1

Positioning FQHCs for Value-Based Payment Arrangements

We have provided a number of links that can be scanned with your smart phone. If you do not have a QR code reader application on

your phone, you can download a number of free apps or use the web link as well (Search: QR Reader). Thanks for coming today!

Pre-Presentation Survey Please take our pre-presentation survey about value-based payment arrangements. https://www.surveymonkey.com/r/VBPPreSurvey

Post-Presentation Survey and Mailing List Sign-Up Did you learn something today? Let us know. If you are interested in learning more, please sign-up on the mailing list. https://www.surveymonkey.com/r/HSSMailingList

Outline: • Understanding the “New World”

– An Introduction to Health Reform and Payment Arrangements – The World of Payers

• A Framework for Building Value-Based Care – Patient-Centered Access – Team-Based Care – Population Health Management – Care Management and Support – Care Coordination and Care Transitions – Performance Measurement/QI

• Tying it all together for value-based care

Objectives: • Attendees will be able to identify and define key terminology commonly utilized in value-based

payment arrangements. • Attendees will learn the details of common value-based payment arrangements and the challenges and

opportunities associated with the payment design. • Attendees will learn operational strategies for positioning facilities for value-based payment

arrangements.

2

Figure 1:

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

Figure 2:

3

Figure 3:

• The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways:

– Payment Incentives: Tying payment to value through alternative payment models; – Care Coordination: Care delivery changes through greater teamwork, integration, coordination of

providers across settings, and a focus on population health; – Data and Technology: Harnessing the power of information to improve care for patients (Burwell,

2015). • CMS Goals: (Announced 1/26/2015)

– 85% of all Medicare fee-for-service payments tied to quality or value by 2016 (90% by 2018). – 30% of Medicare payments tied to quality or value through alternative payment models by the end of

2016 (50% by the end of 2018). • This is the first time in the history of the program that explicit goals for alternative payment models and value-

based payments have been set for Medicare. (http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html)

80

60

37.5

15 12.5 10

15

20

37

55

47

40

2.5

10 12.5

15

20

25

2.5 10 12.5 15

20 25

2011 2014 2015 2016 2017 2018

Medicare Payment Goals

Category 4 Population-based payment

Category 3 Alternative payment models built on fee-for-service architecture

Category 2 Fee-for-service with a link of payment to quality

Category 1 Fee-for-service with no link of payment to quality

4

Types of Payment Models

• Fee-For-Service – Description: Reimbursement for specific, individual services provided to a patient. The amount paid is

usually negotiated between payers and providers (Defined by coding). – Pros: Productivity, Encourages access, Some accountability – Cons: Does not incentivize efficiency or prevention of unnecessary care, Often pays for face-to-face

encounters so limits telephone interventions, care coordination, other non-billable services • Shared-Savings

– Description: A payment model that proposes incentives for providers to reduce health care spending for a defined patient population by offering them a percentage of net savings realized as a result of their efforts (often 50/50).

– Pros: May see significant initial savings, Entry way into value-based payment – Cons: A transitional model (if you do a good job, your margin of savings will get smaller and smaller) –

must transition to a risk-based model, Challenges with attribution, Proactive management of outcomes (claims)

• Bundled Payments – Description: A way of paying for certain high-volume, high-cost procedures. It combines two concepts:

“episode-based” and “bundled”. – Pros: A budget can be established for the bundle up front which can then be reconciled, Potential to

improve coordination among caregivers, Supports flexibility in how and where care is delivered, Simple billing, Clear accountability

– Cons: May distract policy-makers from moving more forcefully away from FFS, Difficulty defining the boundaries of an episode, Potential to increase barriers to patients’ choice of provider, Lack of incentive to reduce unnecessary episodes, Potential to avoid high-risk patients or cases that may exceed the average episode payment.

• Global Payments or “Global Capitation” – Description: Paid to a single health care organization, cover a broader array of services for a larger

population of patients over a longer period of time (HMOs). – Pros: Can result in significant cost savings to payer – Cons: Difficult to calculate rates

• Partial Capitation – Description: A payment model that may include capitation (PMPM) and a fee-for-service model

combined. – Pros: Maintains FFS – Cons: Increasing risk

• Full Capitation – Description: Provider is provided a set payment per member, per month (often paired with quality

outcomes). – Pros: Greatest opportunity for financial reward, Incentivizes efficiency and quality improvement – Cons: If quality outcomes not met, risk for significant financial loss

5

CMS 5-Star Rating

• Medicare uses information from member satisfaction surveys, plans, and health care providers to give overall performance star ratings to Medicare health and prescription drug plans.

• These ratings help you compare plans based on quality and performance. • A plan can get a rating from one to five stars. A 5-star rating is considered excellent. The overall plan rating gives

you a single summary score that makes it easy for you to compare plans based on quality and performance. • For plans covering health services, the overall score for quality of those services covers 36 different topics in

five categories: • Staying healthy: Includes how often members got various screening tests, vaccines, and other check-ups

that help them stay healthy. • Managing chronic (long-term) conditions: Includes how often members with different conditions got

certain tests and treatments that help them manage their conditions. • Ratings of health plan responsiveness and care: Includes ratings of member satisfaction with the plan. • Health plan member complaints and appeals: Includes how often members filed a complaint against

the plan. • Health plan telephone customer service: Includes how well the plan handles calls from members. (CMS,

2015) • Each measure is weighted. The highest-weighted are:

• Blood Pressure (BP Controlled <140/90mmHg) - UDS • Diabetes - UDS

• A1C controlled < 9% • Cholesterol controlled < 100

• Depression Screening (Annually) - UDS • Readmissions (30-day) • Patient-Satisfaction

• Improving or maintaining physical health • Health plan quality improvement

6

HEDIS® • The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of

America's health plans to measure performance on important dimensions of care and service. • Altogether, HEDIS consists of 81 measures across 5 domains of care. • Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it

possible to compare the performance of health plans on an "apples-to-apples" basis. (NCQA, 2015) • A number of HEDIS measures overlap with UDS (12 of 14):

• BMI (Adult) with follow-up plan (ABA) • Hypertension (Controlled: <140/90) (CBP) • Diabetes (Controlled A1C: <9%) (CDC) • CAD with lipid-lowering therapy (CMC) • Colorectal screening (COL) • Tobacco Screening and cessation (MSC) • Cervical Cancer Screenings (CCS, NCS) • IVD with ASA therapy (ASP) • Pre-Natal Care (PPC) • Asthma (ASM, MMA) • Childhood Immunizations (CIS, IMA) • BMI (Child counseling) (WCC)

• HEDIS “Season” • Documentation Gathering: January 1-June 15 (for prior year data) • Quality measure improvement: July-December

• Overview: • 83 Measures (76 process, 4 outcomes, 3 hybrid) • Effectiveness of Care Measures

• Prevention and Screening • Respiratory Conditions • Cardiovascular Conditions • Diabetes • Musculoskeletal Conditions • Behavioral Health • Medication Management • Measures Collected Through the Medicare Health Outcomes Survey • Measures Collected Through the CAHPS Health Plan Survey

• Access/Availability of Care Measures • Experience of Care Measure • Utilization and Relative Resource Use Measures

• Utilization Measures • Relative Resource Use Measures

• Health Plan Descriptive Information Measures

• Effectiveness of Care Measures – Prevention and Screening

• Adult BMI Assessment (ABA)* • Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents

(WCC)* • Childhood Immunization Status (CIS)*

7

• Immunizations for Adolescents (IMA)* • Human Papillomavirus Vaccine for Female Adolescents (HPV) • Lead Screening in Children (LSC)* • Breast Cancer Screening (BCS) • Cervical Cancer Screening (CCS) • Non-Recommended Cervical Cancer Screening in Adolescent Females (NCS) • Colorectal Cancer Screening (COL)* • Chlamydia Screening in Women (CHL) • Non-Recommended PSA-Based Screening in Older Men (PSA) (new measure) • Care for Older Adults (COA)

– Respiratory Conditions • Appropriate Testing for Children With Pharyngitis (CWP) • Appropriate Treatment for Children With Upper Respiratory Infection (URI) • Avoidance of Antibiotic Treatment in Adults With Acute Bronchitis (AAB) • Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR) • Pharmacotherapy Management of COPD Exacerbation (PCE) • Use of Appropriate Medications for People With Asthma (ASM) • Medication Management for People With Asthma (MMA) • Asthma Medication Ratio (AMR)

– Cardiovascular Conditions • Controlling High Blood Pressure (CBP) – (OUTCOME) • Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)

– Diabetes • Comprehensive Diabetes Care (CDC)** – (OUTCOME/PROCESS)

– Musculoskeletal Conditions • Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART) • Osteoporosis Management in Women Who Had a Fracture (OMW) • Use of Imaging Studies for Low Back Pain (LBP)

– Behavioral Health • Antidepressant Medication Management (AMM) • Follow-Up Care for Children Prescribed ADHD Medication (ADD) • Follow-Up After Hospitalization for Mental Illness (FUH) • Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using

Antipsychotic Medications (SSD) • Diabetes Monitoring for People With Diabetes and Schizophrenia (SMD) • Cardiovascular Monitoring for People With Cardiovascular Disease and Schizophrenia (SMC) • Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA) –

(OUTCOME/PROCESS) • Use of Multiple Concurrent Antipsychotics in Children and Adolescents (APC) (new measure) • Metabolic Monitoring for Children and Adolescents on Antipsychotics (APM) (new measure)

– Medication Management • Annual Monitoring for Patients on Persistent Medications (MPM) • Medication Reconciliation Post-Discharge (MRP) • Potentially Harmful Drug-Disease Interactions in the Elderly (DDE) • Use of High-Risk Medications in the Elderly (DAE)

– Measures Collected Through the Medicare Health Outcomes Survey • The Medicare Health Outcomes Survey (HOS) – (OUTCOME) • Fall Risk Management (FRM) • Management of Urinary Incontinence in Older Adults (MUI) – (OUTCOME/PROCESS) • Osteoporosis Testing in Older Women (OTO)

8

• Physical Activity in Older Adults (PAO) – Measures Collected Through the CAHPS Health Plan Survey

• Aspirin Use and Discussion (ASP) • Flu Vaccinations for Adults Ages 18–64 (FVA) • Flu Vaccinations for Adults Ages 65 and Older (FVO) • Medical Assistance With Smoking and Tobacco Use Cessation (MSC) • Pneumococcal Vaccination Status for Older Adults (PNU)

• Access/Availability of Care Measures • Adults’ Access to Preventive/Ambulatory Health Services (AAP) • Children and Adolescents’ Access to Primary Care Practitioners (CAP) • Annual Dental Visit (ADV) • Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) • Prenatal and Postpartum Care (PPC) • Call Answer Timeliness (CAT) • Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP)

(new measure) • *Eligible for rotation for HEDIS 2015. Unmarked measures should be collected.

• Experience of Care Measures • CAHPS Health Plan Survey 5.0H, Adult Version (CPA) – (OUTCOME) • CAHPS Health Plan Survey 5.0H, Child Version (CPC) – (OUTCOME) • Children With Chronic Conditions (CCC)

• Utilization and Relative Resource Use Measures – Utilization Measures

• Frequency of Ongoing Prenatal Care (FPC) • Well-Child Visits in the First 15 Months of Life (W15)* • Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (W34)* • Adolescent Well-Care Visits (AWC)* • Frequency of Selected Procedures (FSP) • Ambulatory Care (AMB) • Inpatient Utilization—General Hospital/Acute Care (IPU) • Identification of Alcohol and Other Drug Services (IAD) • Mental Health Utilization (MPT) • Antibiotic Utilization (ABX) • Plan All-Cause Readmissions (PCR)

– Relative Resource Use Measures • Relative Resource Use for People With Diabetes (RDI) • Relative Resource Use for People With Cardiovascular Conditions (RCA) • Relative Resource Use for People With Hypertension (RHY) • Relative Resource Use for People With COPD (RCO) • Relative Resource Use for People With Asthma (RAS)

• Health Plan Descriptive Information Measures • Board Certification (BCR) • Enrollment by Product Line (ENP) • Enrollment by State (EBS) • Language Diversity of Membership (LDM) • Race/Ethnicity Diversity of Membership (RDM) • Weeks of Pregnancy at Time of Enrollment (WOP) • Total Membership (TLM)

9

Risk Stratification

10

Main Domains of Value-Based Care

• 6 Main Domains – Patient-Centered Access

• Same-day access/timely advice • After-hours care • Alternative types of clinical encounters • Monitoring no-show rates • Working to improve access • Continuity of medical record • Electronic/portal access • Transmission of health record

– Team-Based Care • Continuity of PCP (monitor and work to improve) • Orient patients to practice • Provide written care plans for transition from peds to adult • Provide education on:

• Care coordination • How to request care during and after hours • Use of evidence-based care • Scope of services, including behavioral health services • Care regardless of payer type, helps enroll in insurance • How to transfer records

• Provide culturally- and linguistically-appropriate services • Use data to assess diversity and equity • Provide services in culturally-appropriate ways

• Define roles of team members • Hold regular care team/practice functioning meetings • Use standing orders • Assign a care team to Care Coordination • Train staff in self-management, self-efficacy, behavior change, population management • Involve patients and staff in QI/advisory councils

– Population Health Management • Record patient information (DOB, gender, race, ethnicity, preferred language, telephone

number, email address, occupation, legal guardian, primary caregiver, advance directives, health insurance, other providers)

• Maintain an accurate problem and diagnosis list • Maintain an accurate allergy list • Maintain an accurate medication list • Maintain lists of trends of vitals • Always ask about tobacco use • Record a thorough and accurate family history list • Assess age-appropriate immunizations/screenings • Assess family/social/cultural characteristics • Assess communication needs • Provide advance care planning • Assess and record behaviors that may affect health

11

• Assess and record mental health/substance abuse history • Provide developmental screenings for pediatric patients • Screen for depression • Assess health literacy • Use Data for Population Management

• Assess and work to improve: • Preventative Care Services (>2) • Immunization rates (>2) • Chronic or acute care services (>3) • Patients not recently seen by the practice • Medication monitoring or alerts

• Implement Evidence-Based Decision Support • Mental health, chronic diseases, acute conditions, behavior-influenced condition, well-

visit care, overuse/appropriateness issues – Care Management and Support

• Identify patients for care management (and use data) • Behavioral health conditions • High cost/high utilization • Poorly-controlled or complex conditions • Social determinants of health • Referrals by outside organizations

• Support Self-Care • Incorporate patient preference and goals • Identify treatment goals • Assess and address barriers • Develop a self-management plan/care plan

• Medication Management • Review and reconcile medications during care transitions • Educate on new prescriptions • Assess understanding of current medications • Assess response to medications and barriers to adherence • Document all OTC, herbal, and supplement meds

• Use Electronic Prescribing • Alert prescribers to generic alternatives

• Use the EHR to identify patient-specific resources/materials • Provide self-management tools • Adopt shared decision-making aids • Offer/refer patients to structured health education programs • Know your community resources and assess usefulness

– Care Coordination and Care Transitions • Test Tracking and Follow-Up

• Track lab, imaging, diagnostics (flags abnormals, notifies patients) • Follow-up with hospitals on newborn screenings • Labs, radiology, diagnostics should be ordered electronically and viewed electronically

• Referrals • Carefully evaluate referrals, consider quality/performance info • Maintain agreements with specialists and behavioral healthcare providers based on a

set criteria • Integrate BH within practice site • Communicate clearly with consultants, electronically

12

• Track referrals • Document co-management/other providers in EMR

• Coordinate Care Transitions • Proactively identify patients with unplanned hospital admissions and ED visits • Share clinical info with admitting hospitals and EDs • Develop and maintain a process for obtaining discharge summaries from hospitals/SNFs • Proactively contact patients following a hospital/ED visit • Establish appropriate consents for exchanging info across community partners

• 6 Evidence-Based Strategies to Reduce Readmissions (Bradley et al, 2013) • Partnering with local physicians and physician groups; • Collaborating with local facilities to develop consistent readmission reducing strategies; • Assigning nurses to manage medication plans; • Scheduling follow-up appointments for patients pre-discharge; • Following up with patients post-discharge with test results; and • Developing a post-discharge plan with the patient's primary physicians and sharing

medical records with the physician. • Interventions to Reduce Readmissions

• Multifaceted, complex, and self-management-focused approaches are most-successful. • Telephone call — The discharging clinician, A clinical pharmacist, A clinician from the

patient's primary care clinic • Home visits — Home visits made by a number of different types of providers have been

shown to reduce need for readmission. • Telemonitoring — Use of telemonitoring devices have also been studied as a means for

reducing readmissions. • High-risk patients – A randomized trial in 239 elderly patients with heart failure

compared assigned advanced practice nurses with usual care • Risk factors for readmission

• Clinical factors include the following: • Use of high risk medication (antibiotics, glucocorticoids, anticoagulants,

narcotics, antiepileptic medications, antipsychotics, antidepressants, and hypoglycemic agents)

• Polypharmacy (five or more medications) • More than six chronic conditions • Specific clinical conditions (eg, advanced COPD, diabetes, heart failure, stroke,

cancer, weight loss, depression) • Demographic and logistical factors include:

• Prior hospitalization, typically including unplanned hospitalizations within the last 6 to 12 months

• Black race • Low health literacy • Reduced social network indicators like being alone most of the day with limited

or no family or friend contact by phone or in person • Lower socioeconomic status

– Performance Measurement/QI • Assess and work to improve:

• Preventative Care Services (>2) • Immunization rates (>2) • Chronic or acute care services (>3) • Patients not recently seen by the practice • Medication monitoring or alerts

13

• Vulnerable populations/stratify disparities • Care coordination measures (>2) • Utilization measures affecting cost (>2)

• Measure Patient/Family Experience • Survey patients about access, communication, coordination and whole-person care

(CAHPS) • Survey experiences of vulnerable patient groups • Form a Patient Advisory Committee