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EXPANSION COUNTIES TRAINING III:PHC’S PAY-FOR-PERFORMANCE PROGRAM –QUALITY IMPROVEMENT PROGRAM (QIP)

PresentersAntara Aiama (QI/PI Manager)

Jess Liu (QIP Project Specialist)

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OBJECTIVES QIP Overview & Timeline

Measures

Resources for Providers

Q&A session

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WHAT IS THE QIP?

What is the Quality Improvement Program?

Who qualifies for program?

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TIMELINE

Dec 1, 2013

June 30, 2014

July 31, 2014

Aug 15,2014

Oct 31, 2014

Final date for clinical data submission via e-Reports

Final date for non-clinical data submission

Final payment for QIP 2013-2014 mailed

Measurement period for QIP

2013-2014

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RESOURCESQIP Website:http://partnershiphp.org/Provider/MC_QIP.htm

QIP Inbox: qip@partnershiphp.org

eReports (monitor performance on CLINICAL measures):https://qip.partnershiphp.org/

Monthly Reports (monitor performance on NON- CLINICAL measures) – sent out monthly

Monthly Newsletters – sent out monthly

Other non-QIP-related questions: Sharon McFarlin, Provider Relations Rep (smcfarlin@partnershiphp.org; 707-420-7687)

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MEASURES Unit of Service Measurement Set (Optional)- Measures and Incentive amounts

Fixed Pool PMPM Measurement Set (Required)- Measures: Clinical Domain, Appropriate Use of

Resources, and Access & Operations,

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UNIT OF SERVICE MEASURES

Unit of Service Measure Incentive amount

Advance Care Planning $100 per attestation

PCMH Certification Level 1: $2000 Level 2: $3000 Level 3: $3500

Peer-Led Self Management Support Groups $1000 per group per year

Utilization of CAIR Incentive amount based on Relative Improvement in utilization (See Specifications for details)

Access/Extended Office Hours Equivalent payment of 10% cap

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ADVANCE CARE PLANNING (ACP) ACP conversations with medi-medi and medi-

cal members 65 years or older and/or have a major life-limiting disease

Attestations must be signed by a clinician (physicians, PAs, RN, nurse practitioners)

Only one attestation per patient per fiscal year; maximum of 100 per site

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PCMH CERTIFICATION PCP site must have a minimum of 50 PHC

members to be eligible for this incentive

Submit evidence of certification to PHC by July 31, 2014

PCMH recognition can be from NCQA, AAHC or JCAHO

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PEER LED SELF MANAGEMENT GROUP PCP site must have a minimum of 50 PHC

members to be eligible for this incentive Incentive for new or existing groups that are

open to both PHC and non-PHC members Groups must meet at least 4 times between

Sep 1, 2013 – June 30, 2014 Must submit evidence of at least 16 PHC

member visits

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UTILIZATION OF CAIR Providers with 20 or more members ages 0-

13 years of age are eligible for this incentive

Must submit CAIR registration ID by December 31, 2013

Incentive pays for active utilization of registry; payment is based on performance in comparison to PHC network performance

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ACCESS/EXTENDED OFFICE HOURS

Monitored and reported by Provider Relations representative

Must be open and additional 8 hours beyond normal business hours of the practice site

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FIXED POOL MEASURES Measure Family Internal Peds

Clinical Domain (20 points) Cervical Cancer Screening (24-65 years of age)

X X

Childhood Immunization – DTaP (2 years of age)

X

Appropriate Use of Resources (40 points) Pharmacy Utilization X X XAccess & Operations (40 points total, 10 points each) Avoidable ED Visits X X X Practice Open to PHC Members X X X PCP Office Visits X X X

Submit data on 3NA and one Operations measures for Q3 and Q4

X X X

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CERVICAL CANCER SCREENING – FAMILY & INTERNAL MEDICINE SITES (20 PTS)Threshold: 69.1%

Denominator: The number of continuously enrolled Medi-Cal women 24-65 years of age as of 06/30/2014.

 Numerator: The percentage of continuously enrolled Medi-Cal

women 24 –65 years of age who were screened for cervical cancer according to the evidence-based guidelines:• Women age 24-65 who had a Pap test in the measurement year or the two years prior (July 1, 2011 – June 30, 2014).• Women age 35-65 who had a Pap test and an HPV test on the same date of service in the measurement year or the four years prior (July 1, 2009 – June 30, 2014).

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CHILDHOOD IMMUNIZATION – DTAP – PEDIATRIC MEDICINE SITES (20 PTS)Threshold: 80.6%

Denominator: Children who turn 2 years of age between July 1, 2013-June 30, 2014.

 Numerator: The number of children with at

least four DTaP vaccinations, with different dates of service on or before the child’s second birthday. Do not count a vaccination administered prior to 42 days after birth. Evidence:

Evidence of the antigen or combination vaccine

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PHARMACY UTILIZATION – ALL SITES (40 PTS)Targets:

At least 85% generic rate or 98% formulary compliance rate = full 10 points; Or

83.0-84.9% generic rate or 96.0-97.9% formulary compliance rate = 5 points

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AVOIDABLE ED VISITS – ALL SITES (10 PTS)Target: At or below site-specific, risk-adjusted

threshold

‘Avoidable ED Visits’ identified by using DHCS Statewide Avoidable ED Diagnoses Codes1

To calculate Avoidable Emergency Dept Visits PMPY:Avoidable ED Visits per 1000 = (Avoidable ED visits / Non-Dual Capitated Member Months) *12,0001In 2011, a California statewide collaborative Quality Improvement Project published a list of

diagnoses for non-emergency conditions to determine avoidable ED visits. This list is available in the detailed specifications manual for PHC’s QIP measures.

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PRACTICE OPEN TO PHC MEMBERS – ALL SITES (10 PTS)Targets:

2.5 points per quarter if site remains open to new PHC patients ; 2.5 points additional points at year end if site remains open for all three quarters (i.e. Oct 2013 – June 2014)

Partial Points: Any age restrictions = 1.25 points per quarter

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PCP OFFICE VISITS – ALL SITES (10 PTS)Targets: At or below site specific threshold.

To calculate PCP Office Visits PMPY:PCP Office Visits PMPY = (# Office Visits/ Non-Dual Capitated Member Months)*12

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3NA & OPERATIONS DATA – ALL SITES (10 PTS)

Targets: No targets, pay for reporting

For each quarter, submission must include BOTH third Next Available Appointment (3NA) and one optional measure to be considered complete. Optional measures to choose from are: No Show Rate,

Provider/Team Continuity or Call Abandonment rate

• If 2 quarters of data are submitted for 3NA and one optional measure, provider will receive full credit (10 points total).

• If 1 quarter of data is submitted for 3NA and one optional measure, provider will receive partial points (5 out of 10 points).

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DATA SOURCES PHC Administrative Data:

Outpatient and Inpatient Claims Pharmacy Radiology/Imaging Lab

Provider submitted data: Data uploads into eReports

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OVERVIEW OF DATA VALIDATION PROCESS – QIP EREPORTS DATAFive Key Steps1. Validate source code for all measures2. Validate denominators at the provider level 3. Validate numerators at the provider level 4. Validate preliminary rates at the aggregate

level 5. Provider validation before release of site

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FIXED POOL MEASURES – TRACKING SYSTEMS

Appropriate of Resources Measure Tracked By Systems

Pharmacy Utilization PHC Monthly Reports

Access & Operations Measures Tracked By Systems

Avoidable ED VisitsPHC Monthly

ReportsPractice Open to PHC MembersPCP Office Visits3NA and Operations Data

ProvidersSubmissio

n Template

Clinical Domain Measures Tracked By Systems

Cervical Cancer Screening PHC and Providers eReportsChildhood Immunization – DTaP

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QIP EREPORTSo An online system to:

o Monitor real-time clinical performance rateso See drill-down denominator and numerator lists

o Upload additional data

eReports: https://qip.partnershiphp.org Register for Training Webinar (12-1pm, Oct

9): https://phpevents.webex.com/phpevents/onstage/g.php?t=a&d=662220095

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MONTHLY REPORTS

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SUBMISSION TEMPLATES

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RESOURCESQIP Website: http://partnershiphp.org/Provider/MC_QIP.htm

QIP Inbox: qip@partnershiphp.org

eReports (monitor performance on CLINICAL measures):https://qip.partnershiphp.org/

Monthly Reports (monitor performance on NON- CLINICAL measures) – sent out monthly

Monthly Newsletters – sent out monthly

Other non-QIP-related questions: Sharon McFarlin, Provider Relations Rep (smcfarlin@partnershiphp.org; 707-420-7687)

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NEXT STEPS Provide us with updated contact info Clinical Measures (CCS and DTaP) and

Pharmacy Utilization Familiarize with Specs Sign up for training sessions Start conversation around potential Unit of

Service measures with leadership and staff Form a QI Team and assign responsibilities

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COMPREHENSIVE MEASUREMENT SETClinical Measures Family

(35 pts)

Internal(35 pts)

Pediatric(50 pts)

Child BMI (3-17 years) X XCervical Cancer Screening X XDiabetes Management (18-75 years) –

4 out of 7: LDL testing, LDL control, HbA1c testing, HbA1c control, Retinal eye exam, Nephropathy, Blood pressure control

X X

Well Child Visits (3-6 years) X XChildhood Immunization – Hep B (2 years) X XChildhood Immunization – DTaP (2 years) XNutrition Counseling (3-17 years) XPhysical Activity Counseling (3-17 years) XAdolescent Immunizations (13 years) XMonitoring for Patients on Persistent Medications

X

Controlling High Blood Pressure X

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Appropriate Use of Resources Measures Family(35 pts)

Internal (35 pts)

Pediatric(15 pts)

Acute Bed Days/1000 or Follow-Up Post Discharge

X X

Readmission Rate or Follow-Up Post Discharge X XPharmacy Utilization X X XSpecialist Referral Management (total number of specialty office visits)

X X X

Follow-up post discharge can be a back-up measure for either Acute Bed Days/1000 or Readmission Rate, but not both.

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Access & Operations Measures Family(20 pts)

Internal(20 pts)

Pediatric(25 pts)

Avoidable ED Visits (point earnings independent of PCP Office Visits performance)

X X X

Practice Open to PHC Members X X XPCP Office Visits X X XSubmit data on 3NA and one Operations measures for all 4 quarters

X X X

Patient Experience Measure Family(10 pts)

Internal (10 pts)

Pediatric (10 pts)

Survey Option or Training Option X X X

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Q&A