Quality: Finish Strong in 2016.

Get Ready for 2017

October 28, 2016

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Agenda

Stars: Medicare Advantage Quality

Changes for 2017 Pay for Quality and PCMH Programs – Important Announcements!

Stars:

Medicare Advantage Quality

Topics

Diabetes Incentive Program

High Performer Program

Dual Special Needs Metrics

Medication Management

Medication Reconciliation Post Discharge

Medication Therapy Management

Medication Review

Blood Pressure Control

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CMS Asks:

How Good is Your Medicare Advantage

Plan?

CMS wants to:

Inform beneficiaries as they choose a plan

Encourage best evidence-based practices

Improve/maintain health and well-being

Payments for VALUE rather than volume

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What Gets Scored?

Preventive Screenings Breast Cancer Colorectal Cancer

Chronic Disease Monitoring and Control Diabetes Hypertension Rheumatoid Arthritis Osteoporosis

Medication Oversight Medication Adherence Medication Reconciliation Post Discharge Medication Therapy Management

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Diabetes Incentive

Program

Akamai Advantage

Diabetes Incentive Program

741 members participating (out of 8,700 with diabetes)

Potential to earn $100 in gift cards

Services during 2016

It’s not too late to sign up!

HbA1c Testing

Eye Exam

PCP Visit for Diabetes

Diabetes Education

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High Performer

Program

What is the program?

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You have patients who struggle with preventive services, so you were invited to participate

We selected members who need the most assistance with gaps in care

The program aligns bonus payments with the extra effort from your team

High Performer Program Update

527 Providers invited

Packets mailed early September

Initial gap for each member: $20

Additional gaps for each member: $5

Office incentives: gift cards

40 gaps = $100

Each additional 20 gaps = $50 more in gift cards

10 Offices with the most gaps closed = additional $100

Questions? Call 952-7822

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Dual Special Needs

DSNP: What Gets Measured?

Members who are eligible for BOTH Medicare and Medicaid

All standard Medicare Quality Metrics

Preventive Screenings

Diabetes/Chronic Disease Measures

Medication Management

Four DSNP specific measures

Health Risk Assessment

Care for Older Adults

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Care for Older Adults: Dual Special Needs

Once per calendar year

Four-part assessment:

Medication Review

Functional Status Assessment

Pain Assessment

Advance Care Planning

COA form available with coding

and checklist assessments

• Complete the assessments • Add completed form to your

medical record • File a claim

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Medication

Management

CMS Emphasis: Medication Oversight

Medication Reconciliation Post Discharge

All Akamai Advantage Members

Within 30 days of hospital discharge

Medication Therapy

Management (MTM)

3 Chronic Conditions

8 or more Medications

Refer to Pharmacy

Vendor

Medication Review

Dual Special Needs (DSNP)

Enrollees

Once

per calendar year

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Medication Reconciliation

Post Discharge

Hospital Discharge

30-day window – Medication Reconciliation

Document on claim

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The Quick Version of Documentation

MRP:

Medication

Reconciliation

Post-Discharge

(Medicare)

The percentage of

discharges from 1/1-12/1 of

the measurement year for

members 18+ for whom

medications were

reconciled on or within 30

days of discharge.

Documentation needed: • Medication reconciliation completed by the

prescribing practitioner, clinical pharmacist,

or registered nurse on or within 30 days of

discharge.

• Need documentation that it was completed

and the date that it was done in the

outpatient chart.

Any of the following evidence meets criteria: • Notation that, “I have reviewed patient’s

discharge medications and reconciled

against pre-admit medications”

-or-

• Notation that “no medications were

prescribed upon discharge”

Submit CPT II Code: 1111F

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Medication Therapy Management

Patient receives a free

comprehensive medication

review by a pharmacist

Help for your most complex

patients

3+ chronic diseases

8+ maintenance medications

spend >$ 876.75/quarter on

medications

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Refer patient to HMSA’s vendor: Mirixa (866) 208-1223

Cozeva Medication Tracking

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Take Home Thoughts

Diabetes Incentives

High Performer Program (including office bonuses)

Dual Care: COA forms

Medication Measures

Med Recon help from Pharmacare

Med Management help from Mirixa

Blood Pressure – last chance for

in-control values!

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Akamai Advantage

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Review of Chronic Conditions (RCC) • Deadline for RCC and supplemental

reporting is December 31, 2016. Plan aiming for highest possible completion

Pay for Quality PCPs: Best strategy: work to achieve 4 to 5 stars (90%-95%) on RCC! Payment Transformation PCPs: Goal is 95% or higher for Maximum

74.5%

RCC rate as of 10/24/16

RCC Supplemental Reporting

Most supplemental reporting for RCC requires upload of

medical record into Cozeva. Deadline is December 31.

Disconfirm – Condition has improved; medical record required

Disconfirm – Condition has resolved; medical record required

Disconfirm -- Insufficient evidence of this condition. Medical

record is NOT required. Be sure to submit your complete

attestation in the Cozeva comment box, or upload a document that

contains the attestation.

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Disconfirm - Insufficient Evidence

PCP may choose to allow office staff (e.g., Cozeva Delegates)

to complete attestation and submit supplemental data for

disconfirmation on the PCP’s behalf

Sample: “I, [staff member name], report that Dr. Aloha Lee,

attests that this patient does not have the diagnosis of chronic

renal disease. Dr. Lee has reviewed the pertinent medical

information and finds that the patient has had normal creatinine

levels over the past two years.”

PCPs will be held accountable for all submissions by Cozeva

Delegate users.

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Changes for 2017 Pay for Quality and

PCMH Programs

October 28, 2016

2017: A Transition Year

Staggered starts for Payment Transformation

January 1, 2017 – PCPs in identified Physician Organizations will move fully into Payment Transformation (global monthly payment + new measures), joining the 2016 pilot

April 1, 2017 – Some PCPs begin global monthly payment, but remain on Pay for Quality measures through 2017

July 1, 2017 – Last group of PCPs begins global monthly payment, but remain on Pay for Quality measures through 2017

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Expectation that most PCPs will move to Payment Transformation payment and metrics by 2018

PCPs in Transition to Payment

Transformation

Payment Transformation

(Pilot, April 2016)

Payment Transformation (January 2017)

Payment Transformation

(April 2017)

Payment Transformation

(July 2017)

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Important

Announcements

In 2017, global monthly payment will be made on or about the 15th of the month, with patient attribution from one month earlier

New! Engagement measure to build PCP’s profile on Sharecare find-a-provider application

New! Performance measure – Well-Being 5 being replaced by Sharecare RealAge Assessment

Report to Provider will give more information about processing of each claim; will make account reconciliation easier

Cozeva view will be reset in January 2017

Coming! PO training sessions and webinars 34

Important

Announcements

Supplemental data (commercial, QUEST Integration and Akamai Advantage) for January 2017 class ONLY must be entered into Cozeva by Dec. 31, 2016

Cozeva Pay for Quality view will be locked down for transition to Payment Transformation-only view for January 2017

All other PCPs have regular deadlines for submitting supplemental data:

Jan. 31, 2017 for commercial, QUEST Integration and Akamai Advantage measures

Dec. 31. 2016 for Review of Chronic Conditions

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Payment Transformation

Transition

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Starting Date Cozeva View

January 2017 Only Payment Transformation view

April 2017 July 2017

Pay for Quality and Payment Transformation views; Will be scored on Pay for Quality measures

PCPs starting in April or July will remain on Pay for Quality program (rolling 12 months, quarterly payment). Will use familiar Cozeva dashboard

Will also have “sneak peek” of Payment Transformation Cozeva dashboard

All PCPs will work on 2 Physician Organization quality measures on the Payment Transformation dashboard

Pay for Quality View of Cozeva

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Payment Transformation View

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Colored chiclets and stars replaced by bars Red = below 50th percentile Yellow = Minimum (earning 40% ) Green = Target (earning 100%)

Quality Measures

Changes for 2017

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Being dropped for P4Q because of small denominators; already dropped for Payment Transformation

Appropriate testing for children with pharyngitis

Appropriate treatment for children with upper respiratory infection

Avoidance of antibiotic treatment in adults with acute bronchitis

Quality Measures

Changes for 2017

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Being dropped as a scored PCP measure, will remain as a Physician Organization measure that depends on PCP’s performance

Controlling high blood pressure

Physician Organization measure

Children with Special Health Care Needs Screener

Reporting Blood Pressure

Report both systolic AND diastolic values on claims

For patients age 60 to 85 with hypertension, BP is considered adequately controlled when BP is below 150/90 mm Hg. Report compliant blood pressure values using Cozeva supplemental data.

For patients age 60 to 85 with diabetes, BP considered in control if the blood pressure is below 140/90 mm Hg.

For patients with Medicare primary/HMSA secondary, report using supplemental data on Cozeva or submit secondary claim to HMSA

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CPT codes Description

3074F Most recent systolic BP less than 130 mm Hg

3075F Most recent systolic BP 130-139 mm Hg

3078F Most recent diastolic BP less than 80 mm Hg

3079F Most recent diastolic BP 80-89 mm Hg

Reporting CSHCN Screener

Measure Procedure Code ICD-10 Code

CSHCN Screener© (NEW: ages 3-17, done every 3 years)

Screening done; positive finding for chronic or special health care needs: E/M CPT code + HA modifier + Z87.898

Z87.898 Personal history of other specified conditions

Screening done; negative finding: E/M CPT code + HA modifier

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HA HCPCS code modifier = Child/adolescent program For screener tool: http://www.cahmi.org/wp-content/uploads/2014/06/CSHCNS-Survey-and-scoring.pdf

PCMH for 2017

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Monthly PCMH payments continue until PCP moves to Payment Transformation global payment in January, April or July

At that time, PCMH payment is wrapped into monthly global payment

Old PCMH requirements dropped. Regardless of global payment start date, all PCPs work on PCP Engagement measures

PCMH level advancement discontinued in 2017

Engagement to Encourage Active

Participation

• These are foundational, relatively easy-to-achieve engagement

steps

• Ensures providers are engaged in the systems to succeed in the

new payment model

• Examples: • Use of Cozeva

• Engage all attributed members annually through visit, call, email, mail,

text, online care

• Referring patients to ecosystem programs (e.g.,HMSA Care Model,

HMSA health education workshops, Dr. Dean Ornish Program for

Reversing Heart Disease, community programs )

• New! Sharecare Engagement – build provider profile and upload PCP’s

photo for find-a-provider application

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Engagement to Encourage Active

Participation

• Will be displayed on Cozeva for ALL PCPs in 2017

• Payment Transformation Pilot – will be scored in 2018

• Payment Transformation January 2017 – will be scored in 2018

• Payment Transformation April and July 2017 – will be scored in

2018

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Measure Commercial Akamai Advantage

QUEST Integration

PCP/staff log into Cozeva at least once a month [pass = 100%]

5% 5% 4%

Check on well-being of all patients in panel [patient survey; pass = 75% of respondents report contact]

5% 5% 4%

Refer patients to health programs [Cozeva attestation; pass/fail]

5% 5% 4%

New! Sharecare Engagement 5% 5% 4%

Submit EPSDT forms [audit] 4%

TOTAL 20% 20% 20%

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Engagement: Details

In Payment Transformation, each measure is all-or-nothing across all plans. Performing well adds up to 20 pct. points to the 80% base PMPM the following year. Doing poorly could result in loss of up to 20 pct. points.

PCMH Meets

Payment Transformation

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To calculate global payment PMPMs for 2017, HMSA will use FFS data for 2013-2015 + your PCMH level (Level 1, 2 or 3) as of December 1, 2016

To advance to PCMH level 2 or 3, request and documentation needs to be submitted to HMSA by November 4 for review and approval in time for a Dec. 1 effective date to affect global payment for 2017

PCMH Level Credited for PMPM

Level 1 $1 PMPM

Level 2 $3 PMPM

Level 3 $3.50 PMPM

PCP Affiliation with Physician

Organization

If you are joining or switching to a new Physician Organization, PO must notify HMSA by Dec.15

Be mindful of PO’s Payment Transformation transition date (Jan, April, or July 2017). Affects your quality/performance measures

January 2017 – Payment Transformation performance measures

April 2017 and July 2017

Remain on Pay for Quality measures through 2017

Switch to Payment Transformation measures in Jan 2018

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2017 Trigger

Cancer screenings Breast cancer

Cervical cancer Colorectal cancer

Yes Patient age

Diabetes measures HbA1c in control

Eye exam Attention for nephropathy

Blood pressure control

Yes 2 visits with diabetes as DX

Advance care planning Yes Includes 65+

Patient age

BMI assessment for adults Yes Any outpatient visit with PCP, specialists

Review of Chronic Conditions for Akamai Advantage members

Yes Patient age and DX

Controlling Blood Pressure Yes PO measure

1 visit with hypertension as DX

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Adult Measures

Payment Transformation:

Adult Measures

2017 Trigger

Screening for depression and anxiety (age 18 and older) [Patient Health Questionnaire-4]

Yes Outpatient visit with an eligible PCP type *

Tobacco cessation and followup

Yes Outpatient visit with an eligible PCP type *

Influenza shots Yes Patient age

New! Sharecare RealAge Assessment

Yes Patient age

Patient Experience (survey) N/A [Not a measure in 2017]

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* Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths

2017 Trigger

Well-child visits in first 15 months Yes Patient age

Well-child visits, 3 to 6 years Yes Patient age

Childhood immunizations by age 2 Yes Patient age

Immunizations for adolescents Yes Patient age

Weight assessment and counseling for nutrition and physical activity

Yes Outpatient visit with PCP or

ob/gyn*

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Pediatric Measures

* Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths

Payment Transformation:

Pediatric Measures

2017 Trigger

Developmental screening in child’s first 3 years (annually)

Yes Patient age

Adolescent well-care visit (ages 12 to 21) Yes Patient age

Screening for symptoms of clinical depression and anxiety (ages 12 to 17) [Patient Health Questionnaire-2, -4, -9, -Adolescents]

Yes Outpatient visit with an eligible PCP type *

CSHCN Screener© completion (ages 3 to 17, every 3 years)

Yes PO Measure

Patient age

Patient Experience (survey) N/A [Not a measure in 2017]

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* Eligible PCP type: Peds, FP, GP, IM, APRN, PA, naturopaths

Sharecare RealAge Assessment New!

Commercial members 18 and older who complete

Sharecare RealAge assessment at least once during the measurement year. Gauges how fast you’re aging based on lifestyle and medical history.

Replaces Well-Being 5

More information to be provided. Explore at https://www.sharecare.com/static/realage-test

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Support for PCPs

Your Physician Organization is your quality and transformation leader

Call Cozeva at 1-888-448-5879 for questions or training about Cozeva display

Call HMSA at 948-6820 on Oahu or 1 (877) 304-4672, toll-free or email psinquiries@hmsa.com:

Need training/support from HMSA’s Training Unit for you and your practice team

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