playing to win in mssp€¦ · performance standard requires acos to continue to completely and...

Playing to Win in MSSPFEBRUARY 16, 2016

HEALTH ENDEAVORS 2016 1-888-862-0366 1

CMS Portals – Who is responsible?MFT, HPMS, ACO PORTLET, QNET, EIDM, CAHPS, PUBLIC REPORTING


2/16/2016 COPYRIGHT HEALTH ENDEAVORS 2015

EUA – Password Reset, Annual Certification

https://eua.cms.gov/identityiq/login.jsf

MFT – CCLF, Assignment & Aggregate Reports

https://eftp2.cms.hhs.gov:11443/cfcc/login/login.jsp

HPMS - Participant (TIN, CCN, NPI) Management, Application

https://hpms.cms.gov/app/login.aspx

ACO Portlet - CMS Webinar Recordings, File Retrieval

https://portal.cms.gov/wps/portal/unauthportal/home/

CMS UserID – EUA, MFT, HPMS, ACO Portlet

For help with Form CMS-20037 and CMS User ID: [email protected] or (800) 220-2028

EIDM/QNET – PQRS/GPRO (September, 2016) (used to be IACS/QNET)


CAHPS (Patient Surveys) (August, 2016)

http://acocahps.cms.gov/Content/ApprovedVendor.aspx

Public Reporting Guidance (January, 2016)

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-Public-Reporting-Guidance.pdf

https://eua.cms.gov/identityiq/login.jsf

https://eftp2.cms.hhs.gov:11443/cfcc/login/login.jsp

https://hpms.cms.gov/app/login.aspx


mailto:[email protected]

http://acocahps.cms.gov/Content/ApprovedVendor.aspx

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-Public-Reporting-Guidance.pdf

Primary Care Only

Primary Care + Specialists

Primary Care + Hospital

Primary Care + Specialists + Hospital +Home Health

Hospital Based

Patient History & Demographics

Geography

Management/Governing Body

Organizational Structure

Single EMR

Multiple EMRs

Every ACO Is Different


Best Practices + Unique Decisions

One Strategy Does NOT Fit All

=Your ACO Strategy



Quality Program

GPRO/PQRS

Care Coordination & Case Management

Data Analysis

3 Components of Population Health Management


Quality Improvement

Program

GPRO/PQRS

Control

Out-of-Network Spend

Achieve Shared Savings

Targeted Spend Reduction

Missed Revenue

Opportunities

Physician Engagement

MSSP ACO Goals

Triple Aim

Better care for patients Better health for our communities Lower Costs through improvements for our health care

system

CCM 99490 Annual Wellness Visit After Hours Program/ER Alternatives Specialist Outreach Clinics (Access to Care) Out-of-Network Spend Preventive Care Services (Gaps in Care)

Stop the Admit Visit Stop the ER Visit Preventive Care Services (Gaps in Care) Patient Case Management & Care

Coordination Patient Follow-up & Education Utilization Trends

MRI, CT, Home Health

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How does Shared Savings Work?

COPYRIGHT HEALTH ENDEAVORS 2015

2 Primary Requirements to Earn Shared Savings:

Successful Quality Measures Reporting and Benchmark Performance (GPRO)https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-QM-Benchmarks-2016.pdf

Reduce Spending at least 5% (or a % greater than the assigned Minimum Shared Savings% Rate) below the Historical Benchmark

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/MSSP-QM-Benchmarks-2016.pdf

2/16/2016

How does our ACO know if we are on track to achieve Shared Savings?

COPYRIGHT HEALTH ENDEAVORS 2015

2 Primary Data Analytics to determine your ACO Status:

Year-round GPRO/PQRS Data Collection & Performance Scoring – NPI Level

Actual Benchmark vs. Goal Benchmark (based on Historical Spend) – NPI Level

Quality Accountability Year-round GPRO/PQRS Data Collection & Performance Scoring – NPI Level



Quality of Care

In order to be eligible to share in any savings generated:

In the first performance year of their first agreement period, ACOs satisfy the quality performance standard when theycompletely and accurately report on all quality measures (pay-for-reporting). Complete and accurate reporting in the ACO’sfirst performance year qualifies the ACO for the maximum sharing rate.

In subsequent performance years, quality performance benchmarks are phased-in for performance measures and the qualityperformance standard requires ACOs to continue to completely and accurately report quality data on all measures but theACO’s final sharing rate is determined based on its performance compared to national benchmarks. In addition, ACO’s mustmeet minimum attainment (30th percentile benchmark) on at least 1 pay-for-performance measure in each domain inorder to be eligible to share in savings. Both attainment and improvement in performance are taken into account whencalculating the final sharing rate for ACOs in their second and subsequent performance years.

ACOs are rewarded up to four additional points in each domain, if they demonstrate quality improvement. In this way, theACO becomes increasingly responsible for quality performance and improvement during the first agreement period. When anACO renews its participation in the program for a second or subsequent agreement period, the quality performance of ACOsis assessed in the same manner as ACOs in the third performance year of their first agreement period.


Performance scoring

Financial Accountability Actual Benchmark vs. Goal Benchmark (based on Historical Spend) – NPI

Level


Data Analysis Action Items – Phase IAssign every patient to an individual NPI

◦ Apply algorithms utilizing claims data and patient assign data

◦ Primary Care vs. Specialist

◦ Plurality of Visits

◦ TIN visits and associated NPI visits

HCC Risk Score every patient

◦ Start HCC comparison 2015 vs. 2016

Identify Patient Disease & Wellness Gaps in Care

◦ Provider Patient Profile

◦ Care Coordination & Case Management


Data Analysis Action Items – Phase IActual Benchmark vs. Goal Benchmark (based on Historical Spend) – NPI Level

◦ Establish NPI goal benchmark based on historical spend

Aggregate Expenditure & Utilization

◦ Map CCLF individual patient data back to CMS Aggregate Report

◦ Compare to National FFS Average and MSSP ACOs

Patients Trending to be Costly

◦ Top 30% HCC Score

◦ ED visit and Hospitalization in last 12 months

◦ 2 or more chronic conditions


Get your arms around Patient Population

Use your Claims Data for GPRO!

Who are they?

Who is treating them?

Where are they?

Who is sharing data?


What is HCC Score? Who is Potentially Costly?

What are their disease & wellness gaps in

care?


Assign every patient to an individual NPI

Apply algorithms utilizing claims data and patient assign data

Primary Care vs. Specialist

Plurality of Visits

TIN visits and associated NPI visits


HCC Risk Score every patient

Start HCC comparison 2015 vs.

2016


Identify Patient Disease & Wellness Gaps in Care

Provider Patient Profile

Care Coordination & Case Management


Actual Benchmark vs. Goal Benchmark (based on Historical Spend) – NPI Level

Establish NPI goal benchmark based on historical spend


Aggregate Expenditure & Utilization

Map CCLF individual patient data back to CMS Aggregate Report

Compare to National FFS Average and MSSP ACOs


Patients Trending to be Costly

Top 30% HCC Score

ED visit and Hospitalization in last 12 months

2 or more chronic conditions

Data Analysis Action Items – Phase IISpecialist Spend

Out-of-Network Spend

Admissions & Readmissions Spend


GPRO/PQRS Readiness Action ItemsAssign every patient to individual NPI◦ Apply algorithms utilizing claims data and patient assign data

◦ Primary Care vs. Specialist

◦ Plurality of Visits

◦ TIN visits and associated NPI visits

EMR Gap Analysis◦ Incomplete, Non-performing responses

◦ Quality Measure Central Repository [EMR, CCLF, Manual Key, Lab]

Provider Education on 2016 PQRS/GPRO◦ QM 2016 Measure Requirements

◦ QM 2016 Audit Document

Assess Performance Year Round◦ Email Performance and Progress Scorecards to Providers



Assign every patient to an individual NPI

Apply algorithms utilizing claims data and patient assign data

Primary Care vs. Specialist

Plurality of Visits

TIN visits and associated NPI visits

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Quality Measures 2014 LEGEND – Bottom of Screen


Filters:Patient Claims = Claims Data Available for this patient to assist in answering the Quality Measure


Claims Data will display above the applicable question/module

Click on the Pink Bar to Expand


Claims Summary for this Measure will display including CPT and ICD9 codes


Click on red plus button to view NPI information for Rendering Provider and Facility


EMR & Chart Gap Analysis

Not on Chart(EMR)

Can’t Report


Work Flows/EMR Gap Analysis--

Who/What/Where/When/How

--Quality Measure conducted and documented on a

consistent basis? [What?]

--Responsibility for conducting and documenting the

Quality Measure assigned to staff or providers? [Who?]

--Quality Measure conducted and documented in the

hospital or physician setting [Where?]

--Quality Measure documented in the EMR, paper chart

or other method? [How?]

--Staff aware of the timeframes for capturing each

Quality Measure? [When?]


QM 2016 Import Chart

--CCLF Imports

--EMR Report Imports

--Abstracted by Facility

--Abstracted by Health Endeavors

--EMR CCDA Imports

--Abstracted by Facility

--Abstracted by Health Endeavors

--Manual Key

--Preferences/Defaults

--Carry-Over Pneumonia Module from 2014

--Lab Imports (Hemoglobin A1c)

--Lab Displays

By Patient

By Facility (TIN)

By NPI

ACO (aggregate)

Scorecards – Performance & ProgressQuality & Financial


GPRO/PQRS Data Abstraction & Integration to Central Repository


Facility abstract data from EMR into Electronic

Report or CCDA

Facility remit EMR Data (Electronic

Report or CCDA) for Import

using Submit a Request

Health Endeavors

import EMR Data into

QM 2016 GPRO Tool

Facility abstract EMR Report or CCDA Data to import into

the Health Endeavors QM 2016 Reporting Tool

to complete the GPRO Measures


Health Endeavors

import CCLF data

(monthly) into QM 2016

Imported CCLF data completes QM 2016

Based on the CPT and ICD9

Codes

Health Endeavors imports CCLF data to complete QM 2016

responses based on CPT and ICD9 and ICD10 codes


Complete QM 2016 Import Chart Preferences

Health Endeavors applies your QM 2016

Import Chart Preferences to QM 2016

Tool

Preferences & Defaults – QM 2016 Chart

Default Applicable Modules/Responses to “No” or “Not Done”


Pull Charts and Key Data

Health Endeavors QM

2016 Tool

Manual Chart Abstraction


Approaches to GPRO1. Do nothing and hope for the best

2. 8 weeks of manual chart abstraction

3. Year Round Plan of Action◦ Provider & Staff Education

◦ EMR Gap Analysis

◦ Central Repository of Data

◦ Distribution of Performance Scorecards to NPIs

◦ Patient Gaps in Care

◦ Readiness for Physician Compare Public Posting


Out-of-Network Migration


In-Network/Out-Network MigrationOut-of-Network Leakage


ACO Distribution Model


Example Distribution Criteria Example Distribution Point System

TIN Benchmark2 – met benchmark

1 – did not meet benchmark

Quality Measures2 – successful reporting of quality measures to ACO

0 – did not successfully reporting quality measures to ACO

Patient Survey Results

2 – Satisfied successful percentage per CMS Standards

0 – Did not satisfy the percentage per CMS Standards.

EMR Use and Integration

2 – stage 2 MU attestation

1 – stage 1 MU attestation

0 – no stage 1 MU attestation

Leadership and Participation

2 – took on leadership role

1 – participated on committee

0 – no leadership or committee involvement

CCM 99490


Compliance1. Do not use unsecure text or email of Patient Health Information

2. Do not send CMS TINs or NPIs in a non-secure email.

3. Conduct Conflict of Interest annually.

4. Prepare an ACO Compliance Plan and Medical Practice Compliance Plan.

5. Conduct HIPAA education.


Final & Proposed ACO Rules


https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News-and-Updates.html

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/News-and-Updates.html

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Recap – Beneficiary Assignment1. Identify all beneficiaries that had at least 1 primary care service with a physician who is anACO professional in the ACO and who is a primary care physician.

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Recap – Beneficiary Assignment2. Identify all primary care services furnished to beneficiaries identified by ACO professionals ofthat ACO who are primary care physicians, non-physician ACO professionals and physicians withspecialty designations.

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Recap – Beneficiary Assignment3. Under First Step, a beneficiary identified is assigned to an ACO if the allowed charges forprimary care services furnished to the beneficiary by primary care physicians who are ACOprofessionals and non-physician ACO professionals in the ACO are greater than the allowedcharges for primary care services furnished by primary care physicians, nurse practitioners,physician assistants and clinical nurse specialists who are:

◦ ACO professionals in any other ACO;

◦ Not affiliated with any ACO and identified by a Medicare-enrolled billing TIN.

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Recap – Beneficiary Assignment4. The second step considers the remainder of the beneficiaries identified who have not had a primary careservice rendered by any primary care physician, nurse practitioner, physician assistant or clinical nursespecialist, either inside the ACO or outside the ACO.

The beneficiary will be assigned to an ACO if the allowed charges for primary care services furnished to thebeneficiary by physicians who are ACO professionals with specialty designations specified by CMS aregreater than the allowed charges for primary care services furnished by physicians with specialtydesignations who are:

◦ ACO professionals in any other ACO;

◦ Not affiliated with any ACO and identified by a Medicare-enrolled billing TIN.

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Non-Physician ACO Professional

1. CCN List

2. NPI List for Physicians and Non-Physician ACO Professional

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99495, 99496 – Transitional Care Management (TCM) Services

99490 – Chronic Care Management (CCM) Services

Company Overview

Since 2008, Health Endeavors has been on the cutting edge ofhealthcare technology development and has quickly become thecountry’s most reliable healthcare vendor from coast to coast.

Our unique technology is why the nations largest healthcareproviders rely on Health Endeavors year in and year out to keepthem on the forefront of healthcare technology and challenges.

With offices based in in Scottsdale, Arizona and Omaha, Nebraskasince 2008, we are strategically located to be readily available toclients in any time zone.

Our cloud-based Patient Health Integrated Tools (PHIT) andHospital Admin Tools (HAT) technology are used on a daily basisby over 1.5 million users to improve the care of over 10 millionpatients.

Click here to visit our website!

Recent Regional Contract Announcement:

Greater New York Hospital Association (GNYHA) Contract: GNYHA-IT-054

https://www.jointheendeavor.com/products/aco-center


Kris Gates, J.D., CEO of Health Endeavors, is the primary architect of the Health Endeavors technology suite. Using her

extensive experience gained in both the business, population health management and legal sectors, Health Endeavors

developed a suite of technology solutions to assist healthcare providers with the management and utilization of

administrative and clinical data.

Currently, the Patient Integrated Health Tools (PHIT) and Healthcare Admin Tools (HAT) suites are used by over 1.5

million users. In addition, the PHIT Tools manage over 10 million patients on a daily basis.

Kris worked in programming and SQL database service positions prior to law school for MidAmerican Energy and IBP,

Inc. with a focus on patient health management and data analysis.

In 2001, she earned her juris doctor from Creighton University School of Law with cum laude recognition. In addition to

her technology development experience, Kris provided legal services in private practice and served as corporate counsel to

several large nonprofit health systems, including Banner Health, Alegent Health and Norton Healthcare.

playing to win in mssp€¦ · performance standard requires acos to continue to completely and...

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