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CATHY COSTELLO, JD, CPHIMSDirector, CliniSyncPLUS Services
SCOTT MASH, MSLIT, CPHIMS, FHIMSSDirector, Consulting Operations & HIE Outreach
COMPREHENSIVE PRIMARY CARE PROGRAMS
August 24, 2016
Acronyms We’ll be Using TodayACO Accountable Care Organization MSSP Medicare Shared Savings Program
APMs Advanced Alternative Payment Models ODM Ohio Department of Medicaid
CAHPS Consumer Assessment of Healthcare Providers & Systems
PBPM Per Beneficiary Per Month
CAP Corrective Action Plan PFAC Patient & Family Advisory Council
CPC Comprehensive Primary Care (Ohio Medicaid)
PFPM Physician Focused Payment Models
CPC+ Comprehensive Primary Care Plus (CMS) PMPM Per Member Per Month
ECs Eligible Clinicians PQRS Physician Quality Reporting System
EPs Eligible Professionals PROM Patient Reported Outcome Measures
FFS Fee for Service TCOC Total Cost of Care
MCP Managed Care Plan (Ohio Medicaid) TIN Tax ID Number
2
CPC+ELIGIBILITY & REGISTRATION
FOR MEDICARE
Which Practices are Eligible to Participate?
• Primary care (except for pediatrics)
• NOT practicing in a concierge practice, a rural health clinic (RHC) or a Federally Qualified Health Center (FQHC).
• Can be hospital owned or independent. If hospital owned, need a letter from executive leadership showing there is a commitment
that the increased funding obtained through CPC+ flows to the practice site
• Must have 150 Medicare beneficiaries per practice site
• Can be part of a Medicare Shared Savings ACO
• Must plan on participating for 5 years
Medicare Registration by Practice Site Not by TIN
4
Registration Information
• Must apply at https://app1.innovation.cms.gov/cpcplus between August 1 and September 15, 2016. Supporting documents uploaded at this site.
• Practices register by Track (Track 1 or Track 2) - no change allowed in tracks during the program; can register for Track 2 but may be put in Track 1 by CMS.
• Practices applying to Track 2 will need to submit a letter of support from their Health IT vendor(s) that outlines vendors’ commitment to supporting the practice with advanced health IT capabilities. CMS will sign a Memorandum of Understanding with those health IT vendors supporting
Track 2 practices selected to participate in CPC+.
Medicare Registration by Practice Site Not by TIN
5
Registration Information
Contact information:
• Applicant Contact (individual completing the application)
• Practice Contact (required if the Applicant Contact is not the primary contact in the practice or does not work in the practice)
• Health Information Technology Contact (individual responsible for HIT in the practice)
• Total number of individual physicians, nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNS) who provide patient care at your practice and practice under their own NPI.
• Primary care practitioners, including full-time and part-time staff in your practice: Number of physicians, NPs, PAs, CNSs
• For each primary care practitioner: Name, NPI, Specialty - If practitioner works
at the practice (or satellite office) and/or if the practitioner practices at another
Location.
Medicare Registration by Practice Site Not by TIN
6
Registration Information
Contact information for Organization:
• Name of organization (If other practices from your organization are applying to CPC+, please use identical text in this field)
• Corporate address and phone number
• Number of primary care practice sites, physicians, and Medicare Eligible Professionals (EPs) that are part of this organization
• Name and TIN of all other practices in your organization that are applying for CPC+
• All TINs used by your practice to bill Medicare, including those used since January 1, 2013
• Medicare Shared Savings Program ACO name and TIN (if applicable)
• Percentage of patients by race and preferred language
Medicare Registration by Practice Site Not by TIN
7
Registration Information
Meaningful Use and Health IT:
• Vendor name, Product and Version CPC+ Function (if applicable; Track 2 only)
• Meaningful Use attestation progress among the primary care practitioners in your practice who are Eligible Professionals
• Total number of Medicare EPs
Number of Medicare EPs who plan to attest to Meaningful Use Stage 2
• Total number of Medicaid EPs
Number of Medicaid EPs who plan to attest to Meaningful Use Stage 2
• CMS EHR Certification ID
8
Medicare Registration by Practice Site Not by TIN
Registration Information
Practice revenue and budget information:
• Total revenue in 2015
• Total 2015 revenue by specified payer
• Percentage of patients by insurance type (e.g., commercial, Medicare)
Medicare Registration by Practice Site Not by TIN
9
Registration Information
Care Delivery Structure:
• Care delivery information to answer application questions about care management, access, and quality improvement.
• Organizations through which your practice has received Medical Home recognition (if applicable)
Medicare Registration by Practice Site Not by TIN
10
Registration Information
Letters of Support/Commitment:
• Letter of support from your practice’s clinical leader: each practice must submit a separate letter of support from leadership at the practice site
• Letter from system leadership regarding segregation of CPC+ funds (if applicable)
• Health IT Cover Letter (Track 2 applicants only) Letter of support from Health Information Technology vendor (Track 2 applicants only), if vendor has not submitted a Global Letter of Support.
Medicare Registration by Practice Site Not by TIN
11
Ohio Medicaid• Primary care (FP, IM, general practice, peds, public health, geriatric)
• Can be hospital owned or independent
• Can leave the program at any time with notice to Ohio Medicaid (ODM)
• Can be part of a Medicare Shared Savings ACO
• Re-enrollment not required; automatic rollover unless practice terminates
2017 Eligibility1) > 5,000 Medicaid members (either Medicaid FFS or Medicaid managed care) with NCQA PCMH
accreditation (no level required)
2) > 500 Medicaid members and acceptance into the Medicare CPC+ program; or3) > 500 Medicaid members and NCQA Level III PCMH accreditation
2018 Eligibility • Open to all Medicaid practices
Which Practices are Eligible to Participate?Medicaid Registration by TIN
13
Ohio Medicaid Eligible Provider Types & Specialties
14
Registration Information
Practice Data:
• Practice name
• NPI
• Practice group ID
Contact Information
• Name
• Phone
• Mailing address
Medicaid Registration by TIN
15
Registration Information
Practices must attest to the following:• Commit to share necessary data with the state and payers
• Commit to participate in learning activities
• Commit to meeting start-up activity requirements within 6 months
PCMH certification• Must attest to either NCQA Level II or NCQA Level III
Medicare CPC+ Participation• Has practice applied for Medicare CPC+?
• Has practice (or any locations of organization) been accepted in Medicare CPC+?
Medicaid Registration by TIN
16
Registration Information
Ohio Department of Medicaid website:
http://medicaid.test.ohio.gov/Providers/PaymentInnovation/CPC.aspx#1612552-cpc-enrollment
• Click on the link labeled “Enroll here.”
• This will link to the 1-page application for enrollment into the Ohio CPC program.
• The link will go live on October 1, 2016.
Enrollment: October 1 – October 31, 2016
Medicaid Registration by TIN
17
18
Medicaid Early Enrollment
Early enrollment in Ohio CPC (Medicaid)
will be a simple
online form
More details about Ohio CPC program can be found at: http://Medicaid.ohio.gov/Providers/Paymentinnovation/CPC.aspx
Ohio CPC “Early Entry” Enrollment
Late August 2016
o Ohio Medicaid will identify primary care practices that meet the state’s early entry criteria.
o Invite them to enroll in Ohio CPCo Encourage them to also apply for Medicare CPC+
September 7, 2016Ohio Medicaid will host a webinar for invited practices to learn more about enrolling in the Ohio CPC program.
October 1, 2016Ohio Medicaid will provide an online link to invited practices where they can enroll in Ohio CPC from October 1-31.
Late 2016Ohio Medicaid will invite practices selected for CPC+, that also have 500+ Medicaid members, to enroll in CPC.
January 1, 2017The performance period begins for practices enrolled in Ohio CPC & selected for Medicare CPC+.
• Each payer will have its own registration
• No known eligibility requirements beyond those for Medicare and Medicaid, but each payer may set its own requirements
• Each payer may determine its own procedures for termination from the program.
Private Payers Registration Requirement Unknown
Which Practices are Eligible to Participate?
Aetna CareSource Paramount Health Care
Anthem Gateway Health Plan of Ohio SummaCare
AultCare Health Plans Medical Mutual of Ohio (MMO) The Health Plan
Buckeye Health Plan Molina Healthcare of Ohio United Healthcare
Private Payers Participating:
21
Comparison of Medicaid & Medicare Financial Models
Alignment of Ohio PCMH design with CPC+ model.
23
Proposed Medicare Financial Payment by TrackMedicare FFS Financial Support for CPC+ Practices
24
Medicare Risk Tiers for Payment
Risk Tier Attribution Criteria Track 1 Track 2
Tier 1 1st quartile HCC ** $6 $9
Tier 2 2nd quartile HCC $8 $11
Tier 3 3rd quartile HCC $16 $19
Tier 44th quartile HCC for Track 1:
75-89% HCC for Track 2$30 $33
Complex
(Track 2 only)
Top 10% HCC
OR DementiaN/A $100
Average $15 $28
Table II: Proposed Risk Tiers and Care Management Fee Levels (PBPM) for CPC+
25** Hierarchical Condition Category (HCC) The HCC model is updated regularly by CMS to reflect changes in treatment patterns and costs.
26
Ohio Application of CPC+ payment streams by line of business
Comparison of Medicaid & Medicare Financial Models
If the savings to Medicaid are positive at year-end, the entity receives a % of the savings as a lump-sum payment from Medicaid.
Medicaid PCMH Requirements for PaymentOhio’s PCMH Requirements and Payment Streams
27
CPC+ Functions & Requirements
Function 1: Access & Continuity
• Effective primary care built on trusting & continuous relationship
• Expanding hours and developing alternatives to traditional office visits to ensure timely access
• Intended to increase the likelihood that patient gets right care at the right time to avoid costly urgent & emergency care.
Increased Availability – Medicare CPC+
29
Access & Continuity RequirementsMEDICARE CPC+
Track 1 Track 2
1. Minimum of 95% empanelment to practitioner and/or care teams.
1. Track 1 requirements 1 – 3 +
2. 24/7 access to care team with real-time access to EHR.
2. Offer at least one alternative to traditional office visits as means to increasing access that best meets needs of patient population (e-visits, group visits, home visits, SNF visits)
3. Organization care by teams responsible for a specific, identifiable panel of patients to optimize continuity.
Ohio CPC+ variance: Same-day appointments30
Function 2: Care Management
• Care management for high-risk, high needs patients through risk stratification then empanel patients to care team.
• Identify patients most likely to benefit from targeted, proactive, relationship-base care management.
• Identify patients based on event triggers for short-term care management.
Transition to new care setting
New diagnosis of major illness.
Building Deeper Relationships – Medicare CPC+
31
Care Management RequirementsMEDICARE CPC+
Track 1 Track 2
1. Risk-stratify all empaneled patients1. Use two-step risk stratification process for all
empaneled patients:Step 1: based on defined diagnosis, claims, or other algorithm (not care team intuition)Step 2: adds the care team’s perception of risk to adjust the risk-stratification of patients, as needed.
2. Provide targeted, proactive, relationship-based care management to all patients identified as an increased risk.
3. Provide short-term care management & med rec who have had an ED visit or hospital admit/discharge.
2. Track 1 Requirements 2 – 5 +
4. Ensure patients with ED visit receive follow up interaction within one week.
6. Use a plan of care centered on patient’s actions & support needs in management of chronic conditions.
5. Contact > 75% of patients who were hospitalizedwithin 2 business days. 32
Function 3: Comprehensiveness & Coordination
• Add both breadth and depth to the delivery of care services.
• Expand services and partnerships to meet majority of patient population’s medical, behavioral & health-related social needs
• Relationship with care team intended to lower overall utilization and costs, decrease fragmentation of care and improve health outcomes.
• Care team serves as the hub for all patient services.
Expand and Manage Services – Medicare CPC+
33
Comprehensiveness & Coordination Requirements
MEDICARE CPC+
Track 1 Track 2
1. Systematically identify high-volume & high-cost specialists serving the patient population.
Track 1 Requirements 1 – 2 +
3. Enact collaborative agreements w/ at least 2 groups of specialists identified from analysis
4. Choose & implement at least 1 option forintegrating behavioral health into care.
2. Identify hospitals & EDs responsible for the majority of patients’ visits. Assess & improve timeliness of notification & information transfer
5. Systematically assess patients’ psychosocial needs using evidence-based tools.
6. Conduct an inventory of resources & supports to meet patients’ psychosocial needs.
7. Characterize important needs of high-risk patients populations & identify capability to develop to meet those needs & track over time.
Function 4: Patient & Caregiver Engagement
• Organize a Patient & Family Advisory Council (PFAC)
• Leverage PFAC to understand the perspective of patients while educating them of ongoing transformation of delivery of care.
• Use recommendations of PFAC to improve care & to ensure continued patient-centeredness.
Patient and Family Feedback – Medicare CPC+
35
Patient & Caregiver Engagement Requirements
MEDICARE CPC+
Track 1 Track 2
1. Convene a PFAC at least once in PY2017 & integrate recommendations into care, as appropriate.
1. Convene a PFAC in at least two quarters in PY2017 & integrate recommendations into care, as appropriate.
2. Access practice capability & plan for support of patients’ self-management.
2. Implement self-management supportfor at least 3 high risk conditions.
36
Function 5: Planned Care & Population Health
• Organize care & services to meet entire population of patients served.
• Offer timely & appropriate preventative care and consistent evidence-based management of chronic conditions.
• Improve population health through use of evidence-based protocols in team-based care.
• Measure and act on the quality of care at both the practice & panel level.
Team-Based Population Management – Medicare CPC+
37
Planned Care & Population Health RequirementsMEDICARE CPC+
Track 1 Track 2
1. Use feedback reports provided by CMS & other payers at least quarterly on at least 2 utilization measures at the practice-level and practice data on at least 3 eCQMs, derived from the EHR, at both practice- and panel-level to inform strategies to improve population health management.
Track 1 Requirement 1 +
2. Conduct care team meetings at least weekly to review practice- and panel-level data from payers and internal monitoring and using this data to guide testing of tactics to improve care and achieve practice goals in CPC+.
38
Reporting Requirements – Medicare CPC+
Both Track 1 and Track 2 practices are required to:• Report 9 eCQMs annually
• Administer CAHPS surveys to all patients who have in-person office visits
Track 2 practices must administer PROM• PROM – Patient Reported Outcome Measures
Assess quality performance & eligibility to performance-based incentives
40
eCQMs – Medicare CPC+
• Reported at both the practice-level and panel level.
• At least 2 of 3 outcome measures, at least 2 of 4 complex care measures and any five any remaining measures
• Currently 14 eCQMs on available measures list
Track 1 & Track 2 practices are required to report 9 eCQMs annually
41
Medicare CPC+ List of Reportable eCQMs
Medicare CPC+ eCQM Set – 2017 Performance Period
CMS ID# NQF# Measure TitleMeasure Type/
Data SourceDomain
Report 2 of the Group 1 outcome measures:
Gro
up
1
CMS159v5 0710 Depression Remission at Twelve Months
Outcome/eCQM Clinical Process/Effectiveness
CMS165v5 0018 Controlling High Blood Pressure
Outcome/eCQM Clinical Process/Effectiveness
CMS122v5 0059 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Outcome/eCQM Population/Public Health
42
Medicare CPC+ eCQM Set – 2017 Performance Period
CMS ID# NQF# Measure TitleMeasure Type/
Data SourceDomain
Report 2 of the Group 2 complex care measures:
Gro
up
2
CMS156v5 0022 Use of High-Risk Medications in the Elderly
Process/eCQM Patient Safety
CMS149v5 N/A Dementia: CognitiveAssessment
Process/eCQM Clinical Process/Effectiveness
CMS139v5 0101 Falls: Screening for Future Fall Risk
Process/eCQM Patient Safety
CMS137v5 0004 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment
Process/eCQM Clinical Process/Effectiveness
Medicare CPC+ List of Reportable eCQMs
43
Medicare CPC+ eCQM Set – 2017 Performance Period
CMS ID# NQF# Measure TitleMeasure Type/
Data SourceDomain
Report 5 of the 10 remaining measures (choice of Group 3 and remaining Groups 1 and 2 measures):
Gro
up
3
CMS50v5 N/A Closing the Referral Loop: Receipt of Specialist Report
Process/eCQM Care Coordination
CMS124v5 0032 Cervical Cancer Screening Process/eCQM Clinical Process/Effectiveness
CMS130v5 0034 Colorectal Cancer Screening Process/eCQM Clinical Process/Effectiveness
CMS131v5 0055 Diabetes: Eye Exam Process/eCQM Clinical Process/Effectiveness
CMS138v5 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
Process/eCQM Population/Public Health
CMS166v6 0052 Use of Imaging Studies for Low Back Pain
Process/eCQM Efficient Use of Healthcare Resources
CMS125v5 2372 Breast Cancer Screening Process/eCQM Clinical Process/Effectiveness
Medicare CPC+ List of Reportable eCQMs
45
Ohio Medicaid CPC Clinical Quality RequirementsMust pass 50%
Medicare CPC+ Program
What is Monitoring?The CMS Medicare monitoring program will utilize:
• Integrity, cost, utilization and quality data in their monitoring strategy
• Think QRUR reports
• Reports submitted from practice coaches (CMS contractors)
• Reports submitted by practices
Monitoring confirms that
practices understand and
can track progress towards meeting the care delivery
requirements.
47
Monitoring
Program integrity Data• Prior to start of program to determine eligibility for CPC+
Care Delivery Requirements Achievement Data• Quarterly attestations of care delivery achievements submitted to CMS.
• Certain reported less than quarterly (ex: 24/7 access)
Care Delivery Flag Report• Based on submissions to CMS which identify areas of concern or high
performance.
Medicare Monitoring will include the review of some or all of the following:
48
More Monitoring
Practice Budget Data• Submitted annually by practice.
• Includes a retrospective look at prior year use of CMFs and CPCP & any expected changes for the upcoming year
Cost, Utilization, Patient Experience, and Quality Data• Reviewed at least annually to identify practices that are performing well and
those performing poorly.
Track 2 practices subject to increased monitoring/feedback.
Medicare Monitoring will include the review of some or all of the following:
49
Corrective Action Plan (CAP) - Medicare
• CAP imposed when a practice is:
not meeting requirements in the Participation Agreement
found to be “gaming”
not meeting quality standards
• Expected to remedy the situation within given time frame (usually 6 months)
• CAP will be shared with practices, regional learning faculty & payers.
• Practices that cannot address areas of concern or meet requirements in Practice Agreement will be subject to Termination.
Imposed when a practice is not meeting Participation Agreement, found to be “gaming”, or not meeting quality standards.
50
Medicare Audits
• Practices will be informed of potential audits by CMS or contractor
• Practices required to maintain copies of all documentation related to use of CPC funds & care delivery work for CPC requirements.
• Risk score based on budget data, utilization performance, quality measures and reports may trigger audits.
In addition to quarterly monitoring, practices will be subject to audit
51
Ohio Health Information PartnershipCliniSync and CliniSyncPLUS
Cathy Costello [email protected]
Scott Mash [email protected]
Questions?
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