SCCIPA Provider Meeting - PPMSI Provider...V10.06 Personal history of malignant neoplasm; rectum,...

Provider MeetingMarch, 2011

Wayne Pan, MD, MBA

SCCIPA

2010 Provider Bonuses

SCCIPAA Pacific Partners Medical Group

All BONUS CHECKS were mailed last week

A total of $1.5 million distributed

50:50 split between PCPs and Specialists

Only EXCLUSIVE PCPs and PAR Specialistswere eligible for a bonus



Primary Care Physicians’ bonus formula:1/3 for Pediatrician P4P1/3 for other PCP P4P

1/3 for HCC



2009 75th California percentile tier for old measures and the SCCIPA 2010 average for new measures

Tiers were case-mixed adjusted to each provider’s particular P4P-eligible population to make it fair

Mammogram and chlamydia were excluded from bonus calculation



PCPs who hit the benchmark were assigned a portion of the bonus equivalent to their eligible membership (denominator) multiplied by their

completion percentage



HCC Bonus was ~$104/RAF point assigned to the PCP’s patient panel



Specialty Care Physicians’ bonus formula:Same as December, 2010 distribution


2011 Bonus StructurePCPs: 2011 IHA P4P and HCC

CMS 5 STAR Rating measures

Participation in patient satisfaction training (4 meetings)

Patient satisfaction scores (based on the CAHPS survey)

Responsiveness to PPMSI Med Management inquiries

PhysicianWorkplan


distributed quarterlyfor assigned patientswhose birthdays fall

in the first orsecond quarter

ADULT PCP WORKPLAN

PEDIATRIC PCP WORKPLAN


SCCIPA 2011 PHYSICIAN WORK PLAN MEASURE LIST Current Measures

Measure Description Eligible Population Exclusions Childhood Immunizations

4 Diptheria, tetanus, and acellular pertussis (DTaP)

4 DTaP with different DOS from 42 days old to 2 years old

Children who turn two in 2011 who are continuously enrolled from birth to the second birthday. Must also be enrolled on the child's second birthday.

Any vaccine: Anaphylactic reaction to vaccine or components DTaP: Encephalopathy or progressive neurological disorder, including infantile spasm, uncontrolled epilepsy. IPV: Anaphylactic reaction to streptomycin, polymyxin B or neomycin. MMR, VZV: immunodeficiency including congenital immuno-deficiency syndromes; HIV; cancer of lymphoreticular or histiocytic tissue; multiple myeloma, leukemia, anaphylactic reaction to neomycin or common baker’s yeast. HepB: Anaphylactic reaction to common baker’s yeast

3 Polio (IPV) 3 IPV with different DOS from 42 days old to 2 years old

1 Measles, Mumps, Rubella (MMR)

1 MMR up to second birthday (Accept: Evidence of antigen or vaccine, documented history of illness, seropositive test result)

3 H influenza B (HiB) 3 HiB with different DOS from 42 days old to 2 years old

3 Hepatitis B (Hep B)

3 Hep B with different DOS up to 2 years old. (Accept: Evidence of antigen or vaccine, documented history of illness, seropositive test result)

1 Chicken Pox (VZV)

1 VZV up to second birthday (Accept: Evidence of antigen or vaccine, documented history of illness, seropositive test result)

4 Pneumococcal Conjugate (PCV)

4 PCV with different DOS up to 2 years old

Adolescent Immunizations 1 Menningococcal conjugate (MCV) or Menningococcal polysaccharide (MPSV4)

1 MCV4 or MPSV4 on or between 11th and 13th birthdays.

Adolescents who turn 13 in 2011 who are continuously enrolled for 12 months prior to 13th birthday. Must also be enrolled on 13th birthday.

Anaphylactic reaction to any vaccine or its components. 1 Tetanus, diphtheria,

acellular pertussis (Tdap) or tetanus, diphtheria (Td)

1 Tdap or Td on or between 10th and 13th birthdays.

Chlamydia At least one chlamydia test in 2011.

Sexually active women 16-24 determined by pharmacy data (prescription contraceptives) or encounter data who are continuously enrolled during 2011.

Women with pregnancy test followed within 7 days by either Accutaine or X-ray. (Doesn’t apply to those who qualify based on services other than pregnancy test alone.)

PhysicianWorkplan


2011 Bonus StructureSpecialists: billing or SCCIPA unique patient volume

Overall achievement of SCCIPA in the CMS 5 STAR Rating Program

Participation in patient satisfaction training program (4 meetings)

Patient satisfaction scores (based on the CAHPS survey)

Use of Excelicare Clinical Hub

Responsiveness to PPMSI Medical Management inquiries (timeliness)


MedicareQuestionnaire


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ComingSOON

Colon Cancer Screening


CRCScreeningGUIDELINES


Milliman, 15th edition (2011)

Average-risk adult: Age 50 or older For African Americans, age 45 or older AND No colonoscopy in past 10 years




High-risk family history: First degree family, diagnosed with CRC/ adenomatous polyps AFTER age 60 Age 40 and older AND No colonoscopy in past 10 years




High-risk family history: First degree family, diagnosed with CRC/ adenomatous polyps BEFORE age 60 Age 40 and older OR Age 10 years younger than earliest age of diagnosis of colon cancer in family, or older AND No colonoscopy in past 5 years




High-risk family history CODING: V16.0 Family history of malignant neoplasm; gastrointestinal tract V18.51 Family history of colonic polyps

Please specify family member (parent, sibling, child), age of diagnosis, and type of colon polyp (if applicable) in “Note” field of authorization




High-risk personal history: Lynch syndrome: age >20, repeat colonoscopy annually s/p colon or rectal cancer removal Surveillance colonoscopy at 1 year, 3 years post resection, and then every 5 years s/p removal of 1 or 2 tubular adenomas, less than 1 cm, low-grade dysplasia - No colonoscopy in past 5 years




High-risk personal history: s/p removal of adenoma with advanced neoplasia OR s/p removal of 3 to 10 adenomas AND No colonoscopy in past 3 years s/p removal of more than 10 adenomas AND No colonoscopy in past 2 years




High-risk personal history CODING:

History of colorectal cancer V10.05 Personal history of malignant neoplasm; large intestine V10.06 Personal history of malignant neoplasm; rectum, rectosigmoid junction, and anusLynch Syndrome V84.09 Genetic susceptibility to other malignant neoplasm Please specify “Lynch Syndrome” in “Note” field of authorization




High-risk personal history CODING:

History of colonic polyps V12.72 Personal history of colonic polyps Please specify number and type of adenomas removed in “Note” field of authorization




Medicare rules for HIGH RISK: A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp A family history of familial adenomatous polyposis A family history of hereditary nonpolyposis colorectal cancer A personal history of adenomatous polyps A personal history of colorectal cancer A personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis




Medicare patients who are HIGH RISK: No colonoscopy in past 2 years




Additional CRCScreening diagnosis CODES:Inflammatory Bowel Disease: Crohn’s Disease 555.0 Regional Enteritis or Crohn’s Disease, Small Intestine 555.1 Regional Enteritis or Crohn’s Disease, Large Intestine 555.9 Regional Enteritis or Crohn’s Disease, NOS

Inflammatory Bowel Disease: Ulcerative Colitis 556.0 Ulcerative (Chronic) enterocolitis 556.1 Ulcerative (Chronic) ileocolitis 556.2 Ulcerative (Chronic) proctitis 556.3 Ulcerative (Chronic) proctosigmoiditis 556.4 Pseudopolyposis of colon 556.5 Left Sided Ulcerative (Chronic) colitis 556.6 Universal Ulcerative (Chronic) colitis 556.8 Other Ulcerative colitis 556.9 Ulcerative Colitis, Unspecified


Osteoporosis Screening


ScreeningGUIDELINESosteoporosis


Evidence of osteoporosis, as indicated by 1 or more of the following: Loss of more than 1.5 inches (3.81 cm) in height Kyphosis Osteopenia by plain x-ray Vertebral compression fracture by plain x-ray Spontaneously occurring fracture (eg, fracture from coughing, sneezing, or abrupt movement) Fracture occurring from fall at height no greater than patient's standing height (eg, fragility fracture) Any fracture occurring after age 50 years




Osteoporosis CODING: Evidence of osteoporosis781.91 Loss of height (please specify magnitude of loss in inches)737.10 Kyphosis (acquired) (postural)737.11 Kyphosis due to radiation737.12 Kyphosis, postlaminectomy737.41 Kyphosis associated with other conditions (include associated condition): 356.1 Charcot-Marie-Tooth disease 277.5 Mucopolysaccharidosis 237.70-237.79 Neurofibromatosis 731.0 Osteitis deformans 252.01 Osteitis fibrosa cystic 015.0 Tuberculosis (Pott’s curvature) 737.19 Other kyphosis (acquired) (excludes kyphosis associated with conditions above)




Osteoporosis CODING: Evidence of osteoporosis733.00 Osteoporosis, unspecified733.01 Senile osteoporosis733.02 Idiopathic osteoporosis733.03 Disuse osteoporosis733.09 Other osteoporosis (includes drug-induced)

733.90 Disorder of bone and cartilage unspecified Please specify “osteopenia” in “Notes” field of authorization




Osteoporosis CODING: Evidence of osteoporosisPathologic fracture (includes fragility fracture and spontaneous fracture due to bone structure weakening by a pathological process such as osteoporosis, neoplasms, osteomalacia, etc.)733.10 Pathologic fracture, unspecified site733.11 Pathologic fracture, humerus733.12 Pathologic fracture, distal radius and ulna (wrist NOS)733.13 Pathologic fracture of vertebrae733.14 Pathologic fracture of neck of femur (femur NOS or hip NOS)733.15 Pathologic fracture of other specified part of femur733.16 Pathologic fracture of tibia or fibula (ankle NOS)733.19 Pathologic fracture of other specified siteV13.51 Personal history of pathologic fracture (healed)

Any fracture (code depends on location and type of fracture)820-829




Female age 65 years or older

Male age 70 or older

Chronic long-term medication use: glucocorticoid therapy at dosage-equivalent of 5 mg of prednisone daily for 3 months or more anti-convulsant therapy for 3 months or more heparin therapy for 1 month or more depo-provera therapy for 2 years or more long-term or excess thyroid hormone therapy causing hyperthyroidism proton pump inhibitors for 2 years or more




Osteoporosis CODING: Chronic medication useV58.65 Long-term (current) use of steroidsV58.69 Long-term (current) use of other medications (include associated conditions and document which medication in “Notes” field): 345.00-345.91 Epilepsy 780.39 Other convulsions




Adult patient with the following disease conditions: Rheumatoid arthritis Cushing syndrome Hyperthyroidism Primary hyperparathyroidism Malabsorption (eg, inflammatory bowel disease, celiac sprue) Chronic renal failure Prolonged severe loss of mobility (ie, unable to ambulate outside home without wheelchair for 1 year or longer) Solid organ or allogeneic bone marrow transplant recipient



Osteoporosis CODING: Adult disease conditions714.0 Rheumatoid arthritis714.1 Felty’s syndrome (rheumatoid arthritis with splenoadenomegaly and leukopenia)714.2 Other rheumatoid arthritis with visceral or systemic involvement255.0 Cushing’s syndrome242.90 Thyrotoxicosis without mention of goiter or other cause without mention of thyrotoxic crisis or storm (Hyperthyroidism NOS)252.01 Primary parahyperthyroidism555.0 Regional enteritis or Crohn’s disease, small intestine555.1 Regional enteritis or Crohn’s disease, large intestine555.9 Regional enteritis or Crohn’s disease, NOS556.0 Ulcerative (chronic) enterocolitis556.1 Ulcerative (chronic) ileocolitis556.2 Ulcerative (Chronic) proctitis556.3 Ulcerative (chronic) proctosigmoiditis556.4 Pseudopolyposis of colon556.5 Left sided ulcerative (chronic) colitis556.6 Universal ulcerative (chronic) colitis556.8 Other ulcerative colitis

556.9 Ulcerative colitis, unspecified579.0 Celiac disease585.1 Chronic kidney disease, Stage 1 (some kidney damage; normal GFR)585.2 Chronic kidney disease, Stage 2 (GFR 60-89; mild)585.3 Chronic kidney disease, Stage 3 (GFR 30-59; moderate)585.4 Chronic kidney disease, Stage 4 (GFR 15-29; severe)585.5 Chronic kidney disease, Stage 5 (GFR <15) 585.6 ESRD (GFR<15; undergoing treatment of chronic dialysis or transplantation)585.9 Chronic kidney disease, unspecified586 Renal failure, unspecifiedV42.0 Kidney transplant statusV42.1 Heart transplant statusV42.6 Lung transplant statusV42.7 Liver transplant statusV42.81 Bone marrow transplant statusV42.83 Pancreas transplant statusV42.84 Intestine transplant Status



Postmenopausal female younger than 65 years: Body weight less than 127 pounds (57.6 kg) or body mass index 20 kg/m2 or less History of low-impact (eg, fragility) fracture in first-degree relative age 45 or older History of hip fracture in parent Current smoker Menopause (either natural or surgical) in patient < 40 years No current use of estrogen therapy History of hypogonadism as child or delayed puberty History of untreated hypogonadism Use of estrogen-deprivation therapy (eg, aromatase inhibitors) for breast cancer Alcohol intake of more than 2 drinks per day




Osteoporosis CODING: Postmenopausal female under 65 yearsV85.0 Body mass index less than 19, adultV17.89 Family history of other musculoskeletal diseases Please specify family member (parent, sibling, child), age of fracture, and type of fracture in “Note” field of authorization305.1 Tobacco use disorder (smoking)V07.52 History of aromatase Inhibitors (estrogen-deprivation therapy)256.31 Premature menopause (before age 40; natural or unknown cause)256.2 Postablative ovarian failure (postsurgical menopause)V07.4 On estrogen hormone replacement therapy256.39 Other ovarian failure (delayed menarche, ovarian hypofunction, primary ovarian failure NOS)305.00 Nondependent alcohol abuse; unspecified305.01 Nondependent alcohol abuse; continuous305.02 Nondependent alcohol abuse; episodic303.90 Other and unspecified alcohol dependence; unspecified (chronic alcholism)303.91 Other and unspecified alcohol dependence; continuous (chronic alcholism)303.92 Other and unspecified alcohol dependence; episodic (chronic alcholism)




Premenopausal female: Amenorrhea for 1 year or longer Estrogen-deprivation therapy (eg, gonadotropin-releasing hormone agonists for breast cancer) Chemotherapy-induced ovulatory failure (eg, cyclophosphamide)




Osteoporosis CODING: Premenopausal female626.0 Absence of menstruation (amenorrhea)V07.52 History of aromatase Inhibitors (estrogen-deprivation therapy) 256.39 Other ovarian failure (chemotherapy-induced ovarian failure)




Repeat bone density screening:

No bone density test in past 2 years




Medicare bone density screening criteria:

No bone density test in past 2 years



ALL bone density screenings directed to Valley Radiology (except in Gilroy/Morgan Hill - St. Louise or Dr. Papillon)


http://www.uptodate.com


colon cancer screening


SharedDecisionMaking

+ SCCIPA

LOW BACK PAINPROSTATE CANCER

pilot

Patient SatisfactionSCCIPA

A Pacific Partners Medical Group

3 Modules

Practice ImagePhysician - Healthcare Professional Interaction

Physician Handling Patient Frustration



PracticeImage


PracticeImagechecklistApproximately every two hours throughout the day, assign a staff person to perform the following tasks: Empty trash (in waiting room, work areas, exam rooms, restrooms) Clean any spills Straighten magazines Remove unauthorized (religious or commercial) literature Check temperature Adjust volume of music (soft & calming) Ensure bathrooms are supplied and clean Ensure check-in area is well organized and professional looking Make sure clinical areas are neat and tidyAlways ensure: Plants are healthy and well-tended All signage is polite, clear, and legible Reading materials are current and relevant to patients and their family members Appearance of physicians and staff is always well-groomed and professional Staff wear name badges that include their first name & position (large type face)


PracticeImagetip

Treat all patients and their family members in your practice as you would guests at your own home.


PhysicianHCPinteraction


PhysicianHCPchecklist

Take a moment to assess your own contributions to your practice culture.

Which of the following behaviors would benefit the morale of your practice team? Approach staff members with a pleasant expression Request assistance with respect Thank staff members for their assistance Provide ongoing positive feedback Celebrate successes


PhysicianHCPtipsNothing does greater harm to the credibility of a practice than allowing patients and their family members to witness or to hear disharmony among physicians and staff.

All behavior of the practice must demonstrate courtesy and respect.


MDhandlingPatientFrustration


PatientFrustrationchecklist

Techniques that can improve the way you handle patient frustration:

Pause to ask what is troubling the patient Apologize for the situation Acknowledge the concerns of the patient Express your commitment to providing quality care Proceed with the patient interview


Good listening often alleviates frustration.

PatientFrustrationtip


When encountering a frustrated or upset patient it is important to pause the interview and ask what is troubling the patient. This will help you respond appropriately and avoid miscommunication and confusion.

Listen to and acknowledge your patient’s concerns and apologize if there is a situation in your office that has upset them. Express that you care and are willing to hear more. One of the most common complaints among healthcare providers is that they do not have enough time, while a frequent patient complaint is that healthcare providers do not listen to them.

Assure the patient that you are committed to providing them with excellent care, refocus the patient on the reason for the visit, and continue with the interview.

PatientFrustrationtips


provided by

ThankyouSCCIPA

A Pacific Partners Medical Group


Wayne Pan, MD, MBAMedical [email protected]

SCCIPA Provider Meeting - PPMSI Provider...V10.06 Personal history of malignant neoplasm; rectum,...

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