high intensity care management november 4, 2014 webinar

High Intensity Care Management

November 4, 2014Webinar

Additional 2014 Clinical Model Elements

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Clinical Model Goal

Outreach to 100% of patients on the “accepted” list within 90 days of finalizing list (outreach defined as initial attempt to reach patient via telephonic or in-person verbal contact)

Completion of in-person care management assessment within 3 months of successful outreach for at least 50% of Accepted Members patients, and for 100% of Accepted Members within 6 months

Completion of in-person comprehensive health care assessment [for those patients who have not yet received an annual wellness visit in the current calendar year] within 3 months of successful outreach for at least 50% of patients, and for 100% of patients within 6 months

Quarterly review/update of care plan for engaged patientsHospital to home transition phone follow-up for 30 days for engaged patients; frequency of phone calls dependent upon patient

needs

SNF to home transition initial contact within 24-48 hours of discharge for engaged patientsSNF to home transition follow-up w/PCP (or specialist, as appropriate) within 7 days of discharge for engaged patients

SNF to home transition phone follow-up for 30 days, minimum of one call following discharge for engaged patients; frequency of phone calls dependent upon patient needs

The following elements of the clinical model cannot be tracked/measured via the claims system, but are identified as important goals within the clinical model. Physician Organizations should track these metrics. Metrics will be discussed at joint meetings, in addition, Physician Organizations may be asked to submit data to BCBSM.

Phase 1 Launch10-1-14

Full Launch 4-1-15

HICM Common Clinical Model Components Subset of Core

Model

Core Model

Comprehensive Clinical

Model

1.24/7 phone access to clinical decision-maker with electronic access to pt record ● ● ●

2. Comprehensive health care assessment by PCP, NP, or PA with full diagnoses capture, advance planning (75% w/in 2 months; all w/in 4 months; in-home for homebound) – top priority for July 1, 2014 start

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3. In-home health care assessment by PCP, NP, or PA for homebound ● ●

4. Daytime home visits by RN, MSW or Care Manager (minimum quarterly), including in-home assessments

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5. Patient-specific comprehensive care plan (updated at least quarterly) ● ● ●

6. Care management team includes pharmacist and nutritionist ● ●

7. Access to in-home PT and OT ● ● ●

8. Care transitions management – Hospitals ● ● ●

9. Care transitions management – SNFs ●

10. Access to palliative care team ●

11. Access to hospice ● ● ●

12. Transportation for non-emergent medical visits and Rx 2016

13. Remote patient monitoring (weight, BP, glucose) 2016

14. Standardized staff training ● ● ●

15. Review of all patients on monthly patient lists, common outreach script (2nd outreach by PCP as needed); POs maintain disposition information on all patients on monthly list

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Medicare Advantage STAR Recognition Program

Medicare STAR Ratings

The CMS star rating program is a pay-for-performance program for Medicare Advantage plans

Plans will now receive revenue based on outcomes and the quality of their performance

The higher the quality ranking, the higher the payments and the more competitive the plan is in the marketplace

This is an attempt by CMS to create a new paradigm to bend the cost curve

What’s Measured

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STAR ratings measure a Plan’s performance in delivering quality outcomes

STAR ratings are based on 53 key quality measures (36 related to Medicare and 17 related to prescription drug coverage) across the five following domains (subset of HEDIS measures)

What do CMS STARS Rating Measure

Staying Healthy: screenings, tests, and vaccines Managing chronic (long term) conditions Ratings of health plan responsiveness and care Member complaints, problem getting services, and

choosing to leave the plan Health plan customer service

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What’s It Look Like

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Clinical quality and outcomes

HEDIS

Plan administrative performance and

compliance

Member assessment of their

health (Health Outcomes

Survey)

Member perceptions of Plan, providers and care

CAHPS

2014 Provider Outreach Activities

Diagnosis coding education where DDDS is not part of practice

HEDIS/STARS for all targeted providers Activities include:

• Address and close HEDIS/STARS treatment opportunity gaps

• Address and close Enterprise and BCNA risk adjustment diagnosis gaps

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Activities include:• Support HEB education and sign-up • Support provider staff on scheduling member

appointments • Provide education to providers • Provide reference tools and materials to providers • Retrieve medical records related to treatment

opportunity gaps if necessary

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Activities include:• Retrieve medical records for BCNA risk adjustment

diagnosis gaps, BCNA only• Complete focus-driven activities as specified• Report on outreach activities completed by practice

unit/providers

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Provider Recognition Program

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Breast Cancer screening 10$ Breast Cancer screening 10$ Breast Cancer screening 10$ Breast Cancer screening 10$

Colorectal cancer screening 10$ Colorectal cancer screening 10$ Colorectal cancer screening 10$ Colorectal cancer screening 10$

Diabetes Retinal Eye Exam 10$ Diabetes Retinal Eye Exam 20$ Diabetes Retinal Eye Exam 10$ Diabetes Retinal Eye Exam 20$

Diabetes HbA1C level <=9% 10$ Diabetes HbA1C level <=9% 20$ Diabetes HbA1C level <=9% 10$ Diabetes HbA1C level <=9% 20$

Diabetes monitoring for nephropathy 10$ Diabetes monitoring for nephropathy 20$ Diabetes monitoring for nephropathy 10$ Diabetes monitoring for nephropathy 20$

Diabetes LDL-C level < 100 mg/dl 10$ Diabetes LDL-C level < 100 mg/dl 20$ Diabetes LDL-C level < 100 mg/dl 10$ Diabetes LDL-C level < 100 mg/dl 20$

Diabetes LDL-C testing 10$ Diabetes LDL-C testing 10$ Diabetes LDL-C testing 10$ Diabetes LDL-C testing 10$

Cardiovascular disease LDL-C testing 10$ Cardiovascular disease LDL-C testing 10$ Cardiovascular disease LDL-C testing 10$ Cardiovascular disease LDL-C testing 10$

Cardiovascular disease LDL-C level <100 mg/dl 10$ Cardiovascular disease LDL-C level <100 mg/dl 10$

BCNA 2013 BCNA 2014

Pay As You GoSame measures as Base PRP but payable for one service per each eligible member per year

Bonus PRP

Base PRPQuality Preventative

Diabetes LDL-C level < 100 mg/dl

Glaucoma testing $20-$40 depending on provider score:

score 70%-74% payment $20 each eligible service


High Risk Medications $20 each eligible service --score 10% or<

Cardiovascular disease LDL-C testing

score 70%-74% payment $125


High Risk Medications $450 depending on prac grp score--score 5% or<

>=80% = $5.00 PMPM

Payable to Provider for each eligible service

Adult BMI $10 each eligible service--score 80% or greater

Diabetes treatment with ACE/ARB for hypertension $20--score 87% or>

Cardiovascular disease LDL-C level <100 mg/dl

0%-71% = $0.00 PMPM

72%-74% = $2.00 PMPM

75%-79% = $3.50 PMPM

Quality Payout

Diabetes monitoring for nephropathy

Diabetes LDL-C testing

Breast Cancer screening

Colorectal cancer screening

Payable to Practice Group based on overall score

Adult BMI $200 to practice group--score 67% or greaterAnnual Monitoring for persistent meds $200 to practice group --score 94% or >

Diabetes treatment with ACE/ARB for hypertension $200 to prac grp--score 87% or>

0%-69% = $0.00 PMPM

70%-74% = $2.00 PMPM

75%-79% = $3.50 PMPM

>=80% = $5.00 PMPM

Diabetes HbA1C level <=9%





Diabetes Retinal Eye Exam




Diabetes treatment with ACE/ARB for hypertension $20--score 87% or>

Glaucoma testing $20-$40 depending on provider score:



High Risk Medications $20 each eligible service --score 10% or<

0%-69% = $0.00 PMPM

70%-74% = $2.00 PMPM

Glaucoma testing $125-$300 depending on prac grp score:

MA PPO 2014

Payable to Provider for each eligible service

Adult BMI $10 each eligible service--score 80% or greater

Quality Disease Management

0%-71% = $0.00 PMPM

72%-74% = $2.00 PMPM

75%-79% = $3.50 PMPM

>=80% = $5.00 PMPM






Cardiovascular disease LDL-C level <100 mg/dl


MA PPO 2013





Diabetes Retinal Eye ExamDiabetes Retinal Eye Exam




Diabetes Retinal Eye Exam

Annual Monitoring for persistent meds $200 to practice group --score 94% or >

Diabetes treatment with ACE/ARB for hypertension $200 to prac grp--score 87% or>

Glaucoma testing $125-$300 depending on prac grp score:



High Risk Medications $450 depending on prac grp score--score 5% or<

75%-79% = $3.50 PMPM

>=80% = $5.00 PMPM

Payable to Practice Group based on overall score

Adult BMI $200 to practice group--score 67% or greater


Measure CodesAdults’ Access to Preventive/ Ambulatory Health Services (AAP)

CPT® codes to identify preventive/ ambulatory health services: Office or other outpatient services: 99201-99205, 99211-99215, 99241-99245 Home services: 99341-99345, 99347-99350 Nursing facility care: 99304- 99310, 99315, 99316, 99318 Domiciliary, rest home or custodial care services: 99324-99328, 99334-99337 Preventive medicine: 99381- 99387, 99391-99397, 99401- 99404, 99411, 99412, 99420, 99429 HCPCS: G0402, G0438, G0439, S0620, S0621Ophthalmology and optom etry: 92002, 92004, 92012, 92014 General medical examination: ICD-9-CM diagnosis codes: V70.0, V70.3, V70.5, V70.6, V70.8, V70.9

Adult Body Mass Index (ABA) Assessment

CPT®: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456HCPCS: G0402, G0438, G0439ICD-9-CM Codes to identify BMI: V85.0-V85.5Exclusions: Members with a diagnosis of pregnancy in the measurement year or the year prior to the measurement year.ICD-9-CM: 630-679, V22, V23, V28

Breast Cancer Screening (BCS)

Claims Coding Reference

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Measure CodesAnnual Monitoring for Patients on Persistent Medications (MPM)

Monitoring for ACE Inhibitors or ARBs, Digoxin*, and Diuretics: Drug serum concentration for serum potassium: CPT®: 80051, 84132Drug serum concentration for serum creatinine: CPT®: 82565, 82575Drug serum concentration for blood urea nitrogen: CPT®: 84250, 84525 *Drug serum concentration for Digoxin:CPT®: 80162 Monitoring for Anticonvulsants: Drug serum concentration for phenobarbital: CPT®: 80184Drug serum concentration for carbamazepine: CPT®: 80156, 80157Drug serum concentration for phenytoin: CPT®: 80185, 80186Drug serum concentration for valproic acid and divalproex sodium: CPT®: 80164 Lab panel codes:CPT®: 80047, 80048, 80050, 80053, 80069


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Measure CodesBreast Cancer Screening (BCS)

CPT®: 77055-77057 HCPCS: G0202, G0204, G0206 ICD-9-PCS: 87.36, 87.37Exclusions: Members with a bilateral mastectomy. Any of the following meet criteria for bilateral mastectomy:Bilateral mastectomyICD-9: 85.42, 85.44, 85.46, 85.48Unilateral mastectomyCPT®: 19180, 19200, 19220, 19240, 19303-19307ICD-9-PCS: 85.41, 85.43, 85.45, 85.47Two unilateral mastectomies*50 and 09950 modifier codes indi cate the procedure was bilateral and performed during the same operative session.

Cholesterol Management for Patients with Cardiovascular Conditions (CMC)

CPT®: 80061, 83700, 83701, 83704, 83721 Plus CPT® II: 3048F, 3049F, 3050F



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Measure CodesColorectal Cancer Screening (COL)

FOBT Fecal occult blood test between (FOBT) 1/1/2013 and 12/31/2013: CPT®: 82270, 82274 HCPCS: G0328 Flexible sigmoidoscopy between 1/1/2009 and 12/31/2013: CPT®: 45330-45335, 45337-45342, 45345 HCPCS: G0104 ICD-9-PCS: 45.24Colonoscopy between 1/1/2004 and 12/31/2013: CPT®: 44388-44394, 44397, 45355, 45378-45387, 45391,

45392 HCPCS: G0105, G0121 ICD-9-PCS: 45.22, 45.23, 45.25, 45.42, 45.43AND/ORChart documentation of previously performed colorectal cancer screening tests.Exclusions: Members with a history of either of the following: Colorectal cancer HCPCS: G0213-G0215, G0231 ICD-9-CM: 153, 153.0-153.9, 154.0, 154.1, 197.5, V10.05 Total colectomy CPT®: 44150-44158, 44210-44212 ICD-9-PCS: 44.80-45.83

HEDIS Coding Reference

HEDIS Claims Coding Reference

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Measure CodesComprehensive Diabetes Care (CDC) – Eye Exam

CPT®: 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245CPT® II codes: 2022F, 2024F, 2026F, 3072FHCPCS codes: S0620, S0621, S0625, S3000Exclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0


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Measure CodesComprehensive Diabetes Care (CDC) – HbA1c

CPT®: 83036, 83037 PLUSCPT® II: 3044F, 3045F, 3046FExclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0

Comprehensive Diabetes Care (CDC) – LDL-C

CPT®: 80061, 83700, 83701, 83704, 83721 PLUSCPT® II: 3048F, 3049F, 3050FExclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0

Measure CodesComprehensive Diabetes Care (CDC) – Nephropathy Screening

CPT®: 82042, 82043, 82044, 84156 PLUSCPT® II: 3060F, 3061F, 3066F, 4010FICD-9-CM: 250, 403-405, 580-588, 753, 791Exclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0

Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART)

ICD-9-CM codes to identify rheumatoid arthritis:714.0, 714.1, 714.2, 714.81HCPCS codes to identify pharmacy claims for DMARD in the measurement year:J0129, J0135, J0718, J1438, J1600, J1745, J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J9310

Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)

COPD:Chronic bronchitis: 491Emphysema: 492COPD: 493.2, 496 CPT® codes to identify spirometry testing:94010, 94014-94016, 94060, 94070, 94375, 94620


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Measure CodesOsteoporosis Management in Women Who Had a Fracture (OMW)

Codes to identify bone mineral density test:CPT®: 76977, 77078-77083, 78350, 78351HCPCS: G0130ICD-9-CM: 88.98AND/OR pharmacy claims for osteoporosis drug therapy:HCPCS: J0630, J0897, J1000, J1740, J3110, J3487, J3488


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Open Discussion

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high intensity care management november 4, 2014 webinar

Documents

engaged patients snf

care management team

engaged patients hospital

inhome health care assessment

clinical model elements

accepted members patients

clinical model goal

phone access