PulseThe

ofFall 2019

Congratulations to The Physician Alliance

practices earning patient centered medical

home designation!

Blue Cross Blue Shield of Michigan recently announced that 125 TPA primary care practices earned patient centered medical home (PCMH) designation. These practices show their commitment to providing the best care through open communication along the care continuum and focus on improving quality metrics. PCMH practices receive an additional 15–50 percent reimbursement to E&M billing from BCBSM.

For a complete list of TPA PCMH practices, visit www.thephysicianalliance.org, click on Incentive Programs, then Patient Centered Medical Home. <

2019 TPA numbers:

125

35493%

primary care practices designated patient-centered medical home by Blue Cross Blue Shield of Michigan

primary care physicians are in PCMH practices

of TPA PCPs are PCMH designated

Patient centered careaccomplishments

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Dear members,

The Physician Alliance physicians continue to lead the way in improving patient care in Michigan. Blue Cross Blue Shield of Michigan recently announced that 125 TPA primary care practices earned patient centered medical home recognition. Of the 99 percent of TPA practices nominated for PCMH, 96 percent received the designation. PCMH practices receive an additional value-based reimbursement – this year, 46 percent of our practices are receiving a 25 percent VBR (139 percent increase from 2018) and 49 percent are receiving 30-50 percent VBR (66 percent increase from 2018).

Our staff continues to work with your practices to improve patient care. Together, almost 30,000 gaps in care were reviewed with 14 percent closed through Sept. 30, 2019. These efforts work to improve patient care and outcomes.

Education also remains a top goal for our organization to ensure physicians and practice staff remain aware of new programs and updates within the healthcare industry. By the end of September, we hosted 17 programs with more than 480 attendees. Topics range from improving diagnostic coding and quality metrics to care management insights to practice management and social media tips. Many of our program topics come through feedback from members so please continue to share your thoughts in surveys and to our staff.

I thank you for your continued hard work and commitment to patient care.

In good health,

Michael R. MaddenPresident & CEO

President’s MESSAGE

Learning opportunities available to member practicesThe Physician Alliance offers a variety of education programs complimentary to member physicians and practice staff. Visit www.thephysicianalliance.org and click on Upcoming Events to view and register for upcoming programs focused on coding, mitigating risk management, improving personal and practice profitability and more.

Missed an event? No worries. Visit www.thephysicianalliance.org, click on Videos/Webinars under the Learning Institute to view videos from some past programs.

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Reducing unnecessary emergency department utilization Approximately 10–15 percent of emergency department

(ED) visits are for non-urgent or primary care treatable issues,

according to the Centers for Disease Control & Prevention.

Lack of access to care, such as a primary care practice not having weekend or evening on-call or availability, can be factors in over-use of the emergency department by patients. An increase in ED utilization may result in decrease in care coordination, including the PCP being unaware of a patient’s ED visit, lack of post-ED follow-up care, medication errors and unnecessary tests conducted.

Some tips to decrease unnecessary ED use include:

• Educate patients on appropriate use of ED

• Let patients know if your practice has after-hours care available.

• Alert patients if your physicians are on call after hours.

• Share information on preferred urgent care facilities. If a primary care office doesn’t offer after hours care, a relationship should be established with at least one local urgent care facility to assist with non-emergent after-hours care.

The Physician Alliance created an urgent care toolkit as part of a pilot project aimed at decreasing ED use for non-emergencies (see side article). The toolkit includes a poster educating patients on the benefits of contacting their primary care physician’s office or an urgent care for non-emergency health concerns. A handout can also be downloaded and customized with practice and preferred urgent care facility information to distribute to patients.

Primary care practices and ED providers share responsibility for patient care, yet often lack coordination of services. The Physician Alliance is participating in a Blue Cross Blue Shield of Michigan pilot project aimed at improving this coordination and decreasing ED use for non-emergencies.

The pilot seeks to provide more access to real-time admission, discharge and transfer (ADT) data, clinical data, and facilitation of communication between the primary care and ED setting. Ten practices are participating in the pilot. Primary care physicians will receive a text message when a patient appears in the emergency department at Ascension Providence Rochester Hospital and Henry Ford Macomb. The PCP and ED provider can then discuss treatment options and determine if the patient requires admission. <

PILOT PROJECT

Check out the urgent care materials:

Visit www.thephysicianalliance.org

Click Learning Institute, then Patient Education Materials

Select your materials and either download/print in your practice or complete the online order form for TPA to send materials to your practice.

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Are you codingCORRECTLY?Selecting the correct diagnosis code ensures efficient and accurate processing of medical claims and proper clinical coding for patients. Diagnosis codes support the medical necessity for care and tell the payor why the service was performed.

Ethica provides practices with hands on, face to face assistance to accurately capture diagnostic codes. Coding services include staff education and review of forms, processes and charts. The chart audit process is an in-depth review of patient charts as it pertains to diagnosis coding and selection. For each patient, there is review of the master problem list, recent visit notes, and EOB/charge master slip. Post-audit feedback helps identify potential additional diagnosis codes for hierarchical condition category and risk adjustment factor score purposes. Additional audit information includes:

• The master problem list is compared and reviewed for coding accuracy, and contradictions (i.e. acute diagnoses that are now chronic and/or stable, DM1 vs. DM2).

• The visit note is reviewed for diagnosis coding and associated diagnosis codes in the master problem list (i.e. Heart failure is listed in the master problem list and is mentioned in the visit note associated with HTN, but only benign HTN is coded and billed).

• The EOB/charge master slip is evaluated to compare diagnosis codes selected and billed in comparison to the diagnoses documented in the visit note (i.e. six diagnoses were documented and supported in the visit note but only four diagnoses were billed)

• The master problem list and visit note are reviewed for condition/status diagnoses that may need to be added to or deleted from bill (i.e. amputations, ostomy status, and dependence diagnoses).

*Ethica is a wholly-owned subsidiary of The Physician Alliance.

For more information, contact Ethica at info@ethicaholdings.com or (586) 498-3587. <

Curious about your practice’s performance?Don’t miss reviewing another important performance report! Access reports and information via The Physician Alliance’s secure physician portal. The portal allows physicians participating in TPA's Blue Cross Blue Shield of Michigan Physician Group Incentive Program (PGIP) to access valuable information more securely and at their convenience.

Types of available reports may include:*

• Patient centered medical home designation summary results

• Value-based reimbursement summary results

• Population performance reports (report cards)

• Clinical quality initiative (CLQI) reports

Links to education videos and materials are also available on the portal. Available reports depend on physician specialty, designation and more.

*Physicians may not receive the same type of reports.

How to access your reports:

Visit www.thephysicianalliance.org and click on ‘Physician Login’ at the top right of the page. Access is also available from TPA’s free Physician Education app now in the App Store or Google Play (search “The Physician Alliance Physician Education”).

All PGIP physicians have received (via email) a login and password. If you misplaced your login information, please contact your practice resource team member. If you do not know who your practice resource team member is, please email Teresa Pontello at teresa.pontello@thephysicianalliance.org with your practice name and request for PRT contact information. <

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Risk Adjustment and HCC Coding

CODING CO

RN

ER

In fee-for-service medicine, physician services are paid based on the fee associated with the procedure code(s) submitted to the payer. The diagnosis code supports the medical necessity for the service and tells the payer why the service was performed.

Insurance companies and the Centers for Medicare & Medicaid Services measure the acuity of a group of patients by demographic distribution and diagnosis coding submitted for payment. Some insurance contracts pay a higher rate at the end of a contract year to practices or systems that care for higher risk patients. As healthcare systems transition from fee-for-service to pay-for-performance, more groups will have adjustments made to their overall payments.

Hierarchical condition category (HCC) coding is a risk-adjustment model designed to estimate future health care costs for patients. HCC diagnosis codes reported on claims directly influence a patient’s risk score. HCC codes (as with any additional diagnoses) require MEAT documentation. All additional diagnoses require one element of MEAT documentation pertaining to: Monitoring, Evaluating, Assessing, and/or Treating.

TWO DIAGNOSTIC CODING GUIDELINES TO REMEMBER:

• “Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).”

• “Code all documented conditions that coexist at the time of the encounter/visit and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist.”

THERE ARE THREE TYPES OF DIAGNOSIS CODES:

1. Low level: Diagnosis codes that are not chronic conditions

2. Mid-level: Chronic conditions that do NOT carry weight towards HCC coding

3. High level : HCC codes

EXAMPLE: DERMATOLOGY PATIENT DOCUMENTATION WITH HCC CODES

Monitor: HgbA1c 5.5 (Diabetes), BMI 42.3 (BMI Z68.41) and (Morbid Obesity E66.01)

Evaluate: Patient follows with psychiatrist; compliant on oral medications; reports stable mood (Major Depression)

Assess: Neutropenia, due to inherent immune abnormalities - Lupus. Follow-up with HemOnc (Neutropenia) (Lupus)

Treat: Cleansed wound at the base of the stump with saline, applied skin barrier film to surrounding skin, applied Kaltostat to pressure ulcer base and covered wound with Duoderm (Pressure Ulcer)(Acquired Absence of limb)<

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CMO CORNER

By Karen Swanson, M.D.

Do you get a sinking sensation when you hear the

words “physician engagement” from your health

system leaders, payors, physician organizations,

medical societies, national organizations, community

program directors and everyone else that wants you

to do “one more thing?”

Physician engagement is a high-priority goal for most healthcare organizations because a stressed physician network can create retention issues, lower productivity, and reduce patient safety and quality measures. Many physicians feel they are too busy keeping up with the demands of patient care to even consider becoming an “engaged physician.”

Is it a good idea to ignore the tsunami of engagement invitations and simply care for patients? The answer is maybe. If you are a super subspecialist or if you are planning to retire or change career paths in the next five years or less, it may be better for your work-life balance to sit back and observe. However, you probably need to selectively engage if you plan to practice another 10 years.

CHALLENGES TO PHYSICIAN ENGAGEMENTThe Physician Stress and Burnout Report (2015) by Vital Work-life found the top three external factors causing stress in physicians are healthcare reform (47%), CMS policies (47%) and consolidation in the healthcare industry (30%). The top four work-related stressors included paperwork/administrative demand (42%), too many work hours (28%), personal compensation related issues (27%) and the EHR (25%). Personal life related issues also factor into the stress equation, including work-life balance concerns (56%), not enough time for exercise (46%) or leisure activities (45%). The survey also gauged physician satisfaction with healthcare organizations (health systems, payors, CMS etc.).

Physicians commented that administrators:

• lacked an understanding of the practice of medicine

• lacked respect for clinicians

• were overpaid

• lacked concern for patient safety due to finances driving decision making

• utilize productivity targets that create stress

• do not involve physicians in the decision-making process

• continue to increase the administrative burden placed on physicians

REASONS TO ENGAGEThere are physicians that want to be involved in the decision-making process but are unwilling or unable to carve out the time. It is unlikely administrators can get to the “real root” of daily problems faced by the physician workforce without input from physicians in the trenches. Physician administrators may attempt to bridge this gap but the voice of clinicians is imperative in many situations. Reasons to engage include:

• Many payor initiatives may improve your revenue stream. Consider participating in a workgroup/pilot/committee that discusses new opportunities. An example is creating a new incentive model unique for your specialty.

• Participating in pilots/programs may provide your practice with “free support” to improve office workflows and your practice’s utilization of tools, such as Welcentive or telehealth.

• Some pilots/programs provide a practice with free access to digital technology, such as, a telehealth platform, as well as assistance with effective office workflows and data input and management.

• Engagement in programs may help your practice learn to improve delivery of chronic care and receive reimbursement.

PHYSICIAN ENGAGEMENT:

When should you say “I DO?”

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The challenges facing physicians are almost universal and cause excessive stress and “burnout” in many providers.If practicing physicians refuse to participate in “fixing” the multiple broken parts, the healthcare environment is unlikely to become more physician friendly.

Please consider saying “I do” the next time you are asked to engage in a program or committee that may implement a change to improve your practice and practices of

your colleagues in this chaotic healthcare environment. If you are interested in exploring opportunities for engagement, please contact me at karen.swanson@thephysicianalliance.org or visit The Physician Alliance website (www.thephysicianalliance.org) for updates on HEDIS, PGIP, education opportunities related to coding, compliance and more. <

Sharon Ross, BSN, MSN, NP Carolyn Rada, RN, MSN

The Physician Alliance announces transition of population health role

It is with a mix of sadness and gratitude that The Physician Alliance announces the retirement of Sharon Ross, BSN, MSN, NP as executive vice president of population health management. Since TPA’s inception in 2011, Sharon played a vital role in the development and success of the organization.

Sharon served in several roles in patient care, including as a staff nurse and oncology clinical nurse specialist. After a 14-year career as a patient care provider, Sharon moved to ambulatory care by joining the St. John Medical Group in 1995 as a nurse practitioner. In this role, she assisted in clinical guideline development and project management for quality programs, helping set standards before Blue Cross Blue Shield of Michigan’s Physician Group Incentive Program launched in 2006. When The Physician Alliance formed in 2011, Sharon moved through several leadership roles and also served as dyad executive of Partners in Care, the managed care partnership TPA owns with Ascension St. John Providence.

“Sharon’s ability to understand population health and facilitate strong relationships and partnerships with physicians, colleagues, health partners and others has had a profound impact on the success of our organization,” said Michael Madden, president/CEO of The Physician Alliance. “Her commitment to improving patient care is demonstrated in her ideas, strategies and outcomes. Thousands of patients will never know the significant and positive influence her work has had on their lives.”

Sharon also helped build relationships among interdisciplinary teams to ensure positive outcomes. She admits that pushing new standards forward and getting guidelines accepted along the care continuum was “not easy and included some push back,” but setting standards for improved patient care was important. “Patients need support and to be able to look to their care team for guidance and advice,” said Sharon. “Working together as a team helps keep the focus on patient care and creates opportunities to innovate and implement new ideas and strategies.”

Upon Sharon’s retirement, Carolyn Rada, RN, MSN transitioned into the executive vice president of population health management position and dyad executive of Partners in Care. Carolyn joined TPA in 2015 and has led efforts relating to clinical applications, information technology and practice transformation. Carolyn’s past experiences include working with physician organizations across Michigan. She has been part of the implementation of the PCMH model since its inception in Michigan, as well as receiving recognition from the Centers for Disease Control (CDC) for successfully managing LEAN process improvement projects in primary care. Carolyn is a registered nurse with demonstrated success in leading member physicians to improved quality scores.

The Physician Alliance is fortunate to have Carolyn in this role to lead population health initiatives.<

continued from page 6

20952 12 Mile, Ste. 130St. Clair Shores, MI 48081

PRE SORTEDNON PROFIT MAIL

US POSTAGE

PAIDST. JOHN HEALTH

Dennis Ramus, MD Chairperson

Daniel Megler, MD Vice Chairperson

Trpko Dimovski, MD Treasurer

William Oppat, MD Secretary

Eugene Agnone, MD

Mazin Alsaqa, MD

Bruce Benderoff, DO

Paul Benson, MD

Dennis Bojrab, MD

Sidney Simonian, DO

Robert Takla, MD

Kevin Thompson, MD

Robert Zaid, DO

Michael R. Madden President & CEO

Robert Asmussen Senior Business Advisor

Heather Hall Vice President, Corporate Communications

Jennie Lekich Director, Clinical Informatics

Michele Nichols Executive Vice President, Administrative Services

Carolyn Rada, RN, MSN Executive Vice President, Population Health Management

Kathleen Rheaume, MD – Senior Physician Advisor

Oleg Savka Director, Systems and Informatics

Ashley Shreve Director, Practice Transformation

Karen Swanson, MD Chief Medical Officer

TPA Leadership Team TPA Board of Directors

www.thephysicianalliance.org

Help us keep connected with you!

To ensure TPA news and announcements reach you, please make certain any changes in contact information (name, email, address, phone) are shared with us. Send to thephysicianalliance@thephysicianalliance.org.

(586) 498-3555