Value by Design: A Population Health Primer for Provider Groups
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Transcript of Value by Design: A Population Health Primer for Provider Groups
©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |1©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |1
Value by Design
A Population Health Primer for Provider Groups
August 24, 2016
©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |6
Accelerating Shift to Value-Based Care
2007PQRS Quality Measures
2009ARRA
2010ACA &Meaningful Use
2013Value-Based Modifier
2014ACO / Risk Contracting
2017*MACRA
Per Capita Cost
Experience of Care
The Triple Aim
Health of a Population
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MACRA Makes 3 Key Changes to How Medicare Pays Providers
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How Will MACRA Quality Payment Programs Work?
95% 5%Participation
by Providers
Participation
by Providers
MIPS APMs
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MACRA’s Quality Payment Programs
• Streamlines PQRS, VM, and EHR reporting programs
• Will apply to most Medicare Part B clinicians with a few exceptions
• Generates a MIPS composite performance score (0-100) based on:
– Quality (50%)
– Resource Use (10%)
– Clinical Practice Improvement Activities (15%)
– Advancing Care Information (25%)
Merit-Based Incentive Payment System (MIPS)
• Use certified EHR technology
• Payments based on quality measures similar to what’s listed in MIPS’ quality category
• Entities bear “more than nominal” financial risk ~or~ is a Medical Home Model under CMMI
• Examples of Advanced APMs for 2017 are: MSSP ACO (Tracks 2 & 3), Next Gen ACO Model, Comprehensive
ESRD Care (CEC), Comprehensive Primary Care Plus (CPC+), Oncology Care Model (OCM)
• “MACRA does NOT change how any particular APM functions or rewards value. Instead, it creates extra
incentives for APM participation.”*
Advanced Alternative Payment Models (APM)
Cri
teri
a
* https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-
Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MACRA-NPRM-slides-consumer-version.pdf
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How to Choose Between MIPS and APMs?
http://www.brookings.edu/research/papers/2016/07/12-how-the-money-flows-under-macra-patel-adler-darling-ginsburg
July 12, 2016
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Timeline for MACRA Implementation
April 2015
MACRA
Signed Into
Law
April 2016
Proposed
MACRA Rule
Fall 2016
MACRA Final
Rule
November 1, 2016
Deadline for Final
Quality Measures
for Performance
Period #1
January 1, 2017
MIPS Data
Collection
Begins*
January 1, 2019
First MIPS Payment
Adjustment
(+/- 4%) or 5%
Incentive Bonus for
APMs
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Trend: Risk Bearing Contracts
“There will come a time when the realization occurs that this is a partnership and
that the risk needs to be spread around.”
Two Types of Arrangements:
Upside RiskProvider only shares in the savings (not the losses)
Example: MSSP Track 1
Upside & Downside RiskProvider shares in (a greater) portion of savings but
also responsible for a portion of any losses
Example: MSSP Tracks 2 &3
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Trend: Provider Organizational Structures
PCMH
IPA
CINACO
|16©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |
WHAT CAN I DO NOW?
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Patient-Centered Medical Home Recognition
Tip: Make Sure The Payers You Work With Accept The Accreditation You Are Applying For
National Committee for
Quality Assurance
(NCQA)
Joint Commission
Accreditation Association
for Ambulatory Health
Care (AAAHC)
Utilization Review
Accreditation
Commission (URAC)
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Becoming a Patient-Centered Medical Home
Access to Care
Team-Based Care Population Health
Continuity of Care
Performance Measurement & Quality Improvement
|19©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |
6 TIPS TO THRIVE IN VALUE-BASED
REIMBURSEMENT
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6 Tips to Thrive in Value-Based Reimbursement
Have a Plan & Set GoalsCultivate an Organization
That is Receptive to Change
Continual & Evolving
Communication
Treat Your Practice Like
Your Own Checkbook
Pay Attention to Your
Quality Measures
Use Technology To
Your Advantage
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Tip #1: Have A Plan & Set Goals
Assessments
Gap Analysis
Resources
Budget & operational cost
Evidence-based guidelines
Learning networks & staying up to date
with best practices
Technology
Do you have an EHR?
Does the EHR meet your reporting needs?
Connection to a health information exchange?
Have you optimized your operational workflow with
your technology in mind?
Staff
Is there an EHR “super user”?
Who owns tracking of healthcare trends?
Provider champion and a quality improvement team
Physician alignment on cost / quality reporting
How receptive is your staff to change?
Is your staff consistently working at the top of their
skillset?
Outreach
Do you know your patient panel & demographics?
What options do you have to contact a patient?
What does your patient satisfaction survey say?
©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |22
Tip #2: Cultivate an Organization That is Receptive to Change
There is no “right answer” for everybody and change doesn’t have to be slow – try
lots of things in rapid succession and see what works for your organization
Plan
DoStudy
Act Plan
DoStudy
Act Plan
DoStudy
Act
• Engage all departments (360◦ view)
• Be transparent internally with providers and give
the feedback necessary to align behavior to
outcomes
• Communicate the impact of changes (good & bad)
• Think outside the box for healthcare opportunities
• All members of the team are important to patients!
Make your staff aware of how they contribute to
achieving the organization’s goals
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Tip #3: Continual & Evolving Communication
• Schedule all-staff meetings for education on
trends and quality / referral team activities
• Internal transparency with providers on goals /
impact of actions to drive behavior change
– Validate & communicate their
patient panels
• Pre-visit planning
• Create a patient advisory council and send
patient satisfaction surveys
– Message accomplishments /
mitigation plans
• Develop open communications with hospitals
and community agencies
• Find a cadence and platform(s) that works with
your patient populations
Internal External
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Tip #3: Continual & Evolving Communication
It’s never been easier to engage with your patients!
Use your website, portal, and email as a bi-directional
communication tool
• Practice announcements
– Non-traditional hours
• Post-visit report & referral information
• Summary of care
• Patient satisfaction surveys
– Use a CAHPS vendor if possible
• Treatment goal setting
• Appointment scheduling
• New patient forms
• Prescription Refills
To
Pati
en
tF
rom
Pati
en
t
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Tip #4: Treat Your Practice Like Your Own Budget
“If you can’t measure it, you can’t improve it”– Peter Drucker
In Network Care
• Fix referrals then leakage
• Increase “after hour” care options
• Consider bringing out-of-network high cost services inside your network
Cost Containment
• Operational costs (workflow, staffing/provider ratio, supplies)
• Enable staff to work at the top of their skill set
• Increase preventative services (well visits including vaccinations & screenings)
Overutilization
• Readmissions within 30 days
Optimize Revenue
• Negotiate competitive pricing
• Increase providers/services
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Tip #5: Pay Attention to Your Quality Measures
Ask Yourself: Do you know what your payers are measuring you on?
“If you can’t measure it, you can’t improve it”– Peter Drucker
don’t know what’s being measured
Terri Gonzalez^
^
5 Steps to an Effective Quality Measurement Program
Compile all quality measures across payer contracts into a single place
• Understand what your contracts require for quality measures (what measures are they looking at for your practice?)
Use reporting dashboards for increased visibility into your current performance
Focus on the most achievable measures first
• Patients that haven’t been seen in 2+ years
• Diabetic patients
• BMI gaps
Prioritize remaining gap closure based on which are closest to your contracted threshold
Get creative on the most difficult gaps to close
• e.g., Mobile eye exams, mobile mammography, teen health fair
1
2
3
4
5
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Tip #6: Use Technology To Your Advantage
Use analytics to manage your patient populations
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Tip #6: Use Technology To Your Advantage
How are we doing as a practice overall?1 What and where is my risk?2
What diagnostic categories are driving my costs?3 What are my quality measure gaps?4
©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |30
Population
100%
Impactability Prospective Risk
Moderate Impactability
12% of Members
Low Impactability
75% of Members
High Impactability
12% of Members
High
Low
Op
po
rtun
ity
Goal
Close Gaps
and Steerage
to Managed
Networks
Close Gaps
and Steerage
to Managed
Networks
Manage
High Costs
and Risk
Factors
Manage
High Costs
High Risk
10%
Moderate Risk
1.5%
Low Risk
0.5%
High Risk
8%
Moderate Risk
3%
Low Risk
1%
High Risk
13.5%
Moderate Risk
27%
Low Risk
34.5%
High Cost
1% of Members
Stratifying Populations by Financial Risk & Impactability
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What To Do Next?
Complete Your
Organizational Assessment
Understand Your Patient
Panel (& Communicate with
Providers)
Form Your Quality Team
• Compile Quality Measures
• Measure Performance
Select Your Industry SMEs &
Technology “Super Users”
Identify Your Most
Vulnerable / High Risk
Patients
Schedule All Staff Meetings
Socialize
PDSA Cycles