2020 ar medicaid pcmh - afmc · 2020 ar medicaid pcmh performance based, moving forward. agenda •...
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2020 AR Medicaid PCMH
Performance Based, Moving Forward
Agenda• Status of Current Medicaid PCMH Program• Activities and Validation Process for 2020• Antibiotic Stewardship• Metrics for 2020
o Quality o Core (Low Performance Metrics)o PBIP Measures
• Reconsideration for 2019 PBIP• 2020 Reporting • SHARE Update
Current Medicaid PCMH Program Status
Interesting Year! New Tools ProvidedThankfulMoving Forward
2018 Performance Period compared to 2017
2019 PBIP MeasuresHospitalization was down by 12.3% Emergency room visits down by 3% Adolescent Wellness up by 5.9%
2019 Core MeasureInfant Wellness up by 7.2%BMI still struggled
2020 PCMH Activities and
Validation Processes
Shelley Ruth PCMH QA Manager
2020 Practice Support Activities
Activity3 Month
3/31/20206 Month
6/30/202012 Month
12/31/2020
A Identify top 10% of high-priority patients (including BH clients) •
B Provide 24/7 access to care •
C Document approach to expanding access to same-day appointments •
D Capacity to receive direct e-messaging from patients: Describe method of e-messaging used •
E Childhood/Adult Vaccination Practice Strategy •
F Join SHARE or participate in a network that delivers hospital discharge information to practice within 48 hours
•
G Medication Management: Describe the practices EHR reconciliation process. Document updates to active medication list in EHR for HPB
•
H Care Plans for High Priority Patients: create care plans •
I Patient Literacy Assessment Tool: Choose any health literacy tool and administer the screening to at least 75 patients (enrolled in the PCMH program) or their care givers
•
J Ability to receive Patient Feedback: Indicate method used to receive patient feedback and describe how feedback is used to make improvements
•
K Care Instructions for HPB: Create and share with the patient an after-visit summary of the patient’s visit. Include diagnosis, medication list, tests and results (if available), referrals (if applicable), and follow up instructions
•
L 10-day follow up after an acute inpatient hospital stay •
M Developmental/Behavior Health Assessment for Children and Adolescents •
Fast Track Care Plan Audit Details
§ Fast Track Audit vs. Regular Audit• Only required to submit five care plans for Fast Track• 20% of the attested to care plans are selected for regular audit
§ Qualifications for the Fast Track Care Plan Audit• Must pass at least two consecutive years of care plans audits • Must not have been placed in remediation for care plans
§ Fast Track Disqualifications• Not meeting the 80% target• Placed in remediation
§ Scoring method• Two points for each required element• Care Plan validation spreadsheet
Virtual Validation of Activities
§ Virtual Validation vs Onsite Validation• Submits supporting documentation electronically• Email is the preferred method of submission
§ Qualifications for Virtual Validation• Must pass at least two consecutive years of activity validation• Must not have been placed in remediation for activities
§ Virtual Validation Disqualifications• Not meeting activity requirements• Placed in remediation
§ Process• Complete attestations by deadlines• Submit supporting documentation
OUTPATIENT ANTIBIOTIC STEWARDSHIP WILLIAM GOLDEN MD MACP
MEDICAL DIRECTOR, OFFICE OF HEALTH INFORMATION TECHNOLOGY
Antibiotic Resistance
CDC. Antibiotic resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/
$20 billion in excess direct healthcare costs annually
Stewardship across the spectrum of healthcare
http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
Fleming-Dutra. JAMA 2016;315(17): 1864-1873. The Pew Charitable Trusts. May 2016.
Provider variability: Habit of prescribing antibiotics§ In a large study of 1 million VA outpatient visits for acute respiratory infections (ARIs, many of which
did not require antibiotics)
– Highest 10% of providers prescribed antibiotics in ≥95% of ARI visits
– Lowest 10% prescribed antibiotics in ≤40% of ARI visits
§ In a pediatric network, antibiotic prescribing variability among 25 practices
– 18 to 36% of acute visits resulted in antibiotic prescriptions by practice
– 15 to 57% of antibiotics were broad-spectrum by practice
Child with same complaint in high use practice: 2x as likely to get antibiotics and 4x as likely to get broad-spectrum antibiotics
Jones. Ann Int Med 2015;163(2):73-80.
Gerber. JPIDS 2015;4(4): 297-304.
Meeting the CARB goal
§ Reduction of inappropriate outpatient antibiotic use by 50% by 2020
§ 30% of outpatient antibiotic use is inappropriate
§ Goal: Reduction of overall outpatient antibiotic use by 15% by 2020
Diagnoses leading to antibiotics — United States, 2010–11
OUTPATIENT ISSUES
• Respiratory Conditions
• Unsatisfactory Literature
• Variable Patient Presentations
• Prescribing 2-4x Higher Than Recommended for Select Conditions
• Mixed Track Record For Improvement
• Viral URI i, Sinusitis n, Ears n, Pharyngitis n
WHY COMPARE BROAD VS. NARROW?
Conflicting guidelines
• AOM
• AAP recommends amoxicillin; RCTs used amoxicillin-clavulanate for AOM
• Sinusitis:
• AAP recommends amoxicillin; IDSA recommends amoxicillin-clavulanate
• GAS pharyngitis:
• cephalosporins?
50% of antibiotic use for children is broad-spectrum
Target rate for outpatient antibiotic prescriptions
30%
GLOBAL VALUES
• CDC 6/18 Project
• All Payer Presciption Rates
• USA – 880/1000 Patients
• AR – 1070/1000 Patients
PCMH VARIATION
• Panels of Patients Attributed for > 6 Months
• Scripts Originated from All Sources
• 3-4 Fold Practice Variation
total >=18 <18
Antibiotics/100 patientsPopulation 107.5 103.5 108.5PCMH Median 114 104 118Highest PCMH 220 179 231Lowest PCMH 46 21 25
% Receiving 1 PrescriptionPopulation 50% 49% 50%PCMH Median 54% 49% 55%Highest PCMH 75% 66% 78%Lowest PCMH 28% 14% 18%
PHYSICIAN PERCEPTION OF PATIENT EXPECTATIONS§ Overt requests for antibiotics are rare
§ When physicians think patients/parents want antibiotics, they are more likely to prescribe
• 62% when they thought parent wanted antibiotics
• 7% when they thought parent did not want antibiotics
Knapf Family Practice 2004;21(5):500-6. Mangione-Smith Pediatrics 1999;103(4):711-8
§ Physicians are terrible at predicting which patients want antibiotics
STEWARDSHIP PLAN
• Biannual PCMH Report Card
• Informational Reports 2020
• Accountability 2021
• Quality Metric and Core Metric
• Goal: 15% Reduction by Start of 2022
• 920/1000 Patients
2020 PCMH Quality MetricsCore MeasuresPBIP Measures and 2019 PBIP
Reconsideration
Larry “David” BallardPCMH Program Manager
2020 Quality Metrics and Targets 7 Claim Based Metric 2020 Target 2019 ComparePCP Visits ≥83% 1% ↑Infant Wellness ≥68% 6% ↑Child Wellness ≥72% 1% ↑ Adolescent Wellness ≥53% 3% ↑URI ≤45% 2% ↓ COB ≤30% 5% ↓Tamiflu ≤18% 2% ↓
3 EHR Based (eCQM) Controlling BP ≥62% 4% ↑Tobacco Use ≥80% 5% ↑HbA1c Poor Control ≤28% 5% ↓
2020 Core Metrics (Low Performance) and Targets
• Infant Wellness- If you have 15% or more of your beneficiaries who turn15 months old during the performance period who have 0-1 wellness visits and you do not Pass the Infant Wellness Quality Metric.
• Body Mass Index- if less than 60% of your patient panel (3-17 years of age) have a BMI Measurement. (Self Reporting)
2020 Core Metrics (Low Performance) and Targets
• PCP Visits- If you have ≤60% of your High Priority Beneficiaries with as least 2 visits in the past 12 months. 2020 Target for PCP Visit is 83%
• HbA1c if ≤50% of your diabetes beneficiaries (18-75 years of age) who complete a annual HbA1c. 2019 Target was 75%
o Removed from Quality Metrics but will still be monitored.
Reconsideration for 2019 PBIP Measures
2019 Performance Based Incentive Payment (PBIP) Measure Reconsiderations.
#1 Be Proactive! • Don’t wait until Reconsideration period.
# 2 Special PBIP report ran during Q2 of 2020 for 2019 PBIP measures.
#3 PCMH’s will be given 30 days to submit Reconsideration on these measures! (This will provide DMS adequate time to make determinations before Payment determinations are made)
2019 Performance Based Incentive Payment (PBIP) Measure Reconsiderations.
Again this will be only for PBIP measures. If you see anything questionable then I suggest submitting it. We will not except Reconsideration on these 3 measures after payments are made.
Quality Metric Reconsideration will be like normal. Once Payments are made and if you missed payment because of not passing 2/3 of Quality Metrics.
gdit.com
PCMH 2020 UPDATE
PHMR Overview
The PHMR is a monthly report that allows medical providers to better manage their Medicaid beneficiary population with:
• Being produced monthly with latest processed data • Easy filtering to identify “Gaps in care” and utilization of services to better manage and educate the
populationPHMR reports (individual worksheets)
• Information • Summary• All quality metrics• Point in Time (PIT) attributed beneficiaries report including HPB indicator • Performance Based Incentive Payment (PBIP)
o Acute Hospital Utilization (AHU)o Emergency Department (EDU)
• Emergency room monitoringGDIT Proprietary39 | gdit.com
PHMR new additions
New features for the second half of 2019• All of the additional features are on the PIT attribution report
o Last PCP visit date and where it occurred (within or outside the PCMH)o If the beneficiary is 6 month attributedo For the October 2019 release, beneficiary attribution status (continuous, new or break (last date on
attribution list))
• Always listening to providers and GDIT continuous analysis drives additional features
GDIT Proprietary40 | gdit.com
PERFORMANCE BASED INCENTIVE PAYMENTS (PBIP)
PBIP
For 2019• Continue to see results in quarterly report
For 2020• Same approach for incentive as 2019
o Must pass 2/3 of CORE metrics
o Must meet minimum performance metrics
o Be in the top 10% or 11 – 35 percentile rankings of incentive metrics
• Incentive Metricso AHU: Hospital Utilization
o EDU: Emergency Department Utilization
o Focus Metric: Adolescent Metric
GDIT Proprietary42 | gdit.com
ARTIFICIAL INTELLIGENCE/MACHINE LEARNING
Artificial intelligence/Machine Learning
New tool for 2020• Initial concentration of PBIP metrics
o Testing different modelingo Currently analyzing the identification preventable ER visitso Currently analyzing identifying avoidable hospitalizations
• Identifying the most effective way of delivery to PCMHs
GDIT Proprietary44 | gdit.com
2020 SCHEDULE REPORTS
Schedule reports
New tool for 2020• Quarterly reports
o 2018 Final Reporto Two full reports (current reports)o Two reduced (contain information that PCMH are tracking)
• Monthly PHMR beginning in February• 2019 PHMR Reconciliation Report• Supplemental reports
o Bi annual chronic opioid usageo Bi Annual antibiotic stewardship (new for 2020)
• AI/ML (new for 2020)
GDIT Proprietary46 | gdit.com
SHARE Connecting Providers and Organizations to Improve Quality Care
Anne Santifer, Director [email protected]
48
ConnectionsHospitals 72Provider Practices/Other 660CPC + Practices 160PCMHs 187
WHO SHAREs?
SHARE and PCDH
DAILY ADT REPORT
Daily ADT report
PATIENT FLYER
View our patient consent flyer here.
DAILY ADT REPORT
ü Sent Nightly ü Assists with Follow
up Visitsü Can include all
patients regardless of payer
ü Proven Results
HOW TO GET CONTACT SHARE
Visit our Website: SHAREarkansas.com
ORCall: 501.410.1999
OREmail:
HOW TO GET IN TOUCH