Navicent Health Physician Group Risk-Based Payments: Assessment of Readiness and Performance for Multiple Reporting Requirements

Creating Clinically Integrated Health System-Based Medical Groups Collaborative Case Study Navicent Health Physician Group Risk-Based Payments: Assessment of Readiness and Performance for Multiple Reporting Requirements

Creating Clinically Integrated Health System-Based Medical Groups Collaborative Case Study Navicent Health Physician Group Risk-Based Payments: Assessment of Readiness and Performance for Multiple Reporting Requirements Organizational Profile Our CEO, Dr. Ninfa Saunders, said it best: Navicent Health is focused on three integral parts of our system: strategy, operations, and people, with people being the most important. Without the dedication of our people, both physicians and staff, we would be unable to succeed. Navicent Health and its employees are committed to three core values integrity, kindness, and respect as well as the contributing values of learning, commitment, and teamwork. Above all, we are committed to serving each patient, each of their loved ones, and each customer with kindness. Navicent Health, headquartered in Macon, GA, is represented by thousands of caring individuals who make up the fabric of the care we provide each day. Caring for patients and their loved ones is in our DNA. Navicent Health is an integrated healthcare delivery system that includes Navicent Health Physician Group (NHPG), The Medical Center, Carlyle Place, Beverly Knight Olson Children s Hospital, Navicent Health Foundation, Medical Center Peach County, Navicent Home Health, Pine Pointe Hospice and Palliative Care, Rehabilitation Medicine, and Retail Medicine. The Medical Center, the second largest hospital in Georgia, is a 637-bed, acute care hospital. This acute care facility is a tertiary regional teaching medical center, a designated Level I Trauma Center, and a perinatal center, and is a three-time designated Magnet hospital for nursing excellence nationwide. Rehabilitation Medicine is a 58-bed, inpatient rehabilitation hospital, and Carlyle Place is a continuing care community with a 40-bed, skilled nursing facility. The 106-bed children s hospital is the region s only Level III neonatal intensive care unit. Medical Center Peach County is a 25-bed, critical access hospital, and Pine Point Hospice is a freestanding, 15-bed, inpatient hospital. These strategic business units and associated service lines provide the foundation for our comprehensive continuum of care offering to the region. NHPG is a physician-led and administratively supported multispecialty group of more than 160 physicians, nurse practitioners, physician assistants, therapists, and psychologists providing professional medical services across the Navicent Health continuum of care. NHPG serves patients across central and southern Georgia. Our group has seen phenomenal growth and expansion fostered by our cohesive physician and administrative team striving toward the common goal of excellent patient care and outcomes. We are actively increasing our specialty and primary care footprint to provide the best care possible for the communities we serve. Some of the over 37 specialties in our group include family medicine, obstetrics and gynecology, cardiothoracic surgery, vascular surgery, pediatrics, pediatric surgery, general surgery, critical care, nephrology, neurology, urogynecology, and gastroenterology. The group practices in over 37 practice locations with over 240,000 encounters annually. 2

NHPG is part of two clinically integrated networks as well as being Medicare and Medicaid providers. NHPG is a member of Central Georgia Health Network (CGHN), a physician-hospital organization. As a member of CGHN, NHPG physicians must report on commercial risk measures. NHPG is also a member of TC2, a newly established Medicare Shared Savings Plan Track 3 ACO. As a member of TC2, some NHPG physicians must report ACO measures. Therefore, NHPG physician reporting would span ACO, Physician Quality Reporting System, Meaningful Use, Medicaid Meaningful Use, and now MIPS measures. Executive Summary In an effort to prepare NHPG for risk, we identified what types of reporting would be required by the different specialties represented in NHPG. We provided extensive education to the physician governance group and the local practices with respect to the Merit-based Incentive Payment System (MIPS), the Medicare Access and CHIP Reauthorization Act (MACRA), and Accountable Care Organization (ACO) performance measurement. Then, we estimated our MIPS performance using an internally developed calculator. We estimate that we will receive a positive adjustment for 2017 for any MIPS specialties. Also, we estimate that we will achieve significant financial savings for our ACO reporting specialties. Looking forward, we are continuing to educate our practices on closing the gaps on our ACO quality measures. Program Goals As a result of NHPG being a multidisciplinary practice, with both adult and pediatric specialties, NHPG has multiple reporting requirements. The goal of our project was to assess the multiple types of reporting required by each of the specialties within NHPG. A second goal was to project our expected MIPS and ACO performance for 2017. Interventions First, an inventory and cross tabulation of the physicians and their reporting requirements was created. After being approved as member of a Track 3 ACO, we recognized the need to identify which lane our clinicians would be participating in ACO, MIPS, or Medicaid Meaningful Use. What we found was that our pediatric specialties would be filing under Medicaid Meaningful Use. The primary care clinicians, some Medical specialists, and some surgical specialists would report as part of the ACO. While we were hopeful that all of our adult medical and surgical specialists would be included under the ACO, we recognized a need to prepare to file them under MIPS as well. Second, NHPG created a calculator for the current performance in MIPS. There are three measures very closely connected: that the patient receives an invite to participate in the patient portal; that the patient actually signs up for the portal; and secure messaging. Education was provided to front desk staff about the importance of ensuring that emails were collected when the patient registers for the visit. Once the email was collected, staff was given access into the administrative tool to sign the patient up at the time of his or her visit by using the ipads supplied to the practices. By having the patient signed up for the portal, the clinicians were able to increase the number of secure messages to satisfy that particular measure. In prep for the possibility to file the adult medical and surgical specialist under MIPS, quality measures were identified, performance improvement projects were selected, and reports demonstrating performance of advancing care information (ACI) was completed. Using the formula established by the Centers for Medicare & Medicaid Services (CMS) and data from January 2017-March 2017, we were able to calculate a MIPS composite score of 64. This would indicate we 3

would receive a positive adjustment, but that we were not eligible for the exceptional performance bonus. Our findings indicated opportunities for improvement in quality, specifically in BMI and tobacco cessation measures. In ACI, improvement opportunities were found in transition of care (TOC) and secure messaging. Third, comprehensive educational initiatives were implemented. MACRA represents a significant departure from traditional PQRS reporting and Medicare Meaningful Use reporting. To address the MACRA changes, beginning in 2016, and over a course of six to nine months, multiple education sessions were held at the NHPG physician governance meetings. The focus of the educational sessions was the shift from volume- to value-based care. The Triple Aim was also discussed, including cost management, population health/quality outcomes, and patient satisfaction. There were further discussions on how these areas will impact physician reimbursement both positively and negatively moving forward. As a first-year ACO participant, quality reporting is required regardless of performance. Therefore, in early 2017, education programs were held for the practices on the ACO and its expectations. The focus was to increase general understanding of ACOs and to create sustainable workflows within each practice to ensure our ability to address all measures. Example of Clinician Education What is MACRA? Medicare Access and CHIP Reauthorization Act of 2015 Repeals flawed Medicare sustainable growth rate (SGR) formula that calculated payment cuts for physicians Creates a new framework for rewarding physicians for providing higher quality care by establishing two tracks for payment: Merit-Based Incentive Payment Systems (MIPS), and Advanced Alternative Payment Models (AAPM), and Consolidates three existing reporting systems: Physician Quality Reporting Systems (PQRS) Meaningful Use (MU) Value-Based Payment Modifier (VBPM) 4

Who is Included in MACRA? Nurse Practitioners Physician Assistants Physicians Clinical Nurse Specialist Certified Registered Nurse Anesthetist MACRA Timeline MACRA Timelines and Financial Impact 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 +0.5% +0.5% +0.5% +0.5% PQRS, Value-Based Modifier, and Meaningful Use 1 Medicare Part B Baseline Payment Updates *Non-qualifying AAPM Conversion Factor ** Qualifying AAPM Conversion Factor Merit-Based Incentive Payment System (MIPS) -6% -9% -9% +/-4% +/-5% +/-7% Quality, Cost, Advancing Care Information, and Improvement Activities Qualifying Advanced Alternative Payment Model (AAPM) Participant 5% Incentive payment 1 Cumulative maximum penalty for a 10-provider clinic. +0% Qualifying AAPM Participants Exempt from MIPS +/-9% +0.25%* +0.75%** Do You Know Your Lane? Medicaid MU TC2/ACO MIPS 5

MIPS 2017 Category What 2017 Category Weight Quality Replaces PQRS Report up to 6 quality measures, including an outcome measure, for a minimum of 90 days. 60% Improvement Activities New category Advancing Care Information Replaces Medicare Meaningful Use (MU) Can attest as group and for 4 improvements activities for a minimum of 90 days. Fulfill required measures for a minimum of 90 days: 3 Security Risk Analysis 3 e-prescribing 3 Provide Patient Access (Portal) 3 Send Summary of Care (Electronic) 3 Request/Accept Summary of Care 15% 25% Cost Replaces Value-Based Modifier No data submission required. Calculated from adjudicated claims. Counted starting in 2018 Note: Option to file group or individual How is the Base Score Calculated? MIPS Base Score for ACI MIPS eligible physicians need to fulfill the requirements of all the base score measures in order to receive the 50% base score. If these requirements are not met, they will get a 0 in the overall Advancing Care Information performance category score. In order to receive the 50% base score, MIPS eligible clinicians must submit a yes for the security risk analysis measure, and at least a 1 in the numerator for the numerator/denominator of the remaining measures. The base score Advancing Care Information measures are: Required Measures for 50% Base Score Security Risk Analysis e-prescribing Provide Patient Access Health Information Exchange 6

Fourth, NHPG calculated first quarter ACO cost and quality performance for the attributed lives in NHPG. Our plan to address quality performance included steps to close care gaps through proper EMR documentation, monitoring of financial dashboards, and physician practice education. During the latter part of this year, we will work to close care gaps with longer shelf life and impact closure for multiple years. Those measures include pneumovax vaccination, influenza vaccination, and breast and colon cancer screenings. Meetings will be held with practice staff to identify the best approach for their patient group. Also, during this time period we will also look to schedule patients for their annual wellness exams to be completed during the first quarter of 2018. Patients will benefit by having their prevention and wellness needs addressed without personal/out of pocket expense to them, the practice can close a number of care gaps, and also increase revenue for not only the wellness exam but also additional billable services. ACO Quality and Financial Work Plan September to December 2017 September to December 2017 January to December 2018 Close care gaps that will impact 2018 performance Ensure required documentation in patient s EHR Schedule 2018 annual Medicare exams Review Financial Dashboards to address specific areas for improvement i.e., ER usage or ambulance cost, etc. Provide clinician and staff education Develop practice workflow to address quality measures Outcomes Our assessment showed 50 physicians reporting ACO measures, 29 reporting Medicaid MU, 40 reporting MIPS measures, and all reporting CGHN measures. For the two Tax ID Numbers in NHPG we are below the aggregate benchmark for spending in the ACO. Specifically, we are $9.8 million under in one and $5.3 million under in the other. ED visits and imaging show areas of opportunity. We continue to aggregate our clinical quality outcomes to establish a baseline and identify gaps to close. 7

Difference between Aggregate Goal Benchmark for practice and Total Spend (Actual Claims Spend less Caps plus Non-claim factor) ($9,832,658.69) Below Aggregate Benchmark Drug and alcohol claims are not included Actual Expense Compared to CMS ACO Calculation and National FFS NOTE: This section is not related to the TIN Summary Report above TIN* CMS ACO Calc* % Difference FFS* % Difference Hospital Discharges 330 342-3.71 333-0.92 Emergency Department Visits 1155 962 20.01 761 51.69 Computed Tomography (CT) Events 576 688-16.33 782-26.38 Magnetic Resonance Imaging (MRI) Events 145 210-31.17 296-51.11 Based on 2017 Q1 *per 1,000 beneficiaries Difference between Aggregate Goal Benchmark for practice and Total Spend (Actual Claims Spend less Caps plus Non-claim factor) ($5,268,285.03) Below Aggregate Benchmark Drug and alcohol claims are not included Actual Expense Compared to CMS ACO Calculation and National FFS NOTE: This section is not related to the TIN Summary Report above TIN* CMS ACO Calc* % Difference FFS* % Difference Hospital Discharges 374 342 9.34 333 12.52 Emergency Department Visits 696 962-27.68 761-8.59 Computed Tomography (CT) Events 885 688 28.60 782 13.15 Magnetic Resonance Imaging (MRI) Events 207 210-1.51 296-30.05 Based on 2017 Q1 *per 1,000 beneficiaries As we focus on financial expenses, the use of the Health Endeavors (HE) software will allow us to trend and track claims paid by CMS for patients attributed to our physician group. The software will allow us to identify both high-risk and rising-risk patients and the use of care coordinators working with the patients, clinicians, and practice staff will hopefully reduce overall cost of care. Lessons Learned and Ongoing Activities We cannot emphasize enough the need for ongoing education of clinicians and staff. These programs need to be tailored based on which lane the clinicians will be reporting under. Tapping into the knowledge that the staff has about the patients will help to create the most effective ways to gain patient compliance. Frequent communication and updates on performance will help sustain the positive performance. Use of technology to create performance dashboards is an example that can help with clinician engagement. 8

Project Team Paul Dale, M.D. Chris Hendry, M.D. Lori Cassidy Deb Mack, R.N. Suzanne Branch, R.N. Authors: Paul Dale, M.D., Medical Director, Navicent Health Physician Group Chris Hendry, M.D., Chief Medical Officer, Navicent Health 9