Quality Soup:The Ingredients for Success in Managing
Multiple Quality Programs
Holly Arends, CHSPProgram Manager
Great Plains Quality Innovation [email protected]
www.greatplainsqin.org
11SOW QIN-QIO Map
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Objectives
Managing multiple quality initiatives
• Explain the Requirements
• Provide tips on How to be successful
Taking responsibility for a population
• Strategies to develop a plan
Utensils/Tools to use
• Guidance on resources and how to use them
What are the Drivers?
National Quality Strategy
CMS Quality Strategy
Physician Quality
Programs Strategic Vision
CMS Quality Strategy
AIMS PRIORITIES
1. Better Care
2. Healthier People, Healthier Communities
3. Smarter Spending
1. Make Care Safer by Reducing Harm Caused in the Delivery of Care
2. Strengthen Person and Family Engagement as Partners in Their Care
3. Promote Effective Communication and Coordination of Care
4. Promote Effective Prevention and Treatment of Chronic Disease
5. Work with Communities to Promote Best Practices of Healthy Living
6. Make Care Affordable
Future State Vision
Vision Statement Indicator of Success
CMS quality reporting programs are guided by input from patients, caregivers and healthcare professionals
• Patients, caregivers, and healthcare professionals are key contributors and active participants in measure development, reporting, and quality improvement efforts
Feedback and data drives rapid cycle quality improvement
• Technology enables healthcare professionals to monitor quality measure performance on an ongoing basis at the point of care.
• Quality measurement results drive the planning of quality improvement initiatives.
Public reporting provides meaningful, transparent, and actionable information
• Meaningful, actionable performance data are accessible to and used by variety of audiences (e.g., patients, caregivers, and healthcare professionals).
• Patients and caregivers have timely access to performance information tailored to their needs.
Quality reporting programs rely on an aligned measure portfolio
• An aligned portfolio of health IT-enable quality measures supports all CMS public reporting, quality improvement, and value-based purchasing programs.
• A stable and robust infrastructure exists for developing and implementing health IT-enabled quality measures.
Quality reporting and value-basedpurchasing program policies are aligned
• Principles, policies and processes for all CMS quality reporting and value-based purchasing programs are coordinated.
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APM Framework
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Medicare Access and CHIP Reauthorization Act (MACRA)
Ends the Sustainable Growth Rate (SGR) formula for determining Medicare payments for health care providers’ services.
Make a new framework for rewarding health care providers for giving better care not more just more care.
Combines our existing quality reporting programs into one new system.
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MACRA Challenges to Providers
Attribution of patients
Controlling spending
Population Management
Risk Adjustments
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Managing It All
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CMS Quality Programs
Physician Quality Reporting System (PQRS)
EHR Incentive Program (MU)
Value Modifier (VM or VBM)
Transforming Clinic Practice Initiative(TCPI)
Comprehensive Primary Care Initiative (CPCI)
…..
Actually, 30 different programs that are using quality measures
Future: Aligning Quality Programs
Merit-Based Incentive Payment System (MIPS)
PQRS
Value Modifier
EHR Incentive Program
(MU)
MACRA NPRM Released TODAY!!!!!
Merit Based Incentive Payment System (MIPS) Proposed Framework
• Quality
• Advancing Care Information
• Clinical Practice Improvement Activities
• Cost
January 2017 performance year
2019 payment year
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Proposed MIPS
All eligible clinicians will report through MIPS Medicare Part B clinicians
• Physicians• Physician Assistants• Nurse Practitioners• Clinical Nurse Specialists• Certified Nurse Anesthetists
Exempted• Newly enrolled in Medicare• Less than or equal to $10K in Medicare charges and less than or equal to 100
Medicare patients; OR• Are significantly participating in an Advanced Alternative Payment Model (APM)
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Proposed MIPS
Quality
• Replaces PQRS and Quality component of VBM
• 50% of score
• 6 measures versus 9- choose one cross cutting measure and one outcome
Population Health Measures Individual and Grps 2-9 – 2 measures based on claims data
Groups 10 or more- 3 measures based on claims data
• 200 measures with 80% specialty focused
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Proposed MIPS
Advancing Care Information
• Replaces Medicare EHR Incentive Program (MU)
• 25% of score (year 1)
Base Score- 6 MU objectives/measures
Performance Score- 3 objectives/measures
• Focus on interoperability and information exchange
• Not all or nothing reporting as was seen in MU
• Customizable selections
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Proposed MIPS
Clinical Practice Improvement• Rewards
Care Coordination Patient Safety Beneficiary Engagement
• 15% of score (year 1)• Select activities from 90 options
Expanded Practice Access Population Management Care Coordination Beneficiary Engagement Patient Safety and Practice Assessment Participation in an APM, including a medical home model Achieving Health Equity Emergency Preparedness and Response Integrated Behavioral and Mental Health
Credit for APM and PCMH activity
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Proposed MIPS
Cost
• Based on Medicare claims- no reporting requirement
• 10% of score (year 1)
• 40 episode specific measures
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Proposed MIPS
Advanced Alternative Payment Models These include:
• Comprehensive ESRD Care Model (Large Dialysis Organization arrangement)
• Comprehensive Primary Care Plus (CPC+) • Medicare Shared Savings Program – Track 2 • Medicare Shared Savings Program – Track 3 • Next Generation ACO Model • Oncology Care Model Two-Sided Risk Arrangement (available in 2018)
List update annually Non Medicare models considered in 2019
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Proposed MIPS
Budget neutral
• Negative payment adjustments no more than 4%
4%, 5%, 7%, 9%- increase over time
• Positive payment adjustment no more than 4% -increase over time
$500 million for exceptional performance (exception to budget neutrality) up to 10% additional, first 5 years
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Proposed MIPS
Bear Certain Amount of Financial Risk• If CMS would withhold payments, reduce rates or require repayment
if actual expenditures exceeded expenditures Total risk ( max amt. of losses possible under Adv APM) must be at least 4% of
APM spending target
Marginal risk (the % of spending above the APM benchmark (or target price for bundles) for which the Adv APM Entity is responsible (i.e. sharing rate) must be at least 30%
Minimum loss rate (amt. by which spending can exceed the APM benchmark (or bundle target price) before the Adv APM Entity has responsibility for losses) must be no greater than 4%
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Requirements for Incentive Payments for Significant Participation in Advanced APMs (Clinicians must meet payment or patient requirements)
Payment Year 2019 2020 2021 2022 2023 2024 and later
Percentage of Payments through an Advanced APM
25% 25% 50% 50% 75% 75%
Percentage of Patients through an Advanced APM
20% 20% 35% 35% 50% 50%
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Managing Multiple Quality Initiatives
Aggregate data from disparate sources
Risk Stratification- Identify High Risk Patient Populations
Filter and view through the measure’s lens
Provide feedback to clinicians and staff
Real time administrative and clinical tracking
Simplified reporting of quality data
Transparency to Consumers
Focus on Outcome Measures, when possible
Future: Core Quality Measures Collaborative
The core measures are in the following seven sets:• Accountable Care Organizations (ACOs), Patient Centered Medical
Homes (PCMH), and Primary Care
• Cardiology
• Gastroenterology
• HIV and Hepatitis C
• Medical Oncology
• Obstetrics and Gynecology
• Orthopedics
Quality Program Requirements Impact on Your Office
Data collection Data aggregation Workflow assessment Quality Improvement Data reporting Data feedback to providers Resources Time Financial Reputational
First Things First….
Commitment and Involvement
• Leadership
• Clinician
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What are Your Drivers? What is Your Vision?
Mission
Vision
Values
Stakeholders
Measures and Indicators of Success
Build your business case for improvement activities!
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Vision Examples
Imagine
• Fully Engaged Consumer and Patients
• Transparency of Quality Data
• Feedback reports support rapid cycle improvement
• Full view of patient –all data sources
• Graduated participation in Alternative Payment Model
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Future State Vision
Vision Statement Indicator of Success
CMS quality reporting programs are guided by input from patients, caregivers and healthcare professionals
• Patients, caregivers, and healthcare professionals are key contributors and active participants in measure development, reporting, and quality improvement efforts
Feedback and data drives rapid cycle quality improvement
• Technology enables healthcare professionals to monitor quality measure performance on an ongoing basis at the point of care.
• Quality measurement results drive the planning of quality improvement initiatives.
Public reporting provides meaningful, transparent, and actionable information
• Meaningful, actionable performance data are accessible to and used by variety of audiences (e.g., patients, caregivers, and healthcare professionals).
• Patients and caregivers have timely access to performance information tailored to their needs.
Quality reporting programs rely on an aligned measure portfolio
• An aligned portfolio of health IT-enable quality measures supports all CMS public reporting, quality improvement, and value-based purchasing programs.
• A stable and robust infrastructure exists for developing and implementing health IT-enabled quality measures.
Quality reporting and value-basedpurchasing program policies are aligned
• Principles, policies and processes for all CMS quality reporting and value-based purchasing programs are coordinated.
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Integrate and Aggregate Data
Complex data
Data Silos
Unstructured Data
Asset Inventory• Data
• Systems
• Sources
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Risk Auditing
Where is highest risk and impact• Financial
• Clinical
Use Technology to it’s fullest potential
Claims and Clinical data- Whole picture!!!• Quantitative
Claims data
• Qualitative Patient and referral data
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Identify Your Patients
Table 1 2012 Mean Annual Expenditures per Individual by Spending Group
Spender Tier Spending per Person Percent of Total Spending
Top 1% $97,859 21.8%
Top 5% $43,038 49.5%
Top 10% $28,452 65.2%
Top 30% $12,951 89.6%
Source: NIHC Concentration of Health Care Spending (Washington, DC: National Institute for Health Care Management Foundation, July 2012), http://www.nihcm.org/pdf/DataBrief3%20Final.pdf
Risk Stratification
Patient Categories
• Patients with Advanced Illness
• Patients with Persistent High Spending
• Patients with Episodic High Spending
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Patients With Advanced Illness- Strategies
Patients with Advanced Illness
• Advance Directives, Informed Choice, Advanced Care Plan
• Hospice
• Palliative Care
• Community End of Life versus Hospital
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Patients With Advanced Illness- Strategies
What are your utilization rates of the interventions?
What are your hospital admission and readmission rates for this population?
Mortality rates and location of death in your counties served? Patients in rural and frontier area usually have shorter lifespans
Are you tracking NQF 326/PQRS 47?
Readmission Rates Among Discharge Locations20140401-20150301 GPQIN used Medicare claims data provided by the National Coordinating Center (NCC)
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14.5%
21.9%
18.9%20.1%
15.1%
14.1% 14.2%15.1%
1.6% 1.0% 1.5% 2.0%
16.9% 17.1%
15.1%
16.8%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Rapid City Sioux Empire South Dakota Great Plains QIN
Home Health
Home
Hospice
SNF
Advance Care Plan
50.41%
60.28% 57.82%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
SD Mean National Mean CMS Benchmark
PQRS 47 NQF 326 Advance Care Plan- Performance Rate PQRS 2014
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Filter Through Measure Len
eCQMs
Dashboard
Audit denominator and numerator
Vendor Accountability
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Feedback Reports
Feedback
• Individual performance
• Aggregate (TIN level) performance
• Progress towards goals
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Administrative and Clinical Tracking
Leadership Responsibility
Progress
Regular Monitoring
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Simplified Reporting
Identify Quality Program Participation
Identify data reporting requirements
Plan for submission
Seek assistance
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Transparency
CMS Physician Compare
How will you be transparent to your consumers and patients?
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Tools to Use
Quality Resource and Utilization Report
• Mid Year
• Annual
• Supplemental
Two essential components
• Quality
• Cost
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Performance on Cost:Cost Composite Structure
Summarized at TIN level• Summarizes cost performance
Calculates domain scores for which your TIN had at least 20 eligible cases for at least one cost measure.
2 Value Modifier Cost Domains, 6 Measures• Domain 1-Per Capita Costs for All Attributed Beneficiaries
Per Capita Costs for All Attributed Beneficiaries Medicare Spending per Beneficiary
• Domain 2-Per Capita Costs for Beneficiaries with Specified Conditions Diabetes COPD CAD Heart Failure
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Cost Composite Structure
Based on claims data
• Part A & B, Part D not included
Exhibits 9-11 on QRUR, Exhibits 5-10 on Supplementary
Uses tiering to place the TIN in a Cost Tier Designation -Average, High, Low
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Claims Data
Domain/Measure
Part A and B claims submitted by ALL
providers for Medicare Beneficiaries Attributed
to a TIN
Per episode costs based on Part A and B expenditures
surrounding specified inpatient hospital stay (3 days
prior through 30 days post discharge)
Supplementary Exhibit for full details
Domain 1/ Per Capita Costs for All Attributed Beneficiaries
X Exhibit 5
Domain 1/ Medicare Spending per Beneficiary(MSPB)
X Exhibit 6
Domain 2/ Diabetes X Exhibit 7
Domain 2/ COPD X Exhibit 8
Domain 2/ CAD X Exhibit 9
Domain 2/ Heart Failure X Exhibit 10
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Services Included
E&M Services billed by Eligible Professionals (EPs) Major Procedures billed by EPs Ambulatory/Minor Procedures billed by EPs Ancillary Services Hospital Inpatient Services Emergency Services not included in Hospital Admission Post-Acute Services Hospice All Other Services
*Sub Category – ‘Other Facility-Billed Expenses…’ are those that are billed at facility level versus EP, for example FQHC or RHC
*Review Supplementary Exhibit 5 for full details of applicable Cost Measures, excluding MSPB, which is found in Supplementary Exhibit 6
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How Can Our Costs Be Accurately Compared With Other TINs?
Each measure is
• Payment-standardized
• Risk-adjusted
• Specialty-adjusted
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Payment Standardized
Make comparisons of service use within or across geographic areas.
Maintains differences in choice of care setting, types of providers, and multiple services within encounters
Utilizes a conversion factor x payment modifiers to standardize
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Risk Adjustment
Account for differences in beneficiary level risk-factors
More accurate comparison across settings with varying beneficiary case complexities
Compares TIN actual costs to CMS determined beneficiary expected costs, uses CMS-HCC model
Per Capita Cost Measures – All TIN Attributed beneficiaries Part A&B costs / # of TIN Attributed Beneficiaries
Medicare Spending Per Beneficiary Measure – adjusted by beneficiary age and severity of illness (MS DRG)
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Specialty Adjustment
Different than risk adjustment
Performed at the TIN level
Compares TIN’s risk adjusted costs with TINs of the same specialty
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Exhibit 9: Your TIN’s Performance in 2015, by Cost Domain
Lower score indicates better performance
Higher score indicates opportunity for improvement• See Exhibit 10 for specific measures
Three columns in table• Cost Domain
• Number of Cost Measures included in Composite Score
• Standardized Performance Score (Cost Tier Designation)
Domain Scores represent equally-weighted average, standardized scores in the domain
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Exhibit 9
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Measures, with 20 eligible cases, included
Your TINs Cost Tier Designation. ‘Average’ is shown if the TINs score falls within one Standard Deviation from the mean
Exhibit 10 – Per Capita or Per Episode Costs For Your TIN’s Attributed Medicare Beneficiaries
Summarized at TIN level
Payment-Standardized, risk-adjusted, and specialty adjusted per capita or per episode costs for each measure
Only measures with 20 or more eligible cases or episodes are included
Use this exhibit and it’s supplementary exhibits to identify specific areas of opportunity
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Exhibit 10 – Per Capita or Per Episode Costs For Your TIN’s Attributed Medicare Beneficiaries
For per capita costs detail use Supplementary exhibits 2B and 5 to identify types of costs incurred for beneficiaries
For MSPB costs detail use Supplementary exhibit 4 and 6 to identify to improve care
Identifying patterns of use and costs are the main goal of this and the supplementary exhibits
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Exhibit 10
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National Benchmark
Exhibit 11:Differences between Your TIN Per Capita Costs and Mean Per Capita Costs
Displays Amount By Which Your TIN’s Costs were higher or lower
• All Attributed Beneficiaries
• Beneficiaries with Diabetes
• Beneficiaries with COPD
• Beneficiaries with CAD
• Beneficiaries with Heart Failure
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Exhibit 12: Differences Between Your TIN’s Per Episode and Mean Per Episode Costs
Displays the Amount by which your TIN’s Costs were Higher or Lower than the Benchmark
• MSPB
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How Can I Use the Cost Information?
Develop Strategies• Identify complex patients
• Develop condition specific practice standards
• Identify opportunities to reduce costs Procedures
Condition specific
Complex Chronic Care
Follow up Care
• Identify Shared Savings/Shared Risk partners
• Identify partners in care coordination
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Management
Identify patient populations
Segment into High risk or high spender categories• Clinically
• Financially
Audit for accuracy of segmentation
Stratification• Quantitative
Claims based algorithms
• Qualitative Patient and/or referral algorithms
Risks List Becomes Solutions List
Break down your Risks
• 5 WHYS
What is the abnormal occurrence/condition?• 1. Why is this happening? Do you need to confirm? Method
• 2. Why is this happening?
• Repeat 5 times
• ROOT CAUSE
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The Right Tools
Decision Trees
Quality and Resource Use report (QRUR)
Strategic Vision Plan
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Determine Cost
Participate or Not Participate What will it Cost You?
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2016 Medicare Quality Program
2018 Payment Adjustments
PQRS -2%
EHR Incentive Program (MU)
-3%
Value Modifier -4%x (adjustment factor determine by CMS annually)
Let’s run the numbers
Example of 2016 Payment Adjustment: applicable to 10+ EPs, group,
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Low Quality Average Quality
High Quality
LowCost
0.0% +1x%= +15.92%+2x%= +31.84%
+2x% = +31.84%+3x% = +47.74%
Average Cost
0.0% / -1.0% 0.0% +1x%= +15.92%+2x%= +31.84%
High Cost
0.0% / -2.0% 0.0% / -1.0% 0.0%
Low Quality Average Quality
High Quality
Low Cost $0 +$47,760+$95,820
+$95,820+$143,220
Average Cost
-$3000 $0 +$47,760+$95,820
High Cost -$6000 -$3000 $0
Wrap-Up
Leadership
Aggregating Data
Stratifying Patients
Ongoing Tracking and Monitoring
Feedback
Rapid Cycle Improvements
Knowledge Sharing
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HCP LAN APM Framework
HCP LAN Patient Attribution
HCP LAN Financial Benchmarking
Health Care Payment Learning and Action Network
• https://hcp-lan.org/
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Contact Information
Holly Arends, CHSP
Program Manager
Great Plains Quality Innovation Network
www.greatplainsqin.org
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