CPC’s Episodes of Care Metric

Mylynda Drake, CPC Program Administrator

Ohio Department of Medicaid

August 8, 2019

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Today’s Webinar Agenda

• Efficiency Metric Overview

• Referral Report Refresher

• Episodes of Care Metric Deep Dive

• Important Upcoming Dates for CPC

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Efficiency Metric Overview

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Ohio Comprehensive Primary Care (CPC) Program Requirements and Payment StreamsRequirements

PMPM

Must pass 50%

Must pass 100%

8 activity requirements

• Clinical measures aligned with CMS/AHIP core standards for PCMH

• 24/7 and same-day access to care

• Risk stratification

• Population management

• Team-based care delivery

• Care management plans

• Follow up after hospital discharge

• Tracking follow up tests and specialist referrals

• Patient experience

Total Cost of Care20 Clinical Quality metrics

Payment Streams

Shared Savings

Based on self-improvement & performance relative to peers

All required

Must pass 50%

5 Efficiency metrics

• ED visits

• Inpatient admissions for ambulatory sensitive conditions

• Generic dispensing rate of select classes

• Behavioral health related inpatient admits

• Episodes-related metric

All required

Overview of CPC efficiency metrics

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Metric Rationale

Ambulatory care-sensitive inpatient admits per 1,000

▪ Strong correlation with total cost of care for large practices▪ Metric that PCPs have stronger ability to influence, compared to all IP

admissions

Emergency room visits per 1,000

▪ Limited range of year over year variability for smaller panel sizes▪ Aligned with change in providers’ behavior that the program wants to

incentivize

▪ Reinforces desired provider practice patterns, with focus on the behavioral health population

▪ Relevant for a significant number of smaller practices▪ Stronger correlation to total cost of care than other BH-related metrics

Behavioral health-related1 inpatient admits per 1,000

Episodes-related metric

▪ Links CPC program to episode-based payments ▪ Incentivizes primary care providers to refer their patients to higher-

performing providers

Generic Dispensing Rate

▪ Strong correlation with total cost of care for large practices▪ Limited range of year over year variability for smaller panel sizes▪ Aligned with change in providers’ behavior that the program wants to

incentivize

Ambulatory care-sensitive inpatient admits/1,000 (PQI #90)

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Description Numerator Denominator

Prevention Quality Indicators (PQI) overall composite per 1,000 member months, ages 18 yearsand older. Includes admissions for one of the following conditions: diabetes with short-termcomplications, diabetes with long-term complications, uncontrolled diabetes withoutcomplications, diabetes with lower-extremity amputation, chronic obstructive pulmonarydisease, asthma, hypertension, heart failure, angina without a cardiac procedure, dehydration,bacterial pneumonia, or urinary tract infection

Discharges, for patients ages 18 years and older, that meet the inclusion and exclusion rules for the numerator in any of the following PQIs:

▪ PQI #1 Diabetes Short-Term Complications Admission Rate

▪ PQI #3 Diabetes Long-Term Complications Admission Rate

▪ PQI #5 Chronic Obstructive Pulmonary Disease (COPD) or Asthma in Older Adults

▪ Admission Rate

▪ PQI #7 Hypertension Admission Rate

▪ PQI #8 Heart Failure Admission Rate

▪ PQI #10 Dehydration Admission Rate

▪ PQI #11 Bacterial Pneumonia Admission Rate

▪ PQI #12 Urinary Tract Infection Admission Rate

▪ PQI #13 Angina Without Procedure Admission Rate

▪ PQI #14 Uncontrolled Diabetes Admission Rate

▪ PQI #15 Asthma in Younger Adults Admission Rate

▪ PQI #16 Lower-Extremity Amputation among Patients with Diabetes Rate

Discharges that meet the inclusion and exclusion rules for the numerator in more than one of the above PQIs are counted only once in the composite numerator

▪ Population ages 18 years and older

Emergency department visits/1,000 (HEDIS AMB)

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Description Member months Events and Calculation Exclusions

This measure summarizes utilization of ambulatory care in the ED visit category

Report all member months for the measurement year

▪ Count each visit to an ED that does not result in an inpatient encounter once, regardless of the intensity or duration of the visit

▪ Count multiple ED visits on the same date of service as one visit

▪ Report ED visits as a rate per 1,000 member months

Claims and encounters that indicate the encounter was for mental health or chemical dependency, defined as meeting any of the following criteria

▪ A principal diagnosis of mental health or chemical dependency

▪ Psychiatry.

▪ Electroconvulsive therapy.

▪ Alcohol or drug rehabilitation or detoxification.

Behavioral health-related inpatient admits/1,000 (HEDIS MPT)

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Description Member months Events and Calculation Exclusions

This measure summarizes utilization of mental health services in the inpatient setting

Report all member months for the measurement year

▪ Count all acute and non-acute inpatient discharges from either a hospital or a treatment facility with a mental health principal diagnosis

▪ Report BH-related IP admits as a rate per 1,000 member months

None

Generic Dispensing Rate

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Description Events and Calculation Denominator

This measure calculates the percentage of drug scripts prescribed which are generic

Number of scripts with an NDC code classified as generic name indicator = 1 according to a First Databank extract (specifies whether a product is a brand name product or generically named product using the product name as the criteria. Generically named drug products are products without a proprietary name.)

All scripts written for patients attributed to the practice during the measurement year, by both the PCP and other physicians

Episode-based metric

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Description PAP Performance definition Included episodes

# of attributed member visits to PAPs who are low performing PAPS- # of attributed member visits to high performing PAPs; as a % of all attributed member visits to PAPs (low, high and neutral performing)

• A low performing PAP is one that has average risk adjusted spend in the top quintile.

• A high performing PAP is one thathasaverage risk adjusted spend in the lowest two quintiles and passes quality metrics.

• All other PAPs are neutral performing PAPs.

▪ Asthma▪ COPD▪ Perinatal▪ Colonoscopy▪ Esophagogastroduodenoscopy (EGD)▪ Gastrointestinal hemorrhage (GIH)▪ Cholecystectomy

2019 Ohio CPC Efficiency Metric Thresholds

Metric name 2017 Threshold

2018 Threshold

2019 Threshold

Emergency room visits per 1,000

<=73 <=99.14 <=82.21

Behavioral health-related1

inpatient admits per 1,000<=1.2 <=1.2 <=1.13

Ambulatory care-sensitive inpatient admits per 1,000

<=7 <=2.50 <=2.0

Generic dispensing rate2 78% 78% 78%

Episode-related metric n/a n/a -42.15%

1 Defined using HEDIS logic- Mental Health Utilization.

2 Includes all drug classes and assumes that the threshold will remain unchanged for 2019 performance year.

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CPC entities must pass at least 3 of the 5 efficiency

metrics to meet the minimum 50% passing rate.

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Referral Report Refresher

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Accessing Referral Reports in MITS Provider Portal

Quarterly referral reports include information about PAP performance for attributed members with episodes

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CPC Quarterly Referral Report - Summary Report

(PDF)

Includes:

• Data on your CPC practice’s attributed members

• Average cost per patient

• Percent of referrals to each PAP

• Details on other PAPs within a geographic radius

CPC Quarterly Referral Report - CSV File

Includes:

• Underlying episodes behind the patient activity

shown on the report

• In-depth information on PAP performance by episode

Closer Up View of Referral PDF

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Episodes of Care Metric Deep Dive

Earlier Entire patient claims history Later

Episode duration

Time period before and after the significant medical event where

related claims will be included

Claims that are unrelated to the significant medical event and will

not be included

Provider that will be accountable for the episode

Claims that are related to the significant medical event and will

be included in the episode

Episode Parameters

Claim for significant medical “trigger” event Hip replacement procedure

30 days prior to 60 days post-

op

Vaccinations, chronic condition

medications

Orthopedic surgeon

IP admission, physical therapy,

medications

Example of service

▪ An episode of care (“episode” or “EOC”) is defined as the set of services provided to treat a clinical condition

or procedure for a defined duration

▪ These services occur across the continuum of care and can include: Extended care, Acute hospital care, Ambulatory

care, Home care, Community Outreach, Wellness, etc.

Anatomy of an episode bundle

2 3

Patients seek and providers deliver care as they do today

Calculate incentive payments based on outcomesafter close of12 month performance period

Patients seek care and select providers as they do today

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Review claims from the performance period to identify a ‘Principal Accountable Provider’(PAP) for each episode

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Providers submit claims as they do today

Payers calculate average risk-adjusted reimburse-ment per episode for each PAP

Compare to predeter-mined “commendable” and “acceptable” levels

Payers reimburse for all services as they do today

Providers may

• Share savings: if average costs below commendable levels and quality targets are met

• Pay negative incentive:if average costs are above acceptable level

• See no impact: if average costs are between commendable and acceptable levels

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Ohio’s episode model is retrospective, building on the current FFS infrastructure already in place

7Provider cost distribution (average risk-adjusted reimbursement per provider)

Acceptable

Positive incentive limit

Commendable

Avg. risk-adjusted reimbursement per episode$

Principal Accountable Provider

- No change No incentive payment

Positive incentiveNegative incentive +No Change Eligible for positive incentive payment based on cost, but did not pass quality metrics

Retrospective thresholds reward cost-efficient, high-quality care

NOTE: Each vertical bar represents the average cost for a provider, sorted from highest to lowest average cost

Ohio has implemented the Episodes program in three waves, with Wave 3 episodes tied to payment starting in 2019 and beyond

1 Payment episode status already determined for W1 and W2; W3 episodes will be tied to payment through 3-stage implementation with 9 episodes in the first stage in 2019

2 Reporting for Wave 3 episodes extended through CY18 given need to incorporate physician feedback through reactive clinical process into episode design prior to performance periods

3 Episodes staying in ‘reporting-only’ for a period to-be-determined, or indefinitely by design.

W1

W3

Wave

W2

Episodes

201720162015 20192018 2020

Perfor-mance Y1

Perfor-mance Y2

Perfor-mance Y3

Reporting only

Perfor-mance Y4

Perfor-mance Y1

Perfor-mance Y2

Reporting only

Perfor-mance Y3

Linked to payment1

• Acute PCI, asthma exacerbation, COPD exacerbation, non-acute PCI, perinatal, total joint replacement

• Appendectomy, cholecystectomy, colonoscopy, EGD, GI bleed, URI, UTI

• ADHD, CHF exacerbation, headache, low back pain, neonatal (low-risk), otitis media, pediatric acute LRI, skin/soft tissue infections, tooth extraction

• Ankle sprain/strain, DKA, knee sprain/strain, neonatal (medium-risk), ODD, shoulder sprain/strain, spinal decompression, spinal fusion, wrist sprain/strain

• Breast biopsy, breast cancer surgery3, breast medical oncology3, CABG3, cardiac valve3, femur/pelvis fracture, HIV3, hysterectomy, knee arthroscopy, neonatal (high-risk)3, pancreatitis3, tonsillectomy

Reporting only2

Perfor-mance Y1

Perfor-mance Y2

Perfor-mance Y3

Perfor-mance Y1

Perfor-mance Y2

Perfor-mance Y1

Reporting only2

Reporting only2

2021 2022

Perfor-mance Y5

Perfor-mance Y6

Perfor-mance Y4

Perfor-mance Y5

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Episode Reports are also on the MITS provider portal

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To find out more about Episodes of Care

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2018 method for calculating the EOC metric is not tied to volume

# of ”High Performing” PAPs seen by members

# Total PAPs seen by members

# of ”Low Performing” PAPs seen by members

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2 1

5

1

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3

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or – 0.2

CPC A - 140 episodes across 5 PAPs▪ 10 episodes w/ PAP1, a low performing PAP▪ 10 episodes w/ PAP2, a low performing PAP▪ 10 episodes w/ PAP3, a neutral PAP▪ 100 episodes w/ PAP4, a high performing PAP passing quality

measures▪ 10 episodes w/ PAP5, a high performing PAP NOT passing quality

measures

2018 definition Example calculation

PAP performance is determined by quintiles, NOT thresholds

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Including $$ quintile PAPs as high-performing

2018 definition of ‘high’ and ‘low’ performing PAPs

2019 definition of ‘high’ and ‘low’ performing PAPs

$$$$$

$ +

• Metric calculation will include $$ quintile as a ‘high performing’ PAP

• With current methodology, there are more ‘low performing’ PAPs vs. ‘high performing’ PAPs

$$$$$

$$ +

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2019 episode-related metric methodology

# episodes with

HP PAPs

# episodes with

LP PAPs

Total # of episodes

# episodes

w/ HP PAPs

Additional Display Metric calculation

A CPC practice has:

‘High performing’

‘Low performing’

Neutral

10

40

20

Example

20 - 10

70

=

.14

Total # of

episodes# episodes

w/LP PAPs ( ):

Note: metric performance will continue to be shown as a percentage, with the additional display included in practice reports starting in performance year 2019

= 14%

HP: high performing

LP: low performing

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Example of how EOC Metric looks on Quarterly CPC Practice Report

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Important Upcoming Dates for CPC

Upcoming Dates for CPC

• Enrollment for 2020 10/1/19-11/1/19: All practices must re-attest to meeting activity requirements, and if eligible for CPC for Kids, state intent to participate

• In-Person Learning: last session tomorrow, 8/9, 1:30-4:30 @ Grove City library» If you attended an IPL session, please remember to submit your evaluation

• Webinars» August 27: Payment Innovation Program Update

» August 30: Total Cost of Care Methodology Review

» September 27: Ohio CPC 2020 Enrollment Webinar

» October 25: Trauma Informed Care• Still need a couple of volunteer practices to present

» November 14: Review of 2018 Ohio CPC Outcomes

» December 19: Ohio CPC and CPC for Kids 2020 Introductory Webinar

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