Quality Soup:The Ingredients for Success in Managing

Multiple Quality Programs

Holly Arends, CHSPProgram Manager

Great Plains Quality Innovation Networkholly.arends@area-a.hcqis.org

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

holly.arends@area-a.hcqis.org

www.greatplainsqin.org

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