COST. It s the name of the healthcare reform game. Jennifer Searfoss, ESQ, CPOM, CHCI, CMCS Founder, SCG Health

COST. It s the name of the healthcare reform game Jennifer Searfoss, ESQ, CPOM, CHCI, CMCS Founder, SCG Health

Today s Session Session Description Under the second year of the Medicare Merit-based Incentive Payment System (MIPS), physician practices are again held accountable for their attributed beneficiary cost. And health plans in Maryland are already evaluating network participation and referral patterns depending upon cost episodes. This session will provide a brief history of cost data from a health plan perspective, sources of data and how it is used in network participation, negotiation and referral decisions. Participants will gain an appreciation for what data is available and actionable campaigns that can and do reduce overall healthcare cost to the system. Understand how health plans attribute patients and their cost to your practice, primary care or specialty Identify pending cost models that will update the program for specialist care Crystalize the role of care management in the model and ways that practices can tap into existing workflows to improve care management Working with sample cases, utilize Medicare data to identify important data points, what they mean and options to improve a group s quality and cost scores 2018 Maryland MGMA. All rights reserved. - 2 -

U.S. National Healthcare Expenditure 2016: $3.3 trillion in 2016 or $10,348 per person As one economist said we don t have a debt problem in this country we have a healthcare problem. - Dan Munro, Forbes

Starting in a different place The story of disruption in the music industry

Global Music Report 2017. Data by the International Federation of the Phonographic Industry. Music industry evolution

Parable to healthcare Death of fee for service and drive-thru medicine No new money Volume producers will need to learn new tricks Alternatives to RVU compensation plans? Hay-day of compensation as we knew it peaked 3-5 years ago Compensation peaked 3+ years ago Physician compensation MUST take cut Lessons for the healthcare industry Customer service & bedside manner matter Appeal to the individual consumer Accessibility where & when the patient is IS the future model Establish and maintain a lifelong relationship Need for middle management will be strongly evaluated for ROI

72 million Boomers by 2030 1 Seniors age 85+ are predominately female 2 1:8 Americans 65+ will have Alzheimer s disease by 2030 1 They are familiar with health insurance. They like Medicare Advantage plans 3 Sources: (1) Alzheimer s Association. 2015 Alzheimer s Disease Facts and Figures. (2) Administration on Aging, A Profile of Older Americans: 2011. (3) HHS press release. Medicare Advantage premiums remain stable; enrollment at all-time high. Sept. 21, 2015. All rights reserved. 2013-18 SCG Health, LLC. To distribute or copy, please contact jen@scghealth.com.

More about the patients & costs Stratifying the High Need, High Cost Population Persons with Advanced Illness 28% of Medicare spending in last 6 months of life Persons with persistent high spending patterns Medicaid 60% in Top 10% in one year are Top 10% in the next Medicare 40% in Top 10% in one year are Top 10% in the next Patients with episodic needs 2018 Maryland MGMA. All rights reserved.

Institute for Healthcare Improvement Triple Aim Simultaneous pursuit of three aims Improving the experience of care Improving the health of populations Reducing per capita costs of healthcare

Inspiring dramatic cultural change Involvemen t of patients and families Design principles A clear vision The cultural change required to succeed with team-based medicine is considerable. The organizational culture needs to embrace standardization and reliability and to act every day on the belief that the center of the care is the patient. Teamwork Cultural change Triple Aim focus Source: Rank, B. Triple Aim 2.0: Designing Culture and Care to Support Better Health, Better Experience at a Lower Cost. Group Practice Journal, February 2013.

2018 Performance Goals for the Merit-based Incentive Payment System Avoid Penalty? Go for Bonus? 15 points 70+ points (Quality) (IA) (ACI - min) (Cost) Cost 10% Improvement Activities 15% Advancing Care Information 25% Quality, 50% 42.5 + 15 + 12.5 +? = 70.0

Cost category measures What is already been done Cost based Medicare spending per beneficiary Total per capita cost Episode based Cataract/lens surgery Mastectomy Aortic/mitral valve surgery Coronary artery bypass graft Repair of hip/ femur fracture or dislocation Cholecystectomy and common duct exploration Colonoscopy and biopsy Transurethral resection of the prostate for benign prostatic hyperplasia Hip replacement or repair Knee arthroplasty All 10 have been included in 2014-2016 Supplemental QRURs 2018 Maryland MGMA. All rights reserved. 12

What s Out There Hospital Partners Hospital Compare (for every other state but Maryland) Maryland Health Care Commission WearTheCost.org Episodic Care Fair Health Health Care Cost Institute Quality and Resource Use Report 2018 Maryland MGMA. All rights reserved. - 13 -

Hospital Compare Medicare.gov Review hospitals on Quality & Cost https://www.medicare.gov/hospitalcompare/compare.html NO COST DATA DUE TO MEDICARE WAIVER - 14 -

UnitedHealthcare Premium Designation Program Version 11 live since September 2018; Specialty Specific Episode Evaluation Allergy: Includes Allergy, Allergy and Immunology Cardiology: Includes Cardiac Diagnostic, Cardiology, Cardiovascular Disease, Clinical Cardiac Electrophysiology, and Interventional Cardiology Ear, Nose and Throat (ENT): Includes Laryngology, Otolaryngology, Otology, Pediatric Otolaryngology, Rhinology, Surgery Head and Neck Endocrinology: Includes Diabetes, Endocrinology and Metabolism Family Medicine: Includes Family Practice, General Practice, and Preventive Medicines and Metabolism Gastroenterology: Includes Digestive Diseases, Endoscopy, Gastroenterology, and Hepatology-Liver Disease General Surgery: Includes Colon and Rectal Surgery, Hand Surgery, Proctology, Surgery, and Surgery Abdominal Internal Medicine: Includes Internal Medicine Nephrology: Includes Nephrology Neurology: Includes Neurology, Neurology and Psychiatry, and Neuromuscular Disease Neurosurgery, Orthopedics and Spine (NOS): Includes Back and Spine Surgery, Hand Surgery, Knee Surgery, Neurological Surgery, Orthopedic Surgery, Shoulder Surgery, and Sports Medicine Obstetrics and Gynecology (ObGyn): Includes Gynecology, Obstetrics, Obstetrics and Gynecology Pediatrics: Includes Adolescent Medicine, Pediatric Adolescent, and Pediatrics Pulmonology: Includes Pulmonology Medicine Rheumatology: Includes Rheumatology Urology: Includes Urology 2018 Maryland MGMA. All rights reserved. - 21 -

Aetna Axcel Performance Network Aexcel specialty areas and criteria Cardiology Cardiothoracic surgery Gastroenterology General surgery Neurology Neurosurgery Obstetrics and gynecology Orthopedics Otolaryngology/ENT Plastic surgery Urology Vascular surgery An attestation to the 2015/2016 Meaningful Use 1 or 2 guidelines An attestation to participation in PQRS Participation in a value-based contract with us - Quality measures with incentives to improve or reach targets PROGRAM OVERVIEW Number and types of services performed How often patients return to the hospital Rates of health complications during hospital stays Use of technology Cost of services 2018 Maryland MGMA. All rights reserved. - 23 -

Sign up for EDIM. Get access to the PV-PQRS. https://portal.cms.gov Security Official or Group Representative can access the QRUR and the PQRS Feedback report.

How do I learn more about my group? Download your Quality and Resource Use Report (QRUR) from https://portal.cms.gov CMS.gov > Medicare > Medicare FFS Physician Feedback Program/Value-Based Payment Modifier > How to Obtain a QRUR https://www.cms.gov/medicare/ Medicare-Fee-for-Service-Payment/ PhysicianFeedbackProgram/Downloads/ 2015-QRUR-Guide.pdf

Access tips Use SMS as your MFA confirmation. HIPAA attestation: - If you are a provider: you are a covered entity. - If you are a billing company: you are a business associate.

What s in the report and on the site Annual QRUR The report itself: Table 1 Your attributed doctors. Double-check because PECOS can be wrong. Table 2 MOST IMPORTANT FILE: patients attributed to your practice. Tables 3-5 Medicare spending data. Table 7 PQRS performance data by clinician.

Intro to the QRUR 2013-2016 reports available - Different formats - Supplemental tables have the data you want

Patient attribution Primary care services E/M by clinician If no clinician in PCP specialty, attributed to highest E/M clinician PCP specialties: Family medicine, internal medicine, gerontology NPPs are considered PCP specialties

QRUR Quality for Hospital Gaps Medicare Quality Resource and Utilization Report (QRUR) Lower performance rates for these measures indicate better performance.

QRUR report: a road map

Drill down: Table 4

Drill down: Table 5

Care coordination

Reminder - Cost category measures What is already been done Cost based Medicare spending per beneficiary Total per capita cost Episode based Cataract/lens surgery Mastectomy Aortic/mitral valve surgery Coronary artery bypass graft Repair of hip/ femur fracture or dislocation Cholecystectomy and common duct exploration Colonoscopy and biopsy Transurethral resection of the prostate for benign prostatic hyperplasia Hip replacement or repair Knee arthroplasty All 10 have been included in 2014-2016 Supplemental QRURs 2018 Maryland MGMA. All rights reserved. 35

Developing an Action Plan Where you can start Building Blocks of Care Management Identifying the Target Population Patient & Family Caregiver Engagement Team-Based Care Care Coordination and Infrastructure Patient- Centered Care Health Assessments and Screening Tools Health and Disease Management Programs Transitional Care Quality Measurement and Evaluation Framework 2018 Maryland MGMA. All rights reserved. - 36 -

Tell us about your familiarity with value-based payment terms! http://www.scghealth.com/mips-questionnaire You ll get some summer swag for it!

Questions?