COMPREHENSIVE PRIMARY CARE PROGRAMS

CATHY COSTELLO, JD, CPHIMSDirector, CliniSyncPLUS Services

SCOTT MASH, MSLIT, CPHIMS, FHIMSSDirector, Consulting Operations & HIE Outreach

COMPREHENSIVE PRIMARY CARE PROGRAMS

August 24, 2016

Acronyms We’ll be Using TodayACO Accountable Care Organization MSSP Medicare Shared Savings Program

APMs Advanced Alternative Payment Models ODM Ohio Department of Medicaid

CAHPS Consumer Assessment of Healthcare Providers & Systems

PBPM Per Beneficiary Per Month

CAP Corrective Action Plan PFAC Patient & Family Advisory Council

CPC Comprehensive Primary Care (Ohio Medicaid)

PFPM Physician Focused Payment Models

CPC+ Comprehensive Primary Care Plus (CMS) PMPM Per Member Per Month

ECs Eligible Clinicians PQRS Physician Quality Reporting System

EPs Eligible Professionals PROM Patient Reported Outcome Measures

FFS Fee for Service TCOC Total Cost of Care

MCP Managed Care Plan (Ohio Medicaid) TIN Tax ID Number

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CPC+ELIGIBILITY & REGISTRATION

FOR MEDICARE

Which Practices are Eligible to Participate?

• Primary care (except for pediatrics)

• NOT practicing in a concierge practice, a rural health clinic (RHC) or a Federally Qualified Health Center (FQHC).

• Can be hospital owned or independent. If hospital owned, need a letter from executive leadership showing there is a commitment

that the increased funding obtained through CPC+ flows to the practice site

• Must have 150 Medicare beneficiaries per practice site

• Can be part of a Medicare Shared Savings ACO

• Must plan on participating for 5 years

Medicare Registration by Practice Site Not by TIN

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Registration Information

• Must apply at https://app1.innovation.cms.gov/cpcplus between August 1 and September 15, 2016. Supporting documents uploaded at this site.

• Practices register by Track (Track 1 or Track 2) - no change allowed in tracks during the program; can register for Track 2 but may be put in Track 1 by CMS.

• Practices applying to Track 2 will need to submit a letter of support from their Health IT vendor(s) that outlines vendors’ commitment to supporting the practice with advanced health IT capabilities. CMS will sign a Memorandum of Understanding with those health IT vendors supporting

Track 2 practices selected to participate in CPC+.


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https://app1.innovation.cms.gov/cpcplus


Contact information:

• Applicant Contact (individual completing the application)

• Practice Contact (required if the Applicant Contact is not the primary contact in the practice or does not work in the practice)

• Health Information Technology Contact (individual responsible for HIT in the practice)

• Total number of individual physicians, nurse practitioners (NPs), physician assistants (PAs) and clinical nurse specialists (CNS) who provide patient care at your practice and practice under their own NPI.

• Primary care practitioners, including full-time and part-time staff in your practice: Number of physicians, NPs, PAs, CNSs

• For each primary care practitioner: Name, NPI, Specialty - If practitioner works

at the practice (or satellite office) and/or if the practitioner practices at another

Location.


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Contact information for Organization:

• Name of organization (If other practices from your organization are applying to CPC+, please use identical text in this field)

• Corporate address and phone number

• Number of primary care practice sites, physicians, and Medicare Eligible Professionals (EPs) that are part of this organization

• Name and TIN of all other practices in your organization that are applying for CPC+

• All TINs used by your practice to bill Medicare, including those used since January 1, 2013

• Medicare Shared Savings Program ACO name and TIN (if applicable)

• Percentage of patients by race and preferred language


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Meaningful Use and Health IT:

• Vendor name, Product and Version CPC+ Function (if applicable; Track 2 only)

• Meaningful Use attestation progress among the primary care practitioners in your practice who are Eligible Professionals

• Total number of Medicare EPs

Number of Medicare EPs who plan to attest to Meaningful Use Stage 2

• Total number of Medicaid EPs

Number of Medicaid EPs who plan to attest to Meaningful Use Stage 2

• CMS EHR Certification ID

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Practice revenue and budget information:

• Total revenue in 2015

• Total 2015 revenue by specified payer

• Percentage of patients by insurance type (e.g., commercial, Medicare)


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Care Delivery Structure:

• Care delivery information to answer application questions about care management, access, and quality improvement.

• Organizations through which your practice has received Medical Home recognition (if applicable)


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Letters of Support/Commitment:

• Letter of support from your practice’s clinical leader: each practice must submit a separate letter of support from leadership at the practice site

• Letter from system leadership regarding segregation of CPC+ funds (if applicable)

• Health IT Cover Letter (Track 2 applicants only) Letter of support from Health Information Technology vendor (Track 2 applicants only), if vendor has not submitted a Global Letter of Support.


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Ohio Medicaid• Primary care (FP, IM, general practice, peds, public health, geriatric)

• Can be hospital owned or independent

• Can leave the program at any time with notice to Ohio Medicaid (ODM)

• Can be part of a Medicare Shared Savings ACO

• Re-enrollment not required; automatic rollover unless practice terminates

2017 Eligibility1) > 5,000 Medicaid members (either Medicaid FFS or Medicaid managed care) with NCQA PCMH

accreditation (no level required)

2) > 500 Medicaid members and acceptance into the Medicare CPC+ program; or3) > 500 Medicaid members and NCQA Level III PCMH accreditation

2018 Eligibility • Open to all Medicaid practices

Which Practices are Eligible to Participate?Medicaid Registration by TIN

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Ohio Medicaid Eligible Provider Types & Specialties

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Practice Data:

• Practice name

• NPI

• Practice group ID

Contact Information

• Name

• Email

• Phone

• Mailing address

Medicaid Registration by TIN

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Practices must attest to the following:• Commit to share necessary data with the state and payers

• Commit to participate in learning activities

• Commit to meeting start-up activity requirements within 6 months

PCMH certification• Must attest to either NCQA Level II or NCQA Level III

Medicare CPC+ Participation• Has practice applied for Medicare CPC+?

• Has practice (or any locations of organization) been accepted in Medicare CPC+?


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Ohio Department of Medicaid website:

http://medicaid.test.ohio.gov/Providers/PaymentInnovation/CPC.aspx#1612552-cpc-enrollment

• Click on the link labeled “Enroll here.”

• This will link to the 1-page application for enrollment into the Ohio CPC program.

• The link will go live on October 1, 2016.

Enrollment: October 1 – October 31, 2016


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Medicaid Early Enrollment

Early enrollment in Ohio CPC (Medicaid)

will be a simple

online form

More details about Ohio CPC program can be found at: http://Medicaid.ohio.gov/Providers/Paymentinnovation/CPC.aspx

Ohio CPC “Early Entry” Enrollment

Late August 2016

o Ohio Medicaid will identify primary care practices that meet the state’s early entry criteria.

o Invite them to enroll in Ohio CPCo Encourage them to also apply for Medicare CPC+

September 7, 2016Ohio Medicaid will host a webinar for invited practices to learn more about enrolling in the Ohio CPC program.

October 1, 2016Ohio Medicaid will provide an online link to invited practices where they can enroll in Ohio CPC from October 1-31.

Late 2016Ohio Medicaid will invite practices selected for CPC+, that also have 500+ Medicaid members, to enroll in CPC.

January 1, 2017The performance period begins for practices enrolled in Ohio CPC & selected for Medicare CPC+.

http://medicaid.ohio.gov/Providers/Paymentinnovation/CPC.aspx

• Each payer will have its own registration

• No known eligibility requirements beyond those for Medicare and Medicaid, but each payer may set its own requirements

• Each payer may determine its own procedures for termination from the program.

Private Payers Registration Requirement Unknown

Which Practices are Eligible to Participate?

Aetna CareSource Paramount Health Care

Anthem Gateway Health Plan of Ohio SummaCare

AultCare Health Plans Medical Mutual of Ohio (MMO) The Health Plan

Buckeye Health Plan Molina Healthcare of Ohio United Healthcare

Private Payers Participating:

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Comparison of Medicaid & Medicare Financial Models

Alignment of Ohio PCMH design with CPC+ model.

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Proposed Medicare Financial Payment by TrackMedicare FFS Financial Support for CPC+ Practices

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Medicare Risk Tiers for Payment

Risk Tier Attribution Criteria Track 1 Track 2

Tier 1 1st quartile HCC ** $6 $9

Tier 2 2nd quartile HCC $8 $11

Tier 3 3rd quartile HCC $16 $19

Tier 44th quartile HCC for Track 1:

75-89% HCC for Track 2$30 $33

Complex

(Track 2 only)

Top 10% HCC

OR DementiaN/A $100

Average $15 $28

Table II: Proposed Risk Tiers and Care Management Fee Levels (PBPM) for CPC+

25** Hierarchical Condition Category (HCC) The HCC model is updated regularly by CMS to reflect changes in treatment patterns and costs.

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Ohio Application of CPC+ payment streams by line of business

Comparison of Medicaid & Medicare Financial Models

If the savings to Medicaid are positive at year-end, the entity receives a % of the savings as a lump-sum payment from Medicaid.

Medicaid PCMH Requirements for PaymentOhio’s PCMH Requirements and Payment Streams

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CPC+ Functions & Requirements

Function 1: Access & Continuity

• Effective primary care built on trusting & continuous relationship

• Expanding hours and developing alternatives to traditional office visits to ensure timely access

• Intended to increase the likelihood that patient gets right care at the right time to avoid costly urgent & emergency care.

Increased Availability – Medicare CPC+

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Access & Continuity RequirementsMEDICARE CPC+

Track 1 Track 2

1. Minimum of 95% empanelment to practitioner and/or care teams.

1. Track 1 requirements 1 – 3 +

2. 24/7 access to care team with real-time access to EHR.

2. Offer at least one alternative to traditional office visits as means to increasing access that best meets needs of patient population (e-visits, group visits, home visits, SNF visits)

3. Organization care by teams responsible for a specific, identifiable panel of patients to optimize continuity.

Ohio CPC+ variance: Same-day appointments30

Function 2: Care Management

• Care management for high-risk, high needs patients through risk stratification then empanel patients to care team.

• Identify patients most likely to benefit from targeted, proactive, relationship-base care management.

• Identify patients based on event triggers for short-term care management.

Transition to new care setting

New diagnosis of major illness.

Building Deeper Relationships – Medicare CPC+

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Care Management RequirementsMEDICARE CPC+

Track 1 Track 2

1. Risk-stratify all empaneled patients1. Use two-step risk stratification process for all

empaneled patients:Step 1: based on defined diagnosis, claims, or other algorithm (not care team intuition)Step 2: adds the care team’s perception of risk to adjust the risk-stratification of patients, as needed.

2. Provide targeted, proactive, relationship-based care management to all patients identified as an increased risk.

3. Provide short-term care management & med rec who have had an ED visit or hospital admit/discharge.

2. Track 1 Requirements 2 – 5 +

4. Ensure patients with ED visit receive follow up interaction within one week.

6. Use a plan of care centered on patient’s actions & support needs in management of chronic conditions.

5. Contact > 75% of patients who were hospitalizedwithin 2 business days. 32

Function 3: Comprehensiveness & Coordination

• Add both breadth and depth to the delivery of care services.

• Expand services and partnerships to meet majority of patient population’s medical, behavioral & health-related social needs

• Relationship with care team intended to lower overall utilization and costs, decrease fragmentation of care and improve health outcomes.

• Care team serves as the hub for all patient services.

Expand and Manage Services – Medicare CPC+

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Comprehensiveness & Coordination Requirements

MEDICARE CPC+

Track 1 Track 2

1. Systematically identify high-volume & high-cost specialists serving the patient population.

Track 1 Requirements 1 – 2 +

3. Enact collaborative agreements w/ at least 2 groups of specialists identified from analysis

4. Choose & implement at least 1 option forintegrating behavioral health into care.

2. Identify hospitals & EDs responsible for the majority of patients’ visits. Assess & improve timeliness of notification & information transfer

5. Systematically assess patients’ psychosocial needs using evidence-based tools.

6. Conduct an inventory of resources & supports to meet patients’ psychosocial needs.

7. Characterize important needs of high-risk patients populations & identify capability to develop to meet those needs & track over time.

Function 4: Patient & Caregiver Engagement

• Organize a Patient & Family Advisory Council (PFAC)

• Leverage PFAC to understand the perspective of patients while educating them of ongoing transformation of delivery of care.

• Use recommendations of PFAC to improve care & to ensure continued patient-centeredness.

Patient and Family Feedback – Medicare CPC+

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Patient & Caregiver Engagement Requirements

MEDICARE CPC+

Track 1 Track 2

1. Convene a PFAC at least once in PY2017 & integrate recommendations into care, as appropriate.

1. Convene a PFAC in at least two quarters in PY2017 & integrate recommendations into care, as appropriate.

2. Access practice capability & plan for support of patients’ self-management.

2. Implement self-management supportfor at least 3 high risk conditions.

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Function 5: Planned Care & Population Health

• Organize care & services to meet entire population of patients served.

• Offer timely & appropriate preventative care and consistent evidence-based management of chronic conditions.

• Improve population health through use of evidence-based protocols in team-based care.

• Measure and act on the quality of care at both the practice & panel level.

Team-Based Population Management – Medicare CPC+

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Planned Care & Population Health RequirementsMEDICARE CPC+

Track 1 Track 2

1. Use feedback reports provided by CMS & other payers at least quarterly on at least 2 utilization measures at the practice-level and practice data on at least 3 eCQMs, derived from the EHR, at both practice- and panel-level to inform strategies to improve population health management.

Track 1 Requirement 1 +

2. Conduct care team meetings at least weekly to review practice- and panel-level data from payers and internal monitoring and using this data to guide testing of tactics to improve care and achieve practice goals in CPC+.

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Reporting Requirements – Medicare CPC+

Both Track 1 and Track 2 practices are required to:• Report 9 eCQMs annually

• Administer CAHPS surveys to all patients who have in-person office visits

Track 2 practices must administer PROM• PROM – Patient Reported Outcome Measures

Assess quality performance & eligibility to performance-based incentives

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eCQMs – Medicare CPC+

• Reported at both the practice-level and panel level.

• At least 2 of 3 outcome measures, at least 2 of 4 complex care measures and any five any remaining measures

• Currently 14 eCQMs on available measures list

Track 1 & Track 2 practices are required to report 9 eCQMs annually

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Medicare CPC+ List of Reportable eCQMs

Medicare CPC+ eCQM Set – 2017 Performance Period

CMS ID# NQF# Measure TitleMeasure Type/

Data SourceDomain

Report 2 of the Group 1 outcome measures:

Gro

up

1

CMS159v5 0710 Depression Remission at Twelve Months

Outcome/eCQM Clinical Process/Effectiveness

CMS165v5 0018 Controlling High Blood Pressure

Outcome/eCQM Clinical Process/Effectiveness

CMS122v5 0059 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)

Outcome/eCQM Population/Public Health

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Data SourceDomain

Report 2 of the Group 2 complex care measures:

Gro

up

2

CMS156v5 0022 Use of High-Risk Medications in the Elderly

Process/eCQM Patient Safety

CMS149v5 N/A Dementia: CognitiveAssessment

Process/eCQM Clinical Process/Effectiveness

CMS139v5 0101 Falls: Screening for Future Fall Risk

Process/eCQM Patient Safety

CMS137v5 0004 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment

Process/eCQM Clinical Process/Effectiveness


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Data SourceDomain

Report 5 of the 10 remaining measures (choice of Group 3 and remaining Groups 1 and 2 measures):

Gro

up

3

CMS50v5 N/A Closing the Referral Loop: Receipt of Specialist Report

Process/eCQM Care Coordination

CMS124v5 0032 Cervical Cancer Screening Process/eCQM Clinical Process/Effectiveness

CMS130v5 0034 Colorectal Cancer Screening Process/eCQM Clinical Process/Effectiveness

CMS131v5 0055 Diabetes: Eye Exam Process/eCQM Clinical Process/Effectiveness

CMS138v5 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Process/eCQM Population/Public Health

CMS166v6 0052 Use of Imaging Studies for Low Back Pain

Process/eCQM Efficient Use of Healthcare Resources

CMS125v5 2372 Breast Cancer Screening Process/eCQM Clinical Process/Effectiveness


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Ohio Medicaid CPC Clinical Quality RequirementsMust pass 50%

Medicare CPC+ Program

What is Monitoring?The CMS Medicare monitoring program will utilize:

• Integrity, cost, utilization and quality data in their monitoring strategy

• Think QRUR reports

• Reports submitted from practice coaches (CMS contractors)

• Reports submitted by practices

Monitoring confirms that

practices understand and

can track progress towards meeting the care delivery

requirements.

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Monitoring

Program integrity Data• Prior to start of program to determine eligibility for CPC+

Care Delivery Requirements Achievement Data• Quarterly attestations of care delivery achievements submitted to CMS.

• Certain reported less than quarterly (ex: 24/7 access)

Care Delivery Flag Report• Based on submissions to CMS which identify areas of concern or high

performance.

Medicare Monitoring will include the review of some or all of the following:

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More Monitoring

Practice Budget Data• Submitted annually by practice.

• Includes a retrospective look at prior year use of CMFs and CPCP & any expected changes for the upcoming year

Cost, Utilization, Patient Experience, and Quality Data• Reviewed at least annually to identify practices that are performing well and

those performing poorly.

Track 2 practices subject to increased monitoring/feedback.

Medicare Monitoring will include the review of some or all of the following:

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Corrective Action Plan (CAP) - Medicare

• CAP imposed when a practice is:

not meeting requirements in the Participation Agreement

found to be “gaming”

not meeting quality standards

• Expected to remedy the situation within given time frame (usually 6 months)

• CAP will be shared with practices, regional learning faculty & payers.

• Practices that cannot address areas of concern or meet requirements in Practice Agreement will be subject to Termination.

Imposed when a practice is not meeting Participation Agreement, found to be “gaming”, or not meeting quality standards.

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Medicare Audits

• Practices will be informed of potential audits by CMS or contractor

• Practices required to maintain copies of all documentation related to use of CPC funds & care delivery work for CPC requirements.

• Risk score based on budget data, utilization performance, quality measures and reports may trigger audits.

In addition to quarterly monitoring, practices will be subject to audit

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Ohio Health Information PartnershipCliniSync and CliniSyncPLUS

Cathy Costello [email protected]

Scott Mash [email protected]

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COMPREHENSIVE PRIMARY CARE PROGRAMS

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