Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | | 1 ACI

Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org

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ACI Steering Committee

July 21, 2015


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Today’s Agenda

Public Reporting of TCI on GetBetterMaineUpdate/status of Measure Alignment workUpdate on Primary Care SpendFindings and recommendations of Bailit Health interviews on key primary care payment definitionCMS announcement of potential expansion of CPCI


Review of recommended “payment” measure set

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Measure Name NQF Number

Steward Domain

Process/ Outcome

Care Setting Population Data

Source

Follow-Up After Hospitalization for Mental Illness (FUH) 0576 NCQA Behavioral

Health Process Ambulatory Care

Adult & Pediatric (6 yrs and older)

Claims

Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET)

0004 NCQA Behavioral Health Process Ambulator

y Care

Adult & Pediatric(13 yrs and older)

Claims

Comprehensive Diabetes Care: Medical Attention for Nephropathy (CDC)

0062 NCQA Chronic Illness Care Diabetes Process Ambulator

y Care Adult Claims

Comprehensive Diabetes Care: Eye Exam (CDC) 0055 NCQA Chronic Illness

Care Diabetes Process Ambulatory Care Adult Claims

Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (CDC) 0059 NCQA Chronic Illness

Care Diabetes Outcome Ambulatory Care Adult Claims and

Clinical Data

Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg) (CDC)

0061 NCQA Chronic Illness Care Diabetes Outcome Ambulator

y Care Adult Claims and Clinical Data

Controlling High Blood Pressure (CBP) 0018 NCQA Chronic Illness Care Hypertension

Outcome Ambulatory Care Adult Clinical Data


Review of recommended “payment” measure set (continued)

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Steward Domain

Process/ Outcome

Care Setting

Population

Data Source

Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) 0058 NCQA

Chronic Illness Care: Respiratory Illness

Process Ambulatory Care Adult Claims

TCOC: Total Cost of Care Population-based PMPM Index (TCI) 1604 Health

Partners Cost Cost Setting free All Claims

TCOC: Total Resource Use Population-based PMPM Index (RUI) 1598 Health

Partners Cost Cost Setting free All Claims

Plan All-Cause Readmission (PCR) 1768 NCQA Overuse Outcome Ambulatory Care Adult Claims

ED Utilization for Ambulatory Care-Sensitive Conditions AHRQ Overuse Process Ambulatory

Care All Claims

Well-Child Visits in the 3rd, 4th, 5th, and 6th Years of Life (W34) 1516 NCQA Pediatrics -

Prevention Process Ambulatory Care Pediatric Claims

Adolescent Well-Care Visits (AWC) (12–21 years of age) NA NCQA Pediatrics -

Prevention Process Ambulatory Care Pediatric Claims

Colorectal Cancer Screening (COL) 0034 NCQA Preventive Care Process Ambulatory Care Adult Claims and

Clinical Data

Tobacco Use: Screening and Cessation Intervention 0028 AMA-PCPI Preventive Care Process Ambulatory

Care Adult Claims and Clinical Data

Adult BMI Assessment (ABA) NA NCQA Preventive Care Process Ambulatory Care Adult Claims and

Clinical Data



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Measure Name NQF Number Steward Domain Process/

OutcomeCare Setting Population Data Source

Influenza Immunization 1659 CMS Hospital Process Hospital All Claims and Clincal Data

Venous Thromboembolism (VTE) VTE1; VTE2; VTE3; VTE5; VTE6

0371, 0372, 0373,0375, 0376

The Joint Commission

Hospital Process Hospital Adult Clinical Data

Stroke (STK) STK1; STK4; STK6; STK8

0434, 0437, 0439,0440


Hospital Process Hospital Adult Clinical Data

Cesarean Rate for Nulliparous Singleton Vertex (PC-02) 0471


Hospital - Maternity Process Hospital Adult Claims and

Clinical Data

Elective Delivery Prior to 39 Completed Weeks Gestation (PC-01) 0469


Hospital - Maternity Process Hospital Adult Clinical Data

MHDO #NSPC-3: Patient Fall Rate (Falls With Injury) 0141 Hospital Outcome Hospital Clinical Data

MHMC: Med Spotlight Medication Safety NA MHMC Hospital Process Hospital All Survey



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Measure Name NQF Number Steward Domain Process/

OutcomeCare Setting Population Data Source

3-Item Care Transition Measure (CTM-3) 0228

Univ. of CO Health Sciences Center

Care Coordination Survey Hospital Adult Survey

HCAHPS

- Cleanliness and Quietness of Hospital Environment- Communication about Medicines- Communication with Doctors- Communication with Nurses- Discharge Information- Pain Management- Overall Rating of Hospital- Responsiveness of Hospital Staff - Willingness to Recommend

0166 CMS Hospital Survey Hospital Adult Survey

CAHPS® Clinician/Group Surveys - (Adult Primary Care, Pediatric Care, and Specialist Care Surveys)

0005 AHRQ Consumer Experience Survey Ambulatory

Care Adult Survey


Review of recommended “monitoring” measure set

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Steward Domain

Process/ Outcome

Care Setting

Population

Data Source

Cardiovascular Health Screening for People with Schizophrenia or Bipolar Disorder Who Are Prescribed Antipsychotic Medications

1927 NCQA Behavioral Health Process Ambulatory

Care Adult Claims

Percent of Members with Fragmented Primary Care NA Homegro

wnCare Coordination Process Ambulatory

Care All Claims

Children with Four Topical Fluoride Applications by 4 Years NA IHOC #56 Oral Health Process Ambulatory

Care Pediatric Claims

Use of Imaging Studies for Low Back Pain (LBP) 0052 NCQA Overuse Process Ambulatory

Care Adult Claims

Non-emergent ED Use NA Muskie Overuse Process Ambulatory Care All Claims

Well-Child Visits in the First 15 Months of Life (W15) 1392 NCQA

Pediatric Measures - Prevention

Process Ambulatory Care Pediatric Claims

Use of Appropriate Medications for Asthma (ASM) 0036 NCQA

Chronic Illness Care: Respiratory Illness

Process Ambulatory Care All Claims

Developmental Screening In the First Three Years of Life 1448 NCQA

Pediatric Measures - Prevention

Process Ambulatory Care Pediatric

Claims (Depending on state)


Review of recommended “monitoring” measure set (continued)

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Steward Domain

Process/ Outcome

Care Setting

Population

Data Source

Ambulatory Surgery/1000 --- Utilization Process Ambulatory Care All Claims

Ambulatory Care (AMB)(ED rate only) --- NCQA Utilization Process Ambulatory

Care All Claims

% Generic Scripts --- Utilization Process Ambulatory Care All Claims

High-end Imaging/1000 --- Utilization Process Ambulatory Care All Claims

Inpatient Utilization - General Hospital/Acute Care --- NCQA Utilization Process Hospital All Claims

Primary Care Visits/1000 --- Utilization Process Ambulatory Care All Claims

Skilled Nursing Facility (SNF) Days/1000 --- Utilization Process SNF All Claims

Specialty Visits/1000 --- Utilization Process Ambulatory Care All Claims

ED Utilization: Number of ED visits per 1000 member months --- NCQA Utilization -

Pediatric Process Ambulatory Care Pediatric Claims


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Primary Care Spend Calculation

• Total spend used in denominator$1.02 billion (inc $290m Rx)

• Of that total, primary care spend$53 million

• 5.2% primary care spend• CY 14 commercial non-claims spend - $10.3

million• Current estimate = 6.2% primary care spend


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Findings of Current Payment Practices

• All FFS based, no capitation• Most payers offer small-to-modest PMPM

payments for PCMH support• Payments include quality incentives, care

management and shared savings• Payers focused on ACO contracting


Discern’s Proposed Approach• One size does not fit all– Tier 1- Practice Investment• Initial steps and investment in improvements in cost

reduction, quality improvement and system integration.

– Tier 2- Practice Enhancement • Financial incentives for performance improvement,

continued investment

– Tier 3- Practice Integration• Transition to more advanced payment models,

increased risk to providers balanced by increased integration with system

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Discern’s Recommendations• Define performance expectations and measures for

each tier– Tier 1 – infrastructure and process– Tier 2 – clinical quality; patient engagement– Tier 3 – population clinical and cost outcomes

• Define payment principles for each tier– Tier 1 – fixed payments tied to specific improvements

(leverage CCM)– Tier 2 – emphasis on performance-based payment; risk

for primary care outcomes– Tier 3 – population risk

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RecommendationsDomain Tier 1: Foundational Tier 2: Maturing Tier 3: Advanced

1. Care Management for High Risk Patients

The practice has assigned 95% of patients to provider panels

The practice has developed and implemented a data-driven and clinical assessment methodology to assign a risk status to every empaneled patient

The practice has established a baseline proportion of population in each risk category

The practice has designated care management resources either within the practice or within the ACO’s centralized Care Management structure that are based on assessed patient needs.

The practice has developed and implemented a protocol regarding level of care management services to be provided to each risk level.

The practice has provided care management services to at least 75% of its highest risk patients, including the development, implementation and monitoring of patient-centered care plans.

In addition to meeting the Tier 1 requirements, the practice: the practice includes in its risk

methodology consideration of both clinical and utilization data

the practice has begun implementing one of the following behavioral health integration models:o preferred referral

arrangementso co-located BH serviceso co-located, integrated

BH services the practice has implemented a

protocol for completing medication reconciliation for high risk patients within 72 hours of IP discharge

the practice has implemented a self-management support program for at least three high risk conditions

annually, the practice tracks changes in the proportion of patients in each risk stratification to assess the impact of care management activities

In addition to meeting the Tier 2 requirements, the practice: the practice refines its risk

stratification methodology based on an assessment of the strengths and weaknesses of the implemented methodology to identify those patients who are at highest risk and would benefit from care management support

the practice includes in its risk methodology consideration of the patient’s socioeconomic factors

the practice has established formal referral processes and/or agreements with community-based organizations to address socio-economic determinants of health


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Recommendations

2. Access and Continuity

The practice provides 24-hour, 7- days-a-week patient access to a nurse or other practitioner for patient advice and to inform care by other professionals.

The practice provides 24-hour, 7-days-a-week patient access to nurse or other practitioner who has real-time access to practice’s medical record, for patient advice and to inform care by other professionals.

The practice has implemented at least one form of asynchronous form of communication (e.g., patient portal, email, text messaging) and has made a commitment to respond within two business days.

In addition to meeting Tier 2 requirements: the practice has implemented

open access scheduling, and the practice offers extended

hours, defined as office hours at least 35 hours a week plus at least one evening (after 6pm) and at least one weekend day.


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Recommendations

3. Patient Experience The practice implements one of the following strategies to obtain patient engagement feedback: conducts an initial patient survey

using a validated survey tool to establish a baseline and identify at least one domain needing improvement

forms a patient advisory council and holds meetings quarterly to obtain feedback and documents the nature of feedback and how the practice is using it.

The practice obtains patient feedback by: conducting a practice-based survey

semi-annual, and holding family/patient council

meetings quarterly.The practice develops communications to patients about specific changes being made to the practice in response to patient feedback.

The practice meets Tier 2 requirements.

4. Quality Improvement Activity

The practice implements quality improvement initiatives to improve on at least two of the clinical process measures included in the Maine ACO Core Measure Set.

The practice implements quality improvement initiatives to improve performance on at least two of the clinical process measures included in the Maine ACO Core Measure Set not addressed during the prior 24 months, and two outcome measures.

The practice implements quality improvement initiatives to improve performance on at least four of the clinical outcome measures included in the Maine ACO Core Measure Set.


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Recommendations

5. Quality Improvement Results

The practice annually demonstrates statistically significant improvement for at least two clinical process measures included in the Maine ACO Core Measure Set, unless the practice performs at or above a high-performance benchmark for each measure can the measure set, in which case it will be deemed to meet the improvement target.

The practice annually demonstrates statistically significant improvement for at least a) two clinical process measures, and b) one clinical outcome measure included in the Maine ACO Core Measure Set, unless the practice performs at or above a high-performance benchmark for each measure in the measure set, in which case it will be deemed to meet the improvement target.

Use a two-year look back period.

The practice annually demonstrates statistically significant improvement for at least two clinical outcome measures included in the Maine ACO Core Measure Set or performs at or above a high-performance benchmark for each outcome measure in the measure set.

Use a 2-year look back period.


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Recommendations

6. Care Coordination Across the Medical Neighborhood

The practice has implemented processes (and tracks compliance) with high volume hospitals and high volume post-acute institutional providers regarding: notification of admissions and

clinical information exchange at the time of admission

notification of discharge, clinical information exchange and care transition management at hospital discharge

In addition to meeting Tier 1 requirements: the practice has entered into

compacts/collaborative agreements with at least two groups of high volume specialists in different specialties to improve transitions of care

the practice has developed standard processes and documents for communicating key information during care transitions and upon referral to other providers.

In addition to meeting Tier 2 requirements:

the practice maintains compacts/collaborative agreements with an additional two groups of high volume specialists in different specialties to improve transitions of care


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Recommendations

7. Shared Decision Making

No requirements for Tier 1. The practice identifies shared decision-making resources, develops shared-decision making protocols for at least two health conditions and trains all impacted staff on shared decision-making protocols.

Practice implements shared decision making protocols for at least two health conditions.

Practice tracks shared decision-making initiative by either:o tracking the proportion of

eligible patients who receive shared decision-making aid, or

o creating quarterly counts of pts receiving shared decision-making aids by each health condition.

In addition to meeting Tier 2 requirements: the practice implements shared

decision making protocol for at least two additional health conditions


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Recommendations

8. Health Information Technology

Participating providers attest to meeting Stage 1 Meaningful Use requirements for EHR Incentive Programs.

The practice has created and populated two patient registries: one for high risk patients and one for patients with a selected, high-prevalence, chronic condition (e.g., diabetes, hypertension, asthma, ADHD).

The practice has the ability to access a single medical record shared by the whole care team, and uses the record to manage communication and information flow in support of referrals to other clinicians, transitions of care and when care is received in other health settings.

The practice has added a patient registry for one additional high-prevalence chronic condition and regularly generates reports from its patient registries to assess population management opportunities.

The practice has identified the care settings/providers for which the practice has the ability to exchange health information electronically.

All eligible professionals within the practice are engaged with, and working towards attestation for Stage II of Meaningful Use in the timelines set by the Meaningful Use program.

The practice has added a patient registry for one additional high-prevalence chronic condition and regularly generates reports from its patient registries to assess population management opportunities.

The practice has established health information exchange practices with health care setting/ providers for which it has the ability to exchange health information electronically.


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Recommendations

9. Measure Generation and Reporting Requirements

The practice: generates all clinical data-based

ACO Core Measure Set measures and reports them to Maine Quality Counts

is capable of running reports from its patient registry to identify individual patient care and population management opportunities.

In addition to meeting Tier 1 requirements, the practice has implemented a process to verify its ability to accurately report clinical data-based ACO Core Measure Set measures consistent with prescribed specifications and made corrections required to improve the accuracy of its reporting.

In addition to meeting Tier 2 requirements, the practice routinely generates the following types of measure for internal clinical management: patient engagement or

activation patient functional status and/or

well-being


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Implementing the Recommendations

• With current variation in primary care payment models and attention on ACOs, plan sponsors, health plans and MaineCare will need to support primary care by demonstrating:

• Detrimental impact of FFS on PC delivery to achieve ACO goals• Evidence of effectiveness of value-based payment models• Increased performance accountability contained in the

recommended model – measurable value


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Implementing the Recommendations

• Practice Accountability:• How to assess practice performance?• Survey to gauge performance for 8 of 9

domains (excluding Quality Improvement Results)

• Third party to conduct survey

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Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | | 1 ACI

Text of Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207)...