aco essentials

1/2/2015 COPYRIGHT HEALTH ENDEAVORS 2015

MSSP ACO Essentials

COPYRIGHT HEALTH ENDEAVORS 20151/2/2015

Who is Health Endeavors?A software development company based in Scottsdale, Arizona since 2008. We provide over 30 web-based software solutions to the healthcare industry on a daily basis.

Who are our clients?

40+ MSSP ACOsEarly leader of ACO education in partnership with CMS (2012)

500+ Hospitals & Hospital Systems

Thousands of Physician Practices

MSOs (Management Service Organizations)

Nursing Homes, ASCs, Physician Clinic Systems, Home Health, Hospice


Primary Care Only

Primary Care + Specialists

Primary Care + Hospital

Primary Care + Hospital +Home Health

Hospital Based

Patient History & Demographics

Geography

Management

Structure

Past Experiences

Single EMR

Multiple EMRs

Every ACO Is Different


Best Practices + Unique Decisions

One Strategy Does NOT Fit All

=Your ACO Strategy


ACO ACTION PLAN


ACO ACTION TASKS

1/2/2015

Data Sharing Preferences Collection Process

Get Claims Data

Patient Attribution

Initial, Quarterly, Annual (Add, Removes, Deceased)

Patient Assignment to Primary TIN and NPI

Quality and Financial Accountability

Provider Recruitment

Annual TIN Add/Remove Management

COPYRIGHT HEALTH ENDEAVORS 2015

ACO ACTION TASKS

1/2/2015

ACO Quality MeasuresEMR Gap AnalysisGPRO Reporting PlanCentral Quality Measures Repository ACO Benchmark ScoringProgress ReportsNon-Performing ResponsesQuality Performance by TIN and NPI

QM 2015 Data Import Chart & MeasuresCCLF Mapping to Complete Quality MeasuresEMR Abstraction & Integration Plan


ACO ACTION TASKS

1/2/2015

Claims Data Utilization

Individual & Population Analytics

Financial Performance by TIN and NPI

Gaps in Care

Care Coordination

Financial Analytics/Benchmarks

Population Management

Central Repository

Out-of-Network Expenditures (Leakage)

Patient Disease Registries

Quick Reports


ACO ACTION TASKS

1/2/2015

Training & CommunicationsStaff, Providers and ACO AdministrationPatients

Provider Participation

ComplianceConflict of InterestACO Participation Agreement Contract Management

Patient EngagementPatient SurveysPatient Education

MarketingWebsite (Public Reporting)


Get your arms around Patient Population

Use your Claims Data for GPRO!

Who are they?

Who is treating them?

Where are they?

Who is sharing data?


YOUR ACO

Primary Goals?



Achieve Shared Savings - 5% Medicare FFS Spend Reduction

Care Coordination

Medicare FFS Market Share Strategy

Reduce Leakage – Out-of-Network Expenditures

Non-Attributed Patients

Identify Missed Revenue Opportunities

Coding Audits

Quality Measures

PQRS Incentive/Avoid the Penalty

Clinically Integrated Platform

Commercial Payor Platform

Self-Insured Population

1/2/2015

How does Shared Savings Work?


2 Primary Requirements to Earn Shared Savings:

Quality Measures Reporting and Benchmark Performance (GPRO)

Reduce Spending at least 5% (or a % greater than the assigned Minimum Shared Savings% Rate) below the Historical Benchmark

How do we Reduce Spending & Coordinate Care?


Reduce Spending at least 5% (or a % greater than the assigned Minimum SharedSavings % Rate) below the Historical Benchmark

Spending Reduction Programs Stop the Admit Stop the ER Visit

Care Managers Care Coordination Programs

Patient ManagerWellness Gaps in Care Programs Disease Gaps in Care Programs Patient Education

Claims Data Population Analytics Disease Registries Standardized Data Utilization

Review Utilization TrendsMRI, CT, Home Health

Disease Care Management Protocols (NQF)

1/2/2015

Revenue Opportunities?


Revenue Opportunities Out-of-Network Spend Specialist Outreach Clinics (Access to Care) Alternative Services to ER Visit

After Hours Program Extended Hours Program

Alternative Services to Hospital Admit Outpatient Services Preventive (Gaps in Care) Services

Care Managers Retinal Exam

Missed Revenue Opportunities No Wellness Visit in past 12 months No Part B Visit for Patient since first of year


Technology Tools?

Data Sharing Preferences


Beneficiary Data Sharing Preferences – Collection Process

Determine initial method to collect patient preferences to submit via MFT Portal in XML

Format:

Mail Encounters

◦ How will you electronically process? (initial and changes)

Office Encounters

◦ How will you electronically process office encounters? (initial and changes)

Medicare Encounters

◦ How will you electronically process the information communicated by the patient to

Medicare? (initial and changes)



Patient Notice – Office Encounters

Staff Education – Front Desk PCP Clinics

Notice to Patients Form

Declining to Share Form

Patient Preference Tracking Protocols

Agreed to Share

Declined to Share

Non-Deliverable


ACO Poster Staff Education

Front Desk Scripts Staff Education

Medicare Fact Sheets Beneficiary Fact Sheet

Goal = 95% Claims Data

Assign Primary TIN and NPI


How you GET IT


Even if ACO mails –

the ACO must still conduct the

office encounters


Attributed Patients – Where are you?


No Medical Record with a PCP or SPC in past 2 years

Long-Term Care Nursing Home Care (no claims data?)

Hospice


Financial &

Quality

Accountability

by TIN and NPI

Removed, Added & Deceased


Quality Measures 2015



Develop a PLAN…


Work Flows/EMR Gap Analysis--

Who/What/Where/When/How

--Quality Measure conducted and documented on a

consistent basis? [What?]

--Responsibility for conducting and documenting the

Quality Measure assigned to staff or providers? [Who?]

--Quality Measure conducted and documented in the

hospital or physician setting [Where?]

--Quality Measure documented in the EMR, paper chart

or other method? [How?]

--Staff aware of the timeframes for capturing each

Quality Measure? [When?]


QM 2015 Import Chart

--CCLF Imports

--EMR Report Imports

--Abstracted by Facility

--Abstracted by Health Endeavors

--EMR CCDA Imports

--Abstracted by Facility

--Abstracted by Health Endeavors

--Manual Key

--Preferences/Defaults

--Carry-Over Pneumonia Module from 2014

--Lab Imports (Hemoglobin A1c)

--Lab Displays

QM 2015 Rule Overview



QM 2015 Import Chart

CCLF Mapping to Complete Quality Measures

EMR Abstraction & Integration Plan

Summary Overview of Rule Changes


Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible

professional attests to documenting a list of current medications using all

immediate resources available on the date of the encounter.

This list must include ALL known prescriptions, over-the-counters, herbals, and

vitamin/mineral/dietary (nutritional) supplements AND must contain the

medications’ name, dosage, frequency and route of administration


Depression Remission at 12 months

Adult patients age 18 and older with major depression or dysthymia and

an initial PHQ-9 score > 9 who demonstrate remission at twelve months

defined as a PHQ-9 score less than 5.

This measure applies to both patients with newly diagnosed and existing

depression whose current PHQ-9 score indicates a need for treatment.


Diabetes Retinal Eye Exam

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who had an

eye exam (retinal) performed.

Patients who received an eye screening for diabetic retinal disease. This includes people

with diabetes who had the following: -a retinal or dilated eye exam by an eye care

professional (optometrists or ophthalmologist) in the measurement year OR –a negative

retinal exam or dilated eye exam (negative for retinopathy) by an eye care professional in

the year prior to the measurement year. For exams performed in the year prior to the

measurement year, a result must be available.

Facility abstract data from EMR into Electronic

Report or CCDA

Facility remit EMR Data (Electronic

Report or CCDA) for Import

using Submit a Request

Health Endeavors

import EMR Data into

QM 2015 GPRO Tool

Facility abstract EMR Report or CCDA Data to import into

the Health Endeavors QM 2015 Reporting Tool

to complete the GPRO Measures


Health Endeavors

abstract data from EMR into

Electronic Report or CCDA

Health Endeavors remit

EMR Data (Electronic

Report or CCDA) for Import

using Submit a Request

Health Endeavors

import EMR Data into

QM 2015 GPRO Tool

Health Endeavors abstract EMR Report or CCDA Data to

import into the Health Endeavors QM 2015 Reporting Tool

to complete the GPRO Measures


Health Endeavors

import CCLF data

(monthly) into QM 2015

Imported CCLF data completes QM 2015

Based on the CPT and ICD9

Codes

Health Endeavors imports CCLF data to complete QM 2015

responses based on CPT and ICD9 codes


Complete QM 2015 Import Chart Preferences

Health Endeavors applies your QM 2015

Import Chart Preferences to QM 2015

Tool

Preferences & Defaults – QM 2015 Chart


Pull Charts and Key Data

Health Endeavors QM

2015 Tool

Manual Chart Abstraction


QM 2015 LEGEND – Bottom of Screen


Claims Data will display above the applicable question/module

Click on the Pink Bar to Expand


Claims Summary for this Measure will display including CPT and ICD9 codes


Click on red plus button to view NPI information for Rendering Provider and Facility


By Patient

By Facility (TIN)

By NPI

ACO (aggregate)

Scorecards – Performance & ProgressQuality & Financial



Claims Data Utilization

Individual & Population Analytics

Financial Performance by TIN and NPI

Identify Gaps in Care

Care Coordination Tool

Financial Analytics/Benchmarks

Population Management

Central Repository

Out-of-Network Expenditures (Leakage)

Patient Disease Registries

Quick Reports


Admits & Discharges

Newly Diagnosed

Diabetes, IVD, CAD, HF, HTN

ER Visits

MRI Events

CT Scans

Home Health

SNF

Hospice


Care Coordination Event Tracking & Management Tool

In-Network/Out-Network MigrationOut-of-Network Leakage


ACO ACTION TASKS

1/2/2015

Training & CommunicationsStaff, Providers and ACO AdministrationPatients

Provider Participation

ComplianceConflict of InterestACO Participation Agreement Contract Management

Patient EngagementPatient SurveysPatient Education

MarketingWebsite (Public Reporting)



Health Endeavors ACO Education Database: Click-n-Play Training Modules

Travis RicheyDirector of Business [email protected], ext. 200

Kris Gates, J.D.CEO & [email protected], ext. 220

COPYRIGHT HEALTH ENDEAVORS 20151/2/2015

mailto:[email protected]



MFT

https://eftp2.cms.hhs.gov:11443/cfcc/login/login.jsp

HPMS

https://hpms.cms.gov/app/login.aspx

ACO Portlet

https://portal.cms.gov/wps/portal/unauthportal/home/

CMS UserID

For help with Form CMS-20037 and CMS User ID: [email protected] or (800) 220-2028

IACS

https://idm.cms.hhs.gov/idm/user/login.jsp

QNET

https://www.qualitynet.org/portal/server.pt/community/pqri_home/212

https://eftp2.cms.hhs.gov:11443/cfcc/login/login.jsp

https://hpms.cms.gov/app/login.aspx

https://portal.cms.gov/wps/portal/unauthportal/home/


https://idm.cms.hhs.gov/idm/user/login.jsp

https://www.qualitynet.org/portal/server.pt/community/pqri_home/212


Required Documents to setup vendor access to MFT:

Vendor CMS Authorization Letter (see example)

Business Associate Agreement

CMS Data Use Agreement Addendum (Need Name and DUA

Number)

CMS UserId Form

aco essentials

Technology

aco strategy

aco action tasks12302014data

npi quality

primary tin

patient population

shared savings

gpro reporting period

primary requirements