Thomas W. Wells, MD FACP

What Providers Need to Know About Outpatient Quality Measures

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• I have no financial interests or conflicts to disclose.

Disclosures

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• Understand the history of healthcare quality

• What are the likely directions to come related to healthcare quality

over next 2-5 years

• Understand the need to be successful for you and your patients

• Become familiar with several preventative health and at risk

population measures

Objectives

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• Limitations of Measurement

– Claims data

– Clinicians want to see OUTCOMES data…

• For meaningful outcomes (death, infections, complications) …

» That are RISK adjusted….(and show that my patients ARE sicker)

• Adequately sized sample…..(but not require volume for credentialing – unless I

want)

• That measure the part that I am responsible for…

• AND are timely (like yesterday)

– Left with what is “measureable and obtainable” for large volume diagnosis

mostly centered around HOSPITAL CARE – Hard for MDs to link cause

and effect of their practice to reported metrics (limited attribution model,

“yeah but what about…”)

History of Quality

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While MDs argue about non-validity…• Payers , employers and patients complain about continued COST

of care and inconsistent quality - with CMS driving the agenda…

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The United States continues to have poorer outcomes and higher costs that other developed countries…

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All while health care spending continues to grow…

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… and all payors are pushing for TRANSPARENCY into provider quality and service

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• What cant go on forever will eventually STOP” - Herbert Stein

• Pressure will continue to address increased costs of care, lack of access to care

for some, consistent care for all

• Will need to PROVE you are a good doctor …with data

• Data Attributes will be defined for us (MIPPS, MACRA, etc)

– Expect multiple iterations with some justice and some injustice

– VERY MESSY

– LOCUS of measurement move OUT of hospital to YOUR INDIVIDUAL PRACTICE

– Measurement likely to focus on POPULATIONS of patients

• Patient voice growing LOUDER (paying for larger portion out of pocket)

– Patient voice will be OUTSIDE of our control – twitter, yelp, facebook, etc

– Ignore this AT YOUR PERIL

– Expect to see LESS “VALID” measures of quality to be reported BY patients FOR

PATIENTS (think Amazon reviews)

• No longer able to hide behand “the data are flawed” as data moves from

OUTCOMES to PROCESS measures (you used the protocol yes or no)

Where does this all leave us…

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ACO – Accountable Care Organization

APM – Alternative Payment Model

MACRA –Medicare Access and CHIP

Reauthorization Act

MIPS APM

MSSP, Track 1

Etc.

APM

MSSP, Tracks 2 and 3

Comprehensive Primary Care+

Oncology Care Model

NextGen ACO, etc.

MACRA/ QPP Components

MIPS

MIPS APM

APM

ACO

MIPS APM

APM

MIPS – Merit-Based Incentive Payment System

QPP – Quality Payment Program

MSSP – Medicare Shared Savings Program

CMS and other payors are responding

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• In the final MACRA rule released by CMS in November 2016, all quality programs were integrated

under a single MACRA umbrella

• Piedmont has committed to help ACO participants achieve success on the quality portion of the

MSSP, which includes 23 patient-centric measures

Quality scores in can impact future Medicare Part B reimbursement by +/- 5% in PY2018 and +/-

7% in PY2019. This puts revenues at risk for the providers in the MSSP and providers in the MIPS

program.

Maximum Provider Penalties and Bonuses

… and increasing risk on physicianreimbursement

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MSSP Program OverviewArea Description

Attribution • Original Medicare beneficiaries based on provider participation

• CMS looks at use of primary care services by primary care providers and by

specialists

Risk • Costs and quality adjusted using HCC (hierarchical condition category) methodology

Quality • 23 quality measures

• Quality measured at population level – not provider specific

• All providers in the ACO receive the same quality score

Cost • “Cost” = costs to CMS as paid through medical claims

• Costs can occur both within and outside of Piedmont (SNFs, non-PHC hospitals)

• ACOs are rewarded when they are able to lower growth in Medicare Parts A and B

fee-for-service costs (relative to their unique target) while, at the same time, meeting

quality performance standards

• Current cost benchmark/target is in lowest 25th percentile in country

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BOLD = Impact MIPS quality score

MSSP Program OverviewPatient-centric population health metrics

Domain Measures Measurement

Patient-

Caregiver

Experience

10 ACO CAHPS measures:

Survey

1. Getting Timely Care

2. How Well Providers Communicate

3. Patients’ Rating of Provider

4. Access to Specialists

5. Health Promotion and Education

6. Shared Decision Making

7. Health Status/ Functional Status

8. Stewardship of Patient Resources

9. Courteous and Helpful Office Staff

10. Care Coordination

Care

Coordination/

Patient Safety

4 Care Coordination/Safety measures:

1. Risk-Standardized, All Condition Readmission Claims

2. All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions Claims

3. Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator (PQI) #91) Claims

4. Falls: Screening for Future Fall Risk Web Interface

Preventive

Health

6 Preventive Health measures:

Web interface

1. Preventive Care and Screening: Influenza Immunization

2. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

3. Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan

4. Colorectal Cancer Screening

5. Breast Cancer Screening

6. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease

At-Risk

Populations

3 At-risk Population measures:

Web interface1. Depression Remission at Twelve Months

2. Diabetes Mellitus: Hemoglobin A1c Poor Control

3. Hypertension (HTN): Controlling High Blood Pressure

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Measure can have quality and cost impacts…

Measure Description Patient Benefits Economic Positive

Colorectal Cancer

ScreeningPatient aged 50-75 with

colorectal cancer screening

(FOBT, colonoscopy, FIT-

DNA, flex sigmoidoscopy)

Early detection of cancer • Prevents downstream costs

• Bonus payments for MA

contracts

• Impacts Part B payment

adjustment

Breast Cancer Screening Patients 50-74 who had had a

mammogram between

10/1/2017 and 12/1/2019

Early detection of cancer • Prevents downstream costs

• Bonus payments for MA

contracts

• Impacts Part B payment

adjustment

Statin Therapy for the

Prevention and

Treatment of

Cardiovascular Disease

Patients with ASCVD, LDL>

190, or hypercholesterolemia

who received an order

(prescription) for statin therapy

at any point during the 2019

Lower the risk of recurrent

ASCVD

• Prevents downstream costs

• Bonus payments for MA

contracts

• Impacts Part B payment

adjustment

Hypertension (HTN):

Controlling High Blood

Pressure

Patients whose blood

pressure is adequately

controlled (<140 systolic AND

< 90 diastolic) at their most

recent visit in 2019

By focused concentration on

the blood pressure lower the

risk of end organ damage from

hypertension

• Prevents downstream costs

through avoidable

hospitalizations and other

health issues

• Bonus payments for MA

contracts

• Impacts Part B payment

adjustment

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Measure can have quality and cost impacts…

Measure Description Patient Benefits Economic Positive

Screening for Future

Falls Risk

Patients who were screened

for future falls risk at least

once during 2019

Intervening before falls. As

falls are the leading cause of

both fatal and nonfatal

accidents in older adults.

Avoid downstream costs by

lowering ED and Hospital

costs

Have older adults maintain

their productivity

Influenza Immunization Patients who received a flu

vaccine OR who reported

previous receipt of a flu

vaccine between August 1,

2018 and March 31, 2019

Prevents potential severity of

flu

Avoid downstream costs of

avoidable ED and Hospital

admissions

Diabetes Mellitus:

Hemoglobin A1c Poor

Control*

Patients whose most recent

HbA1c level in 2019 is <=

9.0%

Focused concentration on

HbA1c to lower this and avoid

end organ

Avoid downstream costs by

lowering risks of end organ

damage

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Need to Accurately Reflect the Risk of the Patient

• In the ongoing world of Value Based contracting need to have accurate diagnosis to adjust for the Total medical cost in addition to closing care gaps

What CMS thinks your patient looks like… … vs. what your patient actually looks like.

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1,450 providers – entire

Clinic primary care

network

69,721 Medicare

beneficiaries

10th largest ACO in the

nation

Bottom 20th percentile

for patient risk

MSSP Patient Origin

MSSP Program Overview

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Piedmont’s cost benchmark is lower than national FFS average. This benchmark was

calculated looking at historical spend of MSSP patients from 2014-2016.

$9,257

$10,462

$9,500

$10,291 $10,133

$9,329

PiedmontMSSP ACO

National FFSAverage

Georgia FFSAverage

Methodist(TX) MSSP

ACO

Wellstar (GA)MSSP ACO

UW(Wisconsin)MSSP ACO

PMPY Benchmark

Earned $4.4M in

shared savings in

2017

Earned $7.8M in

shared savings in

2017

Earned $6.7M in

shared savings in

2017

Piedmont is already lower in cost as compared to the market

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• Some success achieved in value-based arrangements, but lots of money left on the table

• Historic focus has been on quality, but costs are integral to picture

• Piedmont’s total cost/utilization has been lower relative to market, but must have strategies to

maintain

• Out-of-network utilization continues to be an opportunity across all contracts

• Coding is cited as an issue from all payors

• Limited provider awareness of and engagement in many of our value-based programs

• Opportunity to continue to streamline programs and enter into program designs that benefit

Piedmont and partner

Many common themes emerge…

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Discussion

&

Questions