/28/2015 7
Pay for Quality Changes for 2016
Primary Care Program Changes for 2016 Pay for Quality and Patient-Centered Medical Home (PCMH) programs started in 2011, and are evolving Moving toward sustainable health care delivery system and a financially viable HMSA Reinforce high-value outcomes in clinical quality, patient safety, cost management and well-being improvement Preserve financial sustainability of primary care programs Recognize clinically integrated models also having provider incentives Raising the bar on performance levels All changes take effect January 1, 2016 Medicaid and QI ESC 6/24/2014 9
Pay for Quality Reduction in max potential Change in eligibility for P4Q payments New threshold to earn payment 2016 Affected Commercial: $4.25 PMPM (reduced $0.25) QUEST Integration: $2.75 PMPM (reduced $0.25) Must be affiliated with a PCMH in 2016 to participate in commercial and Akamai Advantage P4Q programs For all 3 quality programs, must score at least 40% of max potential to earn quality award. If below 40% of max potential, no award is paid for that line of business All PCPs 353 of 982 PCPs (36%) not in a PCMH PO * Will partner with POs on recruitment 498 of 982 PCPs (51%) earned less than 40% * Of these, 219 are in PCMH * As of 2Q 2015 commercial payment 10
2016 Simplification of Quality Metrics Current Commercial: 24 measures QUEST Integration: 23 Akamai Advantage: 14 2016 Commercial: 20 measures QUEST Integration: 18 Akamai Advantage: 13 10/28/2015 11
Quality Metrics Measures being removed (no longer monitored or required for regulatory purposes) for Commercial and QUEST Integration Medication adherence for cholesterol (statins) Medication adherence for hypertension (RAS antagonists) Medication adherence for oral diabetes medications Annual (lab) monitoring for patients on ACEI or ARB Annual (lab) monitoring for patients on diuretics Measure being removed for QUEST Integration Avoidance of antibiotic treatment in adults with acute bronchitis Impact on scoring: Available quality dollars in commercial and QUEST Integration will be redistributed among the remaining measures 12
Quality Metrics Measure being removed for Akamai Advantage Comprehensive diabetes treatment Impact on scoring: $1 PMPM for this measure will be deleted in its entirety Change in display on Cozeva Will track HbA1c (blood sugar) in control (below 9% for commercial and Akamai Advantage, below 8% for QUEST Integration) Change results from feedback from providers 13
Changes to Quality Metrics Body Mass Index (BMI) requirements and reporting will differ by age group Adults ages 21 to 74: report BMI value using Z68.1 to Z68.45 Below age 21: report BMI percentile And for Commercial and QUEST Integration: Children and adolescents ages 3 to 17 will have additional elements for weight assessment and counseling for nutrition and physical activity. Must report all 3: BMI percentile Counseling for nutrition Counseling for physical activity Medicaid and QI ESC 6/24/2014 14
Counseling for Nutrition Medical record documentation must include a a note indicating date and one of the following: Discussion of current nutrition behaviors (e.g., eating habits, dieting behaviors) Checklist indicating nutrition was addressed Counseling or referral for nutrition education Member received educational materials on nutrition during a face-to-face visit Anticipatory guidance for nutrition Weight or obesity counseling Medicaid and QI ESC 6/24/2014 15
Counseling for Physical Activity Medical record documentation must include a note indicating date and one of the following: Discussion of current physical activity behaviors (e.g., exercise routine, participation in sports activities) Checklist indicating physical activity was addressed Counseling or referral for physical activity Member received educational materials on physical activity during a face-to-face visit Anticipatory guidance for physical activity Weight or obesity counseling Medicaid and QI ESC 6/24/2014 16
Pediatric BMI and Counseling BMI codes for patients age 2 to 20 years old Z68.51 Z68.52 Z68.53 Z68.54 BMI pediatric, less than 5th percentile for age BMI pediatric, 5th percentile to less than 85th percentile for age BMI pediatric, 85th percentile to less than 95th percentile for age BMI pediatric, greater than or equal to 95th percentile for age Counseling for Nutrition and Physical Activity: Check HMSA Pay for Quality Guide for details on reporting Medicaid and QI ESC 6/24/2014 17
Advance Care Planning: Current Codes Denominator: Patients 75 & up Numerator: Any one of 7 codes reported on the claim will give credit, beginning Jan. 1, 2016. Must be reported annually. Code 1157F 1158F HCPCS S0257 Description Advance care plan or similar legal document present in the medical record Advance care plan discussion documented in the medical record Counseling and discussion regarding advance directives or end of life care planning and decisions, with patient and/or surrogate Note: Z66 for Do Not Resuscitate will not be recognized in 2016 10/28/2015 18
Advance Care Planning: New Codes for 2016 Code 1123F (Medicare code) 1124F (Medicare code) Description Advance Care Planning discussed and documented advance care plan or surrogate decision maker documented in the medical record Advance Care Planning discussed and documented in the medical record, patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed) by the physician or other qualified health care professional, first 30 minutes; face-to-face with the patient, family members, and/or surrogate 99498 each additional 30 minutes 10/28/2015 19
Changes to Akamai Advantage Quality Metrics for 2016 Review of Chronic Conditions (RCC) Collective performance (as of 10/23/15) = 78.6% confirmed In 2016, Cozeva will provide an ICD-10 translator tool to convert past ICD-9 diagnoses into ICD-10 Deadline for RCC will be September 30, 2016 New adjuster rewards higher levels of performance on RCC Akamai Advantage: Change in Review of Chronic Conditions adjuster 2016 Below 60% = no award 60-69.99% = 75% of earned award 70% or higher = 100% of earned award At bottomline, for Akamai Advantage, PCP must still earn at least 40% of maximum potential to get a quality award. Best strategy: work to achieve 4 to 5 stars on RCC! 20
Payment Update for 2015
Akamai Advantage RCC for 2015 Review of Chronic Conditions for 2015 separate and early payment in January 2016 For 2015: Maximum potential for RCC increased from $5 PMPM to $6.50 PMPM to account for 9 months Thank you for your hard work in addressing chronic conditions for Akamai Advantage members! Continue to code diagnoses in ICD-10 to the highest level of specificity 10/28/2015 22
Performance AND Improvement Points for Measures Added in 3Q 2014 For 3Q 2015, we will award Performance and Improvement points for these measures for all lines of business: BMI Advance Care Planning HbA1C Poor Control Medication Adherence for Oral Diabetes meds Medication Adherence for Cholesterol (Statins) Medication Adherence for Hypertension (ACE/ARB) Providers will benefit if they are high performers or made significant improvements from 3Q 2014 on these measures 10/28/2015 23
PCMH Changes for 2016
PCMH: Changes in Monthly Population Management Fees (PMPM) Commercial 2016 Affected Level 1 = no payment (reduced $1) Of 544 PCPs *: 79 at Level 1 (15%) QUEST Integration Level 2 = $2.50 PMPM (reduced $0.50) Level 3 = $3.00 PMPM (reduced $0.50) Level 1 = no payment (reduced $1) Level 2 = $1.00 PMPM (reduced $0.50) 165 at Level 2 300 at Level 3 Level 3 = $1.50 PMPM (reduced $0.50) * Excludes Straub, KMC; as of 9/28/15 25
New PCMH Requirements Changes reinforce PCMH as foundational to Payment Transformation All PCPs must create a practice transformation assessment and plan, which will focus on concepts that will help providers understand and prepare for payment transformation (2017). Plan due June 30, 2016. Elements of plan: Total panel management Refined set of quality performance measures Better engagement with Provider Organization, fellow providers, HMSA Cost of care management PCMH level verification not needed for PCPs at Level 2 or 3 and who needed to verify status in 2016 26
Take Steps Now! Want to join a Provider Organization? Consult with colleagues and contact a Provider Organization List of POs sent to affected PCPs and available as handout Goal is to be enrolled by Dec. 15, 2015 Want to boost quality score above 40% of maximum potential? Engage your practice team and focus on high-value metrics Your Provider Organization may have resources ARW and HMSA Training unit can assist Want to move beyond PCMH Level 1? Work with your Provider Organization to prepare documentation to move up to Level 2 or 3 before the end of the year 10/28/2015 27
Akamai Advantage: Last Push for 2015
Akamai Advantage Aim for 5 Stars! Diabetes Management (5) Blood Pressure Controlled Eye Exam HbA1c Poor Control Medical Attention for Nephropathy Medication Adherence for Oral Diabetes Medications 10/28/2015 29
Akamai Advantage Aim for 5 Stars! Heart Disease Management (3) Controlling Blood Pressure Medication Adherence for Hypertension Medication Adherence for Cholesterol (statin) Cancer Screenings (2) Breast Cancer Screening Colorectal Cancer Screening Body Mass Index Review of Chronic Conditions (closed for 2015 but continue to code ICD-10 to highest level of specificity) 10/28/2015 30
Commercial, QUEST, Akamai Advantage High Performer Incentives 255 PCPs invited. Includes PCPs with 50 or more HMSA members who scored 75% or better in 2014 quality program. Runs through end of year. Rewards and recognizes PCP and staff for extra effort to close gaps in care with more difficult patients Campaign focuses on these measures for all plans: Cancer screenings (breast, cervical, colorectal) Diabetes measures (HbA1c control, eye exam, nephropathy, BP) Blood pressure control for patients with hypertension BMI Additional AA measures: Osteoporosis and medication therapy management 10/28/2015 31
Commercial, QUEST, Akamai Advantage High Performer Incentives Provider incentive: $20 for first gap per patient $5 for each additional gap per patient Staff Incentive: $100 in gift cards for 50% gap closure $150 in gift cards for 75% gap closure $100 in gift cards for top 10 providers 10/28/2015 32
Akamai Advantage Incentive Program Announcement in early November 138 providers to be invited. Not in other incentive program and have at least 10 gaps in process measures Runs through December 31 Staff Incentive: $75 toward lunch for the staff for 50% gap closure $125 toward lunch for the staff for 75% gap closure 10/28/2015 33
Akamai Advantage Member Incentives Diabetes/kidney disease education Complete 4 hours (or 2 hours if had prior education) by Dec. 31 Credit for any education in 2015 $50 gift cards Diabetic retinal eye exam incentive only to those receiving a announcement letter in early November Complete by Dec. 31 $25 gift cards 10/28/2015 34
A Reminder: Reporting Blood Pressure Controlling Blood Pressure: Report BP on visits for hypertension [I10 Essential (primary) hypertension] Age 18 to 59: below 140/90 mm Hg Age 60 to 85: below 150/90 mm Hg Must report on Cozeva Diabetes Care BP Control <140/90: Age 18 to 75: below 140/90 mm Hg Blood pressure CPT II Codes 3074F 3075F Description Most recent systolic BP < 130mm Hg Most recent systolic BP 130-139 mm Hg Blood pressure 3078F 3079F Most recent diastolic BP < 80 mm Hg Most recent diastolic BP 80-89 mm Hg 10/28/2015 35
Resources Go to hmsa.com/providers for new Pay for Quality and PCMH guides to be posted in November 2016 Call Cozeva at 1-888-448-5879 for questions/training Contact HMSA s Training Unit for quality training for your practice team. Call 948-6820 on Oahu or 1 (877) 304-4672, toll-free or email psinquiries@hmsa.com Include address and zip code of your primary location; contact name, phone number and email address; and preferred day and time. 10/28/2015 36