Frederick Integrated Healthcare Network All Provider Meeting · 2016-03-08 · July 15, 2015 1....
Transcript of Frederick Integrated Healthcare Network All Provider Meeting · 2016-03-08 · July 15, 2015 1....
Frederick Integrated Healthcare Network
All Provider Meeting
July 15, 2015
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Agenda• Medicare Benchmark Report Update Summary Q1 2015• Attribution to Specialists – steps the ACO is taking to help minimize
• FMH Employee Health Plan contract update• EcW ‐ EMR Integration status and Reporting update• Care Management update• CME
• Dr Mark Glass‐Royal: “Overutilization of Advanced Imaging and the Choosing Wisely Initiative”
• Wrap‐up
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Financial and Utilization Results Summary Q1 2015
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Where are the opportunities?• ESRD costs are > National ACOs• Disabled and non‐Dual Eligible costs are > National ACOs and rising in FIHN
• COPD admissions > National ACOs • Imaging Cost and Utilization > Milliman and National ACOs
• Part B Drug Cost > National ACOs
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MillimanData recently released• Hospital Utilization – within Milliman standards except...
• One day length of stay admissions – rate highest among all other Premier ACOs
• Rates of Emergency Room use determined preventable through PCP access are the highest of any Premier ACO
• Urgent Care utilization 4x higher than Milliman • High Tech Imaging utilization 3.5x higher than Milliman• SNF Length of Stay and cost is higher than other ACOsPatterns:PCP access/patient education issues driving avoidable hospital utilization
High Tech imaging utilization SNF costs – report card and preferred Agreements
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Quick
Large
Impact on quality
Time to Return on Investment
Leakage ‐ inpatient
Small
Long
Population health interventions by time to ROI and impact on quality
Post‐hospital transition management
Patient access
Utilization –end of life
care
Leakage – OP non‐procedural
Leakage – OP procedural
Disease management
Case management
Utilization – discretionary procedures
Post acute care management
Leakage ‐ imaging
Utilization ‐ imaging
Utilization ‐ pharmacy
ROI – Return on Investment, OP ‐ outpatient
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Attribution to Specialists• Medicare attributes patients to the ACO based on a 2 step process sifting through 12 months of claim data:• PCP visit – Internal Med., Family Practice, Geriatrician, General Practice
• If no PCP visit, attributed to specialist providing medical care (evaluation and management visits)
• Attribution to a PCP is important – attributed provider is responsible for ACO quality measures/PQRS compliance
• Sample quality measures: mammography screening, flu shots, pneumonia vaccine, colonoscopy, tobacco use, depression screening, fall screening
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Reducing Attribution to Specialists• List of specialist attributed Medicare patients distributed in May (based on CMS data thru October 2014)• Is the patient scheduled to be seen soon?
• Encourage patient to see a PCP this year and annually• Provide the list of PCPs accepting new Medicare patients if the patient has no PCP
• Is staff able to outreach to a few patients to encourage PCP visits?
• What FIHN is doing to help:• Looking in NexGen to see if specialist attributed patients have seen a PCP in the past or midlevel provider
• FIHN will tell the PCPs about these patients and help with a post card campaign to get the patient in to be seen 12
Attribution to Specialists• FIHN will re‐run reports quarterly to see if patient attribution to specialists is declining and provide feedback
• If the patients remain attributed to a specialist, FIHN will work with you to assist in the quality measure compliance
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FMH Employee Health Plan contract update
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FMH Employee Health Plan contract update
• 45/1832 members opted out of data sharing• UMR provided 12 months of claim data to FIHN• Updated reports on cost and quality measures available in July
• Claim data will then be loaded in the e‐CW product• Drill down reporting will then be available on quality and cost opportunities
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Measures selected with FMH Human Resources and FIHN
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Emergency Room visits/1000
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Radiology Utilization/1000
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Mammography Screening
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Hypertensive patients with Lipid Panel
Patient Detail Reports• Patient level detail reports will be delivered to the practice• Showing gaps in care for the preventive measures (mammography and hypertensive with lipid panel)
• Showing the patients with opportunity for the utilization measures (ER visits)
As we drill down into claim detail we will publish rates of imaging utilization by referring/ordering provider
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EcW ‐ EMR Integration status and Reporting update
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Analytics/Care Mgmt : Rollout
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Rollout Steps Status
Receive Claims File Received
Publish Analytics Live ‐ Internal
Extract data from eCW and NextGen EHRs In Progress
Deploy eHX HIE (Health Information Exchange)Installation in progress
July/Aug
Publish Test System : Analytics, Care Management, Data Verification
COMPLETE
Live Care Management System (limited users) Live
Live eHX data Sharing (2 practices) July/Aug
Data Analyst , Hired = Aron FejesFIHN IS Liaison, Hired = Sean ShillingereCW on‐site analyst = Sahil Jain
eCWEHR‐only ACO Measure Score Card1/1/2015 – 6/19/2015
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Ejection Fractionmissing
eCWEHR‐only ACO Measure Score Card1/1/2015 – 6/19/2015
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• continued
IS Liaison Work• The FIHN IS Liaison (and/or eCW Analyst) will work with your practice to:• Understand how to document ACO performance measures
• Publish and deliver meaningful performance reports to your practice
• Help you understand the reports• Field requests for additional reports (subject to approval by FIHN leadership)
• Field questions about the use of Information Technology used for FIHN 26
Care Management update
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Care Management Update• Current State
• 1 CM dedicated to FIHN MSSP practices• 110 patients “engaged” thru July 6
• 65 provider generated referrals• 45 proactive outreach following hospital encounters• Referrals from 11 practices
• Future State (Late Aug/September)• 4.5 Additional FTEs – embedded in provider practices
• 2.0 social workers• 2.5 RNs• Pilot with Care Transitions Pharmacist
• On site medication management/consultation
• E‐clinical works – on hold until staff are onboard, trained and deployed
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Mark Glass‐Royal, M.D.Chairman, Department of imaging Services, FRHSPresident, Radiology Associates of Frederick
Overutilization of Advanced Imagingand the Choosing Wisely Initiative
The Challenge
• How to interpret Guidance from Choosing Wisely
• 19 recommendations re Head and Spine Imaging
Crowded Literature: Numerous Reports reUnnecessary Imaging
• 2000‐2007 Imaging grows faster (Medicare)
• 20‐50% of studies provide no useful clinical management information (America’s Health Insurance Plans)
• $7‐$12B per year (Peer 60)
• Sorting fact from fiction
Nieman Survey
Why?
• Imaging is a valuable tool ‐ Physicians need to know
• Patient driven requests….My Aunt Minnie/I had a body scan
• Do something ‐ I’ve been here with my kid for five hours….
• Ease of access (2006 data) ‐MRI: 7,930 (41% increase from 1995)
‐ CT: 10,150
Why Else?
• ABIM/RWJ Study
‐ 72% of physicians report “Knowingly ordering at least one unnecessary test a week”
‐ More than 50% said they order unnecessary tests to avoid potential malpractice suits
Until Meaningful Tort Reform….
The Dilemma
What to do?•Choosing Wisely
• 300‐120‐19 (many are duplicative)
Choosing Wisely Recommendations
TheChoosing Wisely lists were created by national medical specialty societies and represent specific, evidence‐based recommendations clinicians and patients should discuss.
Each list provides information on when tests and procedures may be appropriate, as well as the methodology used in its creation.
Choosing Wisely Initiatives: Spine • Imaging of the spine in patients with acute low back pain during the early phase of symptom onset is unnecessary. • Red flags that may indicate that early imaging of the spine is required can include neurological deficit such as weakness or numbness, any bowel or bladder dysfunction, fever, history of cancer, history of intravenous drug use, immunosuppression, steroid use, history of osteoporosis or worsening symptoms
American Assn. of Neurological Surgeons and Congress of Neurological Surgeons
Many other specialty societies agree…• Don’t order low back x‐rays as part of a routine pre‐placement medical examination (American College of Occupational and Environmental Medicine)
• Don’t initially obtain x‐rays for injured workers with acute non‐specific low back pain (American College of Occupational and Environmental Medicine)
• Avoid lumbar spine imaging in the emergency department for adults with non‐traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspected of having a serious underlying condition (such as vertebral infection, cauda equine syndrome, or cancer with bony metastasis) (American College of Emergency Physicians)
• Don’t order an imaging study for back pain without performing a thorough physical examination (American Academy of Physical Medicine and Rehabilitation)
Many other specialty societies agree…• Don’t recommend advanced imaging (e.g., MRI) of the spine within the first six weeks in patients with non‐specific acute low back pain in the absence of red flags. (North American Spine Society)
• Don’t do imaging for low back pain within the first six weeks, unless red flags are present. (American Academy of Family Physicians)
• Don’t obtain imaging studies in patients with non‐specific low back pain (American College of Physicians
• Avoid imaging studies (MRI, CT or x‐rays) for acute low back pain without specific indications (American Society of Anesthesiologists – Pain Medicine)
• Don’t obtain imaging (plain radiographs, MRI, CT, or other advanced imaging) of the spine in patients with non‐specific acute low back pain and without red flags (American Assn. of Neurological Surgeons and Congress of Neurological Surgeons)
Choosing Wisely Initiatives: Head
• 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.• Physicians can safely identify patients with minor head injury in whom it is safe to not perform an immediate head CT by performing a thorough history and physical examination following evidence‐based guidelines
American College of Emergency Physicians
Many other specialty societies agree…• Don’t routinely obtain CT scanning of children with mild head injuries (American Assn. of Neurological Surgeons and Congress of Neurological Surgeons)
• Avoid ordering a brain CT or brain MRI to evaluate an acute concussion unless there are progressive neurological symptoms, focal neurological findings on exam or there is concern for a skull fracture (American Medical Society for Sports Medicine)
• Avoid CT scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules (American College of Emergency Physicians)
• CT scans are not necessary in the immediate evaluation of minor head injuries; clinical observation/Pediatric Emergency Care Applied Research Network (PECARN) criteria should be used to determine whether imaging is indicated (American Academy of Pediatrics)
Choosing Wisely Initiatives: Head• Don’t do imaging for uncomplicated headache
• Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings.
American College of Radiology
Other specialty societies agree…• Don’t perform CT imaging for headache when MRI is available, except in emergency settings (American Headache Society)
• Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine (American Headache Society)
Choosing Wisely Initiatives: Head • In the evaluation of simple syncope and a normal neurological examination, don’t obtain brain imaging studies (CT or MRI) (American College of Physicians)
• Don’t order CT scan of the head/brain for sudden hearing loss (American Academy of Otolaryngology –Head & Neck Surgery Foundation)
Don’t routinely screen for brain aneurysms in asymptomatic patients without a family or personal history of brain aneurysms, subarachnoid hemorrhage (SAH) or genetic disorders that predispose to aneurysm formation (American Assn. of Neurological Surgeons and Congress of Neurological Surgeons)
Look Closely• Words Matter• Every recommendation is qualified…minor, serious, insignificant, red flags, routinely, etc.
• Imaging not a reflex – need for imaging should be based on sound clinical judgment
I am not here to tell you how to practice medicine
Next StepsPhysicians –
• High Utilizers‐ deploy care managers• Transitions in Care Management – 48 hour initial contact• Patient wellness visits – collect quality measures – identify rising risk
• Participate in EHR Integration with FIHN IT• Specialists – Choosing Wisely, ensure patients have a PCP• End of Life Quality ‐Advanced Directives/ MOLST/DNR
• FIHN –• Deploy medical and cost management strategy – engage providers• CG‐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 savings• Payor contracting – future Agreements
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Future All Provider Meeting Dates
•October 14, 2015 – final for 2015
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