Frederick Integrated Healthcare NetworkHealthcare Network

All Provider MeetingMMay 4, 2015

11

AgendaN t k P ti i ti Ri h d G h MD• Network Participation – Richard Gough, MD

• E Clinical Works analytics status – Phil Stiff• Legislative Update – Jennifer Teeter• Legislative Update – Jennifer Teeter• MC Benchmark Reports & Priorities – Jennifer Teeter• Medicare patient visit templates – Johnson Koilpillai, MDp p J p ,• Employee Health Plan Benchmarks – Jennifer Teeter• Compliance Reminder/Patient Mailing – Jennifer Teeter• Hospice and Palliative Care –Jennifer Teeter• Updated High Utilizer Reports  ‐Johnson Koilpillai, MD• Choosing Wisely overview –Richard Gough, MD• Care of Patients with Congestive Heart Failure – CME 

Anwar Malik, MD 2Anwar Malik, MD 2

Network Participationp

PCPs Specialists Total84 (83% of available)

173 257

Non par

33Future provider contracting strategy –Preferred SNFs, HH Agencies, Radiology, Urgent Care, Lab

Medicare Beneficiary File : RoughAttributionRough Attribution

Monocacy Health Partners 4376PCP 3639Immediate Care 385 Cardiovascular Specialists of Immediate Care 385Onc 105Ortho 85Urology 54Wound Care 34

Frederick 182Syed, G 151Nahar and Rengen Fred. Kidney Care Assoc 113Patel H (Cardiology Associates) 110Wound Care 34

Pain & Palliative 31Surgery 28Thoracic 11B h i l 4

Patel, H (Cardiology Associates) 110Medical and Pulmonary Services 90Cancer Care Center           74Frederick Gastroenterology Specialists 74

Behavioral 4Middletown Valley Family Practice       1069MMI  893Menocal, J 430

pHassen, I 71Cowen, J (Frederick Ctr for Advanced Card..) 56Belani, A 39M C 32

4

Aziz, S 429Saied, J (X'cel) 389Kazmi, S 382Kane, Tyra 363

Moorman, C 32Kidney Center          32Coyne, M 31Kossoff, D 27Romanic, B 22 4Zaidi, S (Primary Medical Services) 343

Haque, S      280

Romanic, B 22Florin, R (PrimeDoc) 2

S i lt Att ib tiSpecialty Attribution

55

MSSP/ACO PCPs taking new Medicare patientsSajjad Aziz, MDSajjad Aziz, MD 801 Toll House Avenue, Suite C-3 Frederick MD 21701, 301-663-1566

Syed Haque, MD 700 Montclaire Avenue

Gaffar A Syed, MD, PA 801 Toll House Avenue, Bldg. H-4 Frederick MD 21701, 301-698-9444

X'cel Primary Care (Saied)700 Montclaire Avenue Frederick MD 21701, 301-662-6943

Internal Medicine Specialists of Frederick, LLC 70 Thomas Johnson Dr, Ste 101

X cel Primary Care (Saied)15 W. 7th Street Frederick MD 21701, 301-698-5050

Union Bridge Family Practice104 N th M i St tFrederick MD 21702, 301-668-9393

Sibte Kazmi, MD 814 Toll House Ave Frederick MD 21701 301-662-8310

104 North Main Street Union Bridge MD 21791, 410-775-2622

Parkview Medical Group 194 Thomas Johnson Drive, Suite A Frederick MD 21701, 301-662-8310

Menocal Family Practice 110 Baughman's Lane, Suite 140 Frederick MD 21701, 240-215-1138

,Frederick MD 21702, 240-215-6370

7211 Bank Court, Suite 230 Frederick MD 21703, 240-215-6370

6

Middletown Valley Family Medicine, PA 300 S. Church St. PO Box 20 Middletown MD 21769, 301-371-9000

1502 South Main St., Suite 202 Mt. Airy MD 21771, 240-215-6370

3000-D Ventrie Ct. 6Primary Medical Services, PC (Zaidi)801 Toll House Avenue, Suite E-1 Frederick MD 21701, 301-662-3229

Myersville MD 21773, 240-215-6370

Population Health Analytics opu atio ea t A a ytics

E Clinical Works UpdateE‐Clinical Works Update

77

Analytics/CareMgmt : RolloutAnalytics/Care Mgmt : RolloutRollout Steps Status

Extract data from eCW and NextGen EHRs: Testing in In ProgressExtract data from eCW and NextGen EHRs:  Testing in progress

In Progress

Deploy eHX HIE (Health Information Exchange)Installation in progress

May/Junep g

Publish Test System : Analytics (maybe) – contingent upon CMS fileCare ManagementData Verification

June

Data Verification

Live Care Management System (limited users) June

Live eHX data Sharing (2 practices) June

8

Receive Claims File June/July

Analytics Live June/July

8

Next StepsNext Steps• eCW on‐site analyst

• Sahil Jain• Sahil Jain

• FIHN ACO IS analyst• Position posted. p

• Train practices on CCMR tool• Conduct workflow sessions with practices, case managementT k• Track measure success

• Trivergent ACO Data analyst• Position Hired

• Facilitate eCW with data extraction and interfaces

• Produce CMS data for upload/download

• Maximize benefits of EHR integration and eCW toolset 9Maximize benefits of EHR integration and eCW toolset

• Configure applications9

Legislative UpdateLegislative Update

A l S i bl G h R d i h i !Annual Sustainable Growth Rate reduction threat is over !  MedPAC passed new MC Phys Fee Schedule rule½% ll i ll t 5½% overall increase annually next 5 yearsValue based payment changes “reporting” to “performing”2% sequestration continues2% sequestration continues

• Medicare future plans – by 2018• 50% of payment Alternative Payment Methodologies• 50% of payment Alternative Payment Methodologies• 90% of FFS payments tied to quality

1010

1111

Value Based Modifier – 2017 start, based on 2015 ,performance.  Providers in an ACO report through the ACO.  Unsuccessful reporting results in 2‐4% penalty.

Home Health and Skilled Nursing Facility payment held at 1% increase.  Future in value based payment ‐ 2018p y

Drive toward ACOs stronger now than ever

Medicaid Federal subsidies to states to increase provider payment to the Medicare rate are finishedthe Medicare rate are finished 

• Maryland budget insufficient to pay MC rates for MA• E&M code rates cut to 87% of Medicare April 1 12E&M code rates cut to 87% of Medicare April 1 12

Medicare Benchmark ReportsMedicare Benchmark Reports

1313

Medicare BenchmarkDataMedicare  Benchmark Data

Cost Benchmark weighted average $10 865 per beneficiary/yearCost Benchmark weighted average $10,865 per beneficiary/yearCosts by enrollment type (difference from other ACOs)

$83,258 ESRD – (8% above other ACOs) 60 persons$10,936 Disabled – (15% above)  1280 persons$ A d d l ( % l )$11,735 Aged dual – (8.5% lower) 411 persons$9,556 Aged non‐dual – (8% above) 8472 persons

Total 10,223 persons

Persons are calculated in Person years – number of assigned beneficiaries adjusted for total months each beneficiary was classified as a MC FFS enrollee.  

1414

Benchmark data continuedBenchmark data continuedAge co‐hort:

Age < 65 16% (disabled)Age < 65 16% (disabled)Age 65‐74 46% (young Medicare population)Age 75‐84 25%Age 85+ 11%g

Distribution by County:Carroll 7.2%Frederick 70.7%Howard 2.1%

%Montgomery 5.7%Washington 4.1%Other 10 2% (combination of multiple counties with <1%) 15Other – 10.2% (combination of multiple counties with <1%) 15

Utilization ReportA h f llAreas where we perform well:• 30 day readmission rates • Admission rates for CHF improving• Admission rates for CHF improvingAreas of Opportunity:• Ambulatory Sensitive Condition Admissions:  COPD or yAsthma, Bacterial Pneumonia

• ER visits that lead to hospitalization• CT and MRI rates• Specialists acting as PCP, patients with no PCP• Hie a hi al o ditio hi h olu e ode Diabete

16

• Hierarchical conditions, high volume codes:  Diabetes, Vascular disease,  heart arrhythmias, COPD, CHF, Cancer, Renal Failure

16• Hospice Utilization is half the rate of other ACOs and 30% of Fee for Service Medicare 

Medicare Patient Visit Templates

1717

Medicare Patient Visit Questionnaire –Helps to Capture  below Preventative Measures   p p

1818

Medicare Wellness Visit Medicare covers a yearly ʺWellnessʺ visit: Your provider will ask you to fill out a questionnaire, called a “Health Risk Assessment,”

It also includes:• A review of your medical and family history• Developing or updating a list of current providers and prescriptionsprescriptions

• Height, weight, blood pressure, and other routine measurements• Detection of any cognitive impairment• Personalized health advice• A list of risk factors and treatment options for youA i h d l (lik h kli t) f i t ti• A screening schedule (like a checklist) for appropriate preventive services. 

• This visit is covered once every 12 months (11 full months must 19have passed since the last visit). 19

CMSLink to a Physician ToolCMS Link to a Physician ToolCMS Physician Tool:  http://www.cms.gov/Outreach‐and Education/Medicare Learning Networkand‐Education/Medicare‐Learning‐Network‐MLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf

Patient Tools to assist practices in capturing QualityMeasures at theWellness Visit

• Free” Medicare Well Visit InformationMedi a e Vi it Health Ri k A e e t

Quality Measures at the Wellness Visit

• Medicare Visit Health Risk Assessment• Medicare Visit Provider Assessment Form

2020

FMHEmployee Health PlanFMH Employee Health Plan Benchmark Reports

2121

Measures selected with FMH Human Resources and FIHNMedicalResources and FIHN Medical Directors

2222

Financial BenchmarkFinancial Benchmark

2323

Emergency Roomuse by PracticeEmergency Room use by Practice

2424

Radiology Utilization by Practice

2525

Breast Cancer Screening by practiceea a e ee i g y p a i e

2626

Patients with Hypertension receiving a lipid panelreceiving a lipid panel

2727

Medicare Compliance Reminder/PatientMailingPatient Mailing

2828

Medicare RegulationsMedicare Regulations

• Poster in PCP offices explaining ACO participation

• Beneficiary Notification ‐ right to opt‐out of CMS sharingBeneficiary Notification  right to opt out of CMS sharing historical claim data 

• Notification via 2 methods• Face to Face PCP office visit, record in EMR• Beneficiary mailing by ACO, ACO tracks

• Initial mailing completed 4/24/15

2929

Medicare RegulationsMedicare Regulations

• Beneficiary can use Form to opt out or call Medicare directly to declare opt‐out choice

• Medicare will send ACO claim data on any attributed beneficiary who does not opt out of data sharing

• ACOs benefit from data to develop actionable plans to meet goals  g

3030

What is different for patients, why is data sharing beneficial?why is data sharing beneficial?Patient experience is improvedPatient experience is improved 

• Support outside of physician office visits • Care Managers, social workers, navigatorsCare Managers, social workers, navigators • Pharmacists – medication reconciliation, fewer drug interactions• Home monitoring ‐ catch problems before they happen

• Shared medical records: doctors, hospitals, pharmacies p p• improved communication between providers• reveals gaps where care is lacking• reduces duplication and out of pocket costsh l th t iti f f iliti id t th• helps smooth transitions from facilities or one provider to another

Proactive outreach reduces hospital admissions and out of pocket cost for patients better care over time 31of pocket cost for patients, better care over time 31

Palliative Care and HospicePalliativeCareandHospice

3232

Population health interventions by time to ROI and impact on quality

LargeUtilization –

Post-hospital transition management

Patient access

end of life care

Disease management

Post acute care management

Impact on quality

g

Case management

Utilization – discretionary q y

Leakage - inpatient

Leakage OP

yprocedures

Utilization - pharmacy

SmallLeakage – OP non-procedural

Leakage – OP procedural

Leakage - imaging

Utilization - imaging

33QuickTime to Return on InvestmentLong

g g g

ROI – Return on Investment, OP - outpatient

33

Hospice – Improvement Neededp p44% of the patients who die at FMH were discharged from a prior admission with terminal end stage disease 10 daysprior admission with terminal end stage disease 10 days before being readmitted

Do these patients want to die in the hospital? –70% of people want to die at home

Are their wishes being carried out?How do we know if we don’t ask?

• Show Video ‐ http://www.nhdd.org/• Conversation Project starting in the community ‐http://theconversationproject.org/starter‐kit/intro/

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Utilization – End of Life CareU i i a io E o i e a e•Advance DirectivesMaryland Advance Directive  Formhttp://www.oag.state.md.us/healthpol/adirective.pdf

• The IHI Conversation Project, launched in F d i k 4 it tiFrederick, 4 community meetings:  http://theconversationproject.org/

3535

Palliative Care Task ForceP lli ti ti f ti t ith h iPalliative care ‐ supportive care for patients with chronic or terminal illness

• Palliative care patients can continue treatment –ppalliative care is not the same as hospice

• Core Indicators for palliative consultation benefit –Physical Decline

BMI change

Multiple comobidities

Dependence for Activities of Daily Living

Karnofsky scale

Would you be surprised if the patient died within the next year?

• Above triggers referral to Palliative Care ‐ pain and anxiety management, dietary, social, pharmacy supportA Pl f ti t 36• A Plan for supportive management 36

Utilization Management OpportunitiesUtilization Management Opportunities

3737

ACO Reduction of Avoidable Utili atio /Co tWhe e to ta t?Utilization/Cost Where to start?• MSSP Goal:  3.5% cost reduction, $3.8M estimated

• Equivalents:  $400 per beneficiary, 379 admissions • Data from CMS – April timeframe

• FMH Employee Health Plan:  Up to 13% savings will p y p gbe shared, $840,000

• Equivalents:  $455 per member, 84 admissions• Data from TPA/UMR reports underwayData from TPA/UMR reports underway

• MSSP/ACOs experience data delays due to –• Beneficiary mailing opt out notice timingy g p g• CMS delays in sending claim data • Challenges of incorporating CMS data into analytic t ltool

38

Physician Report Overview• Data Source:

–HSCRC Potentially Avoidable Utilization Reporty p–Case level, Inpatient data only

• Data Period and Payor:–Calendar Year 2014 ‐ January through November–Medicare FFS patients only

• Comparison groups:• Primary Care Physician• FIHN MSSP Providers• All FRHS  FRHS

Admission StatisticsAdmission Statistics• IP Admissions = Count of Inpatient cases

• Average LOS (Length of Stay) = Sum of total Inpatient days / IP Admissions

A SOI (S i f Ill ) S f l SOI ( i l l• Average SOI (Severity of Illness) = Sum of total SOI (severity level assigned to each Inpatient case) / IP Admissions• SOI ranges from 1 (least severe) to 4 (most severe)

• Unique Patients = Count of distinct patients

• High Utilizer Patients = Count of distinct patients, with:>= 2 Inpatient stays, and >= $50,000 total charges

40

Readmissions and RevisitsReadmissions and Revisits• Readmissions

Inpatient Readmissions = Inpatient cases that occur within 30 days– Inpatient Readmissions = Inpatient cases that occur within 30 days of an initial Inpatient stay

– Cases Eligible for readmission = All Inpatient cases, excluding:

( ) h(1) Deaths

(2) Transfers to another acute hospital

– Readmission Rate (%) = Inpatient Readmissions / Eligible Cases– Expected Readmissions

• Target line on Readmission Rate graph

• Expected calculation = Physician cases by DRG severity of illness x State averageExpected calculation   Physician cases by DRG severity of illness x State average readmissions by DRG severity of illness

• RevisitsE Ob i i i h i hi– Emergency Department or Observation visits that occur within 30 days of an initial Inpatient stay. The Initial visit must be Inpatient.41

Potentially Avoidable Utilization (PAU)

• PAU is volume that can be potentially avoided though improved ambulatory care  PAU includes:p y• Admissions for Prevention Quality Indicator (PQI) Diagnosis as defined by AHRQ – 13 diagnosis

• Inpatient (IP) 30‐day readmissions (intra and inter‐hospital)O i (OP) 30 d i i ER/Ob i• Outpatient (OP) 30‐day revisits to ER/Observation (after an IP stay)

42

Hospital Potentially Avoidable Utilizationospita ote tia y A oidab eUti i atioPreventable Admissions – Prevention Quality Indicators ‐diagnosis for which strong primary care would reduce rates f h it li ti N ti l Q lit F d ti d dof hospitalization. National Quality Foundation endorsed measures used by state agencies.

Lower extremity amputation in patients with diabetesUncontrolled Diabetes, Long Term Diabetes, Short TermUncontrolled Diabetes, Long Term Diabetes, Short Term Diabetes

Adult AsthmaAnginagUrinary Tract InfectionBacterial PneumoniaDehydrationyCOPDHypertensionCHF 43Perforated Appendix

43

Updated High Utilizer Reports for PCP dditi l i f tiPCPs – additional information• Emergency Room High Utilizers and rate• Emergency Room High Utilizers and rate comparisons

• Observation High Utilizers and rate• Observation High Utilizers and rate comparisons

• Inpatient Utilization Rate comparison• Inpatient Utilization Rate comparison

44

4545

4646

4747

4848

Care Management Goals –ExperiencedACOGuidanceExperienced ACO Guidance

• Top 15% of highest cost/risk patients should be in care management to improve management of multiplemanagement to improve management of multiple concurring chronic conditions

Goals for care management based on MC attribution:Parkview – 545Middletown – 160Drs Menocal Aziz Kazmi Saied Kane Zaidi 60Drs. Menocal, Aziz, Kazmi, Saied, Kane, Zaidi – 60Haque – 42Syed – 23

• Care management referral form, feedback loop• Strategy to increase referrals – outreach to PCP &  49gypatients with 2 or more admissions or >$50,000, or 3 or more ER or Observation visits

49

Care Management Referral Form – Top of Form

5050

Bottom of FormBottom of Form

5151

What Specialists should do nowWhat Specialists should do now

• Encourage patients to have a PCP (quality measures)

• Consider use of Generic Prescriptions• More to come when we have CMS claim data• Review Choosing Wisely recommendations from your specialty 

52

http://www.choosingwisely.org/doctor‐patient‐lists/

52

5353

5454

5555

5656

5757

American Academy of PediatricsFiveThings Physicians andPatients ShouldQuestionFive Things Physicians and Patients Should Question

5858

The American Academy of Family PhysiciansʹFiveThings Physicians andPatients ShouldQuestionFive Things Physicians and Patients Should Question

5959

60

Next FIHN All Provider MeetingRadiology Using Wisely Focus 60ad o ogy Us g se y ocus

Next Steps both contractsPhysicians –

• High Utilizers‐ deploy care managers• Transitions in Care Management – 48 hour initial contactTransitions in Care Management  48 hour initial contact• Patient wellness visits – collect quality measures – identify rising risk 

• Participate in EHR Integration with FIHN ITParticipate in EHR Integration with FIHN IT• Specialists – Choosing Wisely, ensure patients have a PCP• End of Life Quality ‐Advanced Directives/ MOLST/DNR 

• FIHN• FIHN –• Beneficiary opt‐out mailing and strategy to engage beneficiaries• Deploy medical and cost management strategy – engage providers• CG‐CAHPS vendor contracting – customer service surveyCG‐CAHPS vendor contracting  customer service survey• Use integrated EMR data to report on quality measures • Future provider contracting strategy – Preferred SNFs, others• Participation Fee – FMV assessment, paid from savingsp , p g• Payor contracting – future Agreements

61

Future All Provider Meeting DatesDates

•July 15 , 7‐8:00 a.m.O t b 14 7 8 00•October 14 , 7‐8:00 a.m.

6262