2nd QCIPN Town Hall Meeting
December 10, 2014
Presenters:
Amita Goyal Garson Lee, MD Donna Mah, MDWhitney Limm, MD Donald Blair, MD Gregg Shimomura, MDAnna Loengard, MD Nadine Salle, MD Alan Suyama, MD
Agenda
TOPIC TIME(minutes)
I. Administrative Updates• QCIPN Membership and Website • Physician Compensation
10
II. Choosing Wisely & QCIPN Clinical Policies 40
III. Initiatives Update 20
IV. Panel Discussion• Questions and Answers
20
3
Participating PhysiciansActive as of November 2014
October 31st was the final date to join QCIPN in the first contract year (Aug 2014 to Jul 2015).
Physician Count Total QCIPN MDs
PHYSICIAN ORGANIZATION PCPs Specialists Total % Queen's Staff % Emails % W-9 Forms
Central Medical 10 3 13 46% 100% 100%
Direct 0 158 158 70% 100% 51%
Filipino 27 18 45 38% 69% 89%
Five Mountain 13 1 14 0% 93% 93%
HIPA 54 59 113 42% 88% 81%
HQPO 35 0 35 26% 100% 97%
KMA 9 4 13 0% 100% 100%
OPG 13 8 21 29% 90% 100%
PMAG 111 388 499 61% 84% 64%
QMG 15 117 132 100% 100% 100%
West HIPA 10 1 11 0% 100% 100%
TOTAL 297 757 1054 60% 89% 73%
QCIPN Website
• Website: http://queenscipn.org– User Name: QCIPNMD– Password: toweavehealth
• Content:– Updates– Policies & Procedures– QCIPN Meeting Recordings and Presentations– Tools and Other Documents
HMSA Physician Compensation Policy
First Year Policy• Sets the terms for how QCIPN will compensate PCPs and Specialists
related to the HMSA contract• Effective August 1, 2014 to July 31, 2015• To be eligible for compensation, QCIPN PCPs and Specialists must:
– Have a W-9 Form submitted to the QCIPN– Comply with the terms and conditions set forth in the physician
participation agreement, and– Comply with the requirements outlined in the QCIPN Membership
Qualification and Technology Requirements Policy
Second Year and/or Additional Payers• Physician compensation policies will be developed specific to each
new payer contract• Goal will be to relate QCIPN payment criteria and methodology
with how physicians are compensated
Physician Compensation ExampleFirst Year
Estimated Physicians Distributions
$ 6,600,000
297 PCPsQuarterly Payment
757 SpecialistAnnual
Payments
PCP Payment Methodology based on:
– Attributed Lives
– PCMH Level
Specialists Payment Methodology based on:
– Meeting Participation
– Specialty Endeavors
– Unique QCIPN Lives
60% of Taxed Revenue will be distributed to Physicians
PCP Payment Examples
Quarter 1 PCP Physician Compensation Pool
7
HMSA Quarter 1 Payment Distribution Amount
PMPM Possible Payments $6.00
Less: General Excise Tax (4.712%) $0.28
Net Revenue for Distribution $5.72
60% Physician Distribution $3.43
50% Specialist Pool Allocation $1.71
50% PCP Pool Allocation $1.71
PCP Payment Allocation – 1st Quarter (Aug – Oct 14)
PCP Pool ($1.71 x 564,503 member months) ~ $965,000
Process Payments ( 70%) Paid Quarterly ~ $675,500
Performance Payments* ( 30%) ~ $289,500
*Final Payment to PCPs for first contract year will include Performance payments if performance metrics are met and compensation is received by HMSA.
PCP Compensation Methodology
8
PCP Payment Projections
Physician QuarterlyDistribution
HMSA Member Months
PCMH Score PCMH Weighted Member Months
Percent of PCMH Weighted
Membership
Distribution to Each Practice or
PCP
Minimum Payment 30 1.0 30.00 0.00006 $38.99
Maximum Payment 6,690 1.0 6,690.00 0.01287 $8,695.63
PCMH LevelLevel achieved by quarter end used for
calculation
Level 3 1.00Level 2 0.85Level 1 0.60
Distribution to PCP’s Q1
70% Process Payment $675,500
*Average PCPs will earn approximately $2,000 per quarter
Specialty Payment Methodology
Participation PoolDistribution for meeting
attendance
• Minimum of 4 QCIPN meetings attended to qualify• Payment of $150 per meeting, and up to $1,000 for attendance at QCIPN 6 meetings• Total maximum payments will be ~ $750,000
Specialty Specific Endeavor Pool
Distribution to all specialists who participate on specific
endeavors developed by the QCIPN Board
• QCIPN Quality Committee to help prioritize specialty endeavors that:
•Encourage and improve PCP and Specialist collaboration•Achieve the triple aim
• QCIPN Board to determine and approve compensation per specialty endeavor, which could include payment for participation in endeavors and completion of deliverables
Activity PoolDistribution based on unique
QCIPN patients
• Remainder of the total Specialty pool will roll over and be paid out based on clinical activity for unique QCIPN patients
Distribution Pools: Total Distributions ~$3.3M :
Q1
Physician Payments Timing
Q1 Q2 Q3 Q4
Aug 14 Sept 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May15 Jun15 Jul 15 Aug 15 Sept 15 Oct 15
QCIPN Town Hall Meetings – Minimum for 4 required to qualify for payments
1ST PCP Payment
2nd PCP Payment
3rd PCP Payment
Final PCP &
Annual Specialist Payment
SAVE THE DATE: • The 3rd QCIPN Town Hall Meeting will be on February 4, 2015. • To receive credit for the meetings, attestation for 1st and 2nd Town Hall Meetings must be submitted by February 4, 2015.
Choosing Wisely
Dr. Whitney Limm
Queen’s Clinical Integration SVP
QCIPN President
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Choosing Wisely: Promotes conversations between physicians and patients by helping patients choose care that is:
• Supported by evidence• Not duplicative of other tests or procedures
already received• Free from harm• Truly necessary
Specialty Societies asked to identify “Five Tests or Procedures Physicians and Patients Should Question”to spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments
http://www.choosingwisely.org
Date of download: 11/1/2014Copyright © 2014 American Medical
Association. All rights reserved.
From: The “Top 5” Lists in Primary Care: Meeting the Responsibility of Professionalism
Arch Intern Med. 2011;171(15):1385-1390. doi:10.1001/archinternmed.2011.231
Figure 1. “Top 5” activities in family medicine. AACE indicates American Association of Clinical Endocrinology; ACOG, American College of
Obstetrics and Gynecology; ACPM, American College of Preventive Medicine; AHCPR, Agency for Healthcare Policy and Research; Ann
IM, Annals of Internal Medicine; Cochrane, Cochrane Database of Systematic Reviews; DEXA, dual energy x-ray absorptiometry; ECG,
electrocardiogram; NOF, National Osteoporosis Foundation; Pap, Papanicolaou; and USPSTF, US Preventive Services Task Force.
Figure Legend:
Reaction from
Emergency Room Physicians
• The campaign puts ER physicians at risk for medical liability.
• One of the campaign’s goals is to save money.
• Other specialty societies are telling ER physicians what to do and not do-- creating a culture of “finger pointing”.
• Payers will use these recommendations to deny reimbursement for specific tests and procedures.
1. Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules.
2. Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.
3. Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up
4. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.
American College of Emergency Physicians - Choosing Wisely
• American Academy of Ophthalmology– Don’t perform preoperative medical tests for eye surgery
unless there are specific medical indications
• American Academy of Orthopaedic Surgeons– Avoid performing routine post-operative deep vein
thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty
• American College of Cardiology– Don’t perform annual stress cardiac imaging or advanced
non-invasive imaging as part of routine follow-up in asymptomatic patients
Choosing Wisely Initiatives
• American Academy of Pediatrics– Computed tomography (CT) scans are not necessary in the
routine evaluation of abdominal pain
• American College of Radiology– Don’t image for suspected pulmonary embolism (PE) without
moderate or high pre-test probability
• The American College of Obstetricians and Gynecologists– Don’t perform routine annual cervical cytology screening
(Pap tests) in women 30–65 years of age
Choosing Wisely Initiatives
• American College of Physicians– Don’t obtain imaging studies in patients with non-specific
low back pain
• American College of Surgeons– Don’t do computed tomography (CT) for the evaluation of
suspected appendicitis in children until after ultrasound has been considered as an option
• American Psychiatric Association– Don’t routinely prescribe two or more antipsychotic
medications concurrently
Choosing Wisely Initiatives
• Endocrine Society and American Association of Clinical Endocrinologists– Don’t routinely order a thyroid ultrasound in patients with
abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland.
• American Gastroenterological Association– Do not repeat colorectal cancer screening (by any method) for
10 years after a high-quality colonoscopy is negative in average-risk individuals
• American Society of Nephrology– Don’t initiate chronic dialysis without ensuring a shared
decision-making process between patients, their families, and their physicians
Choosing Wisely Initiatives
“Medicine is a science of uncertainty and an art of probability.”
William Osler
“The palest ink is better than the best memory.”
Chinese Proverb
Chest Pain Policy
Dr. Garson Lee
Associate Medical Director, Physician Relations
Hospitalist Program
Purpose: • Reduce unnecessary stress testing on low risk
patients.• Improve quality and safety by limiting
unnecessary exposure to radiation.• Improve cost by reducing unnecessary testing
and reducing emergency department length of stay.
Procedure:• Appropriate Use Criteria will be followed for all
patients with low risk chest pain.
Chest Pain PolicyPolicy #CBPG-001
Institute for Healthcare Improvement. (2013). 28 Oct 2014, from: http://www.mehmc.org/.
• Evidence on Pretest probability and accuracy of exercise stress testing
Chest Pain PolicyPolicy #CBPG-001
Pre-test Probability False Positive False Negative
Low 91 14
Intermediate 13 44
High 4 65
Weiner, CASS, NEJM 1979; 300:1350
• Accuracy of test
Chest Pain PolicyPolicy #CBPG-001
Sensitivity Specificity
Exercise ECG 68 77
Stress echo 76 88
Planar thallium 79 73
0%
20%
40%
60%
80%
100%
120%
Stress ECG (25)
Stress Echo (70)
Dobut Echo (1)
Stress NM (11)
Appropriate
Rarely app
Chest Pain PolicyPolicy #CBPG-001
Our Performance in August 2014 (n=106)
Chest Pain PolicyPolicy #CBPG-001
How are we going to implement this?
• What are we tracking?– Compliance with AUC criteria by using the chest pain order
form
– Rate of stress testing in asymptomatic low risk population
Chest Pain PolicyPolicy #CBPG-001
Pulmonary Embolism Policy
Dr. Donald Blair
Queen’s Medical Director of Imaging
• Revolution in Imaging
• Change in the approach to diagnosis
• ‘Unnecessary’ Imaging Studies
• Evidence based protocol to identify patients that don’t have PE without the use of Imaging– Negative Imaging study is as good as a negative
protocol
Pulmonary Embolism Testing
Overview
• Goals: – Improve patient care
• We reserve Imaging for those patients more likely to have the disease
– Increase % of exams that are positive
– More efficient expenditure of health care dollars
• If the protocol deems a patient to not have PE then they do not. False negative rate comparable to Imaging.
– Improve population Health - Decrease radiation exposure to population
• Decrease the number of exams performed per 1000 lives/ER visits– Improved expenditure of health care dollars
Pulmonary Testing ProtocolGoals
• A clinical prediction rule -Identify the best combination of medical sign, symptoms, and other findings in predicting the probability of a specific disease or outcome
• Wells score:[15]
• Clinical signs and Symptoms of DVT — 3.0 points• PE is #1 diagnosis or equally as likely— 3.0 points• tachycardia (heart rate > 100) — 1.5 points• immobilization (≥ 3d)/surgery in previous four weeks — 1.5 points• history of DVT or PE — 1.5 points• hemoptysis — 1.0 points• malignancy (with treatment within 6 months) or palliative — 1.0 points
Pulmonary Testing ProtocolWells Criteria
• Wells Score > 4 — PE likely. Consider diagnostic imaging. (CTA, V/Q, MRA)
• Wells Score 4 or less — PE unlikely. Consider D-dimer.
– D-dimer elevated Imaging
– D-dimer not elevated No PE
Pulmonary Testing ProtocolAlgorithm
• Increase in Percentage of Positive Yield– 404 ER patients, (+) yield before was 8.4% and 16.7 %
after algorithm
• False Negative Rate– 32% of 3306 patients (82% Outpatients) had Unlikely
Wells Score and Negative D-dimer.
– 0.5% incidence of VTE over next 3 months
– 1.3% incidence of VTE over next 3 months in CT (-) pts
Pulmonary Testing ProtocolLiterature
Drescher F.S. et al. Annals of Emergency Medicine Vol 57 No 6 p613-621Christopher Study Investigators. JAMA Vol 295 No 2 p172-179
• False Negative Rate– 45% of 598 patients had Unlikely Wells Score and
Negative D-dimer.
– 1.5% had PE over next 3 months
• Decrease the number of exams performed per 1000 lives/visits– 6838 ER patients, CTA ordering decreased 20.1%
from 26.4 to 21.1 exams per 1000 patients
Pulmonary Testing ProtocolLiterature
Geersing G-J et al. BMJ 2012;345:e6564Raja A.S. Et al. Radiology Vol 262 Num 2 p 468-474
• Carelink will ask for the Wells score
• IP and ER
• Outpatient
– Draw D-dimer at POB 3
– Patient goes to Imaging and awaits results
Pulmonary Testing ProtocolNuts and Bolts
• Wells, revised Geneva, simplified Wells and simplified revised Geneva were studied on 807 patients
• They excluded PE in 22-24% of patients when combined with D-dimer
• The failure rate were similar (0.5 – 0.6%)
Pulmonary Testing ProtocolComparing CPR
Douma R.A. et al. Annals of Internal Medicine 2011: 154:709-718
• 3346 ER patients, 2898 Not High Likelihood for PE
• 28% D-dimer below 500
• Additional 11.6% D-dimer between 500 and age adjusted D-dimer level
• 3 month False negative rate 0.3%
Pulmonary Testing ProtocolAge Adjusted D-dimer
Righini M. et al. JAMA 2014;311(11):1117-1114
Pediatric Asthma Policy
Dr. Nadine Tenn Salle, FAAP
Dr. Donna Mah, FAAP
QCIPN Board of Directors
Total pediatric inpatient volumes are expected to decrease by 8%, this is in part due to an increased focus on disease management of chronic disorders.
Disease management drives shift of services to outpatient setting.
Pediatric Asthma
Pediatric Asthma
Pediatric asthma services are ripe for care redesign.
–Prevalence: 1 in 10 children
–Emergency Room visits: one of the top 5 diagnoses
–Inpatient: 2nd most common inpatient admissions
Pediatric Asthma
Predicted impact over the next 1-5 years:
–Medical homes with registries for pediatric asthma patients will become standard.
–Compliance with evidence-based care and improved coordination will be a main focus
–Payer scrutiny and penalties for unnecessary care are likely to emerge early in asthma care, targeting potentially avoidable asthma admission and ED visits.
–Mandated quality reporting will increase as metrics evolve and national benchmarks emerge.
Pediatric Asthma
Long term impacts
–Molecular diagnostics and pharmacogenetics will improve disease management and reduce IP and ED but potentially add complexity to the care pathway.
Pediatric Asthma
Program components
–Reference: QCIPN Pediatric Asthma Policy
Pediatric Asthma
Patient Engagement
–Foster self/family management of asthma which has been shown to drive improvements in asthma control
–Utilize emerging patient engagement tools for pediatric patients and their families
Pediatric Asthma
Payment
–Choosing meaningful outcomes and process measures for asthma
Pediatric Asthma
Year One:Community standard for diagnosis of asthma
Primary care (pediatricians) will be asked to create and manage (deleting) their (asthma) registry
Increase CME on targeted asthma interventions and appropriate diagnosis and treatment of bronchiolitis
Pediatric Asthma
Year Two:•Utilizing PCP governed asthma registries to implement:
a.Planned asthma visit
b.Classification of asthma severity
c.>4YO receive spirometry
d.Asthma action plan
Pediatric Asthma
Year Three: Achieve the triple aim
Improve the community standard of diagnosing and managing asthma in pediatric patients
Increase parent/patient understanding of asthma and appropriate management.
Improve cost by improving use of appropriate medical treatment and reducing unnecessary room use
Reduce mortality and morbidity of pediatric asthma
Pediatric Asthma
Preoperative Diagnostic Testing
Dr. Alan T. Suyama
Queen’s Medical Director, Anesthesia Services
The purpose of this policy is to:
•Reduce the number of unnecessary preoperative laboratory tests
•List outcome metrics to measure effectiveness of the policy.
Perioperative Testing
Justification:
• Increased cost of care related to unnecessary testing and potential for false positive results
• Patient inconvenience
• Little benefit to improving the health of surgical patients
Perioperative Testing
• Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.
• Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/ esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.
Perioperative Testing
Choosing WiselyAmerican Society of Anesthesiologists
• Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.
• Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.
Perioperative Testing
Choosing WiselyAmerican College of Physicians
• Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.
Perioperative Testing
Choosing WiselyAmerican College of Surgeons
• Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery.
• Prior to cardiac surgery, there is no need for pulmonary function testing in the absence of respiratory symptoms.
Perioperative Testing
Choosing WiselyThe Society of Thoracic Surgeons
Quality Initiative Proposal: No routine preoperative diagnostic testing in ASA class 1 and ASA class 2 patients undergoing outpatient or ambulatory surgery.
Population Health and Well-Being
Dr. Gregg Shimomura
QCIPN Board of Director
58
Workgroup 3
Workgroup 3 – Population Health and Well-Being Initiative
HMSA/Healthways Care Model• Predictive model determines 4 cohorts of patients that benefit from
assistance• Assign RN’s, SW’s, Dieticians to work via Care Plans directly with patients• Control costs of care by providing broader patient support foundation
Population Health – Healthways Well-Being Assessment• Self Help• Online interactive survey: health, labs, work, behaviors, emotion• Self Plan with online tools, resources, and services• www.hmsa.com/wbc
59
Care Model
HMSA/Healthways Care Model
4 Cohorts:• Complex Cases• Short-Term Care• Re-Admit Risk• Late-Stage Chronic
Focuses on smaller number of patients. Predictive modeling program identifies who will decrease costs of care with additional support
Enhanced patient engagement with improved communication PCP primary focus; Specialists involved too Healthways Care Model nurses - >100 staffed Collaboration between Program and Physicians Need for phone numbers from PCP’s Hospital post-acute initiatives
60
Well-Being Assessment
Healthways Well-Being Assessment
Preventive Aspects to Disease Development Social Determinants of Health Adjunctive Care Management Support (Science Behind WBA) (Data Collected from WBA)
At the Least: Acknowledgement of the Importance of Health Behaviors Resources for Motivated Patients
Advanced Care Planning
Dr. Anna Loengard
QCIPN CMO
• Provide care consistent with patients’ goals across all sites of care
• Achieve QCIPN/HMSA contracted metrics for year one
Advance Care Planning
ACP Initiative Goals
Advance Care Planning
Goals of Care Known, Documented and Respected
ACP documents
AT HOME
OUTPATIENT SETTING
HOSPITAL
QCIPN-HMSA Year 1 ACP Metrics
Year 1 Advanced Care Planning Metrics
Process Metrics
• Develop and approve Policy for this initiative
• Engage Respecting Choices
• Educational meetings with founding PO’s on policy
Performance Metrics
• Establish a Respecting Choices Program with at least 32 trained facilitators
• QCIPN physicians refer at least 200 non-inpatient commercial and/or Medicare advantage members for Advanced Care Planning discussion
• The ACP policy was out for comment and is under review
• Respecting Choices has been engaged for “Last Steps” program– 32 facilitators will be trained in Feb 2015
• Lori Protzman RN is developing ACP clinic and working with Physician Organizations– Starting on punchbowl and looking for additional
sites
ACP Metrics
Where We Are Now:
• Support physicians in explaining ACP to patients
• Discuss importance of AHCD and help patients to express their general preferences
• Communicate outcome of clinic to provider– AHCD signed/POLST initiated
• Phone follow-up with patient on experience– Track outcome measures
ACP Clinic
Goal of the ACP Clinic:
• Refer any patient you think should have an AHCD
– Both PCPs and Specialists welcome to refer
• Introduce the ACP clinic to patient/families
• Lori will let you know when patient has attended
ACP Clinic
QCIPN Providers:
• Starting January 5, 2015 ACP clinic will be scheduled in the diabetes education center:
– Monday 1-2pm
– Thursday 9-10
– Friday 10-11
• Call Lori at 691-7716 to refer a patient
• We will have ACP referral form on website soon
ACP Clinic
ACP CLINIC SCHEDULE:
“What’s the matter with you?”
AND
“What matters
to You?
Patient Focus
Enhance the Conversation
70
Closing & Questions
Contact Information:
General Inquiries: [email protected]
Whitney Limm, MD: [email protected]
Anna Loengard, MD: [email protected]
Amita Goyal: [email protected]