Value by Design: A Population Health Primer for Provider Groups

©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |1©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |1

Value by Design

A Population Health Primer for Provider Groups

August 24, 2016

©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |6

Accelerating Shift to Value-Based Care

2007PQRS Quality Measures

2009ARRA

2010ACA &Meaningful Use

2013Value-Based Modifier

2014ACO / Risk Contracting

2017*MACRA

Per Capita Cost

Experience of Care

The Triple Aim

Health of a Population


MACRA Makes 3 Key Changes to How Medicare Pays Providers


How Will MACRA Quality Payment Programs Work?

95% 5%Participation

by Providers

Participation

by Providers

MIPS APMs


MACRA’s Quality Payment Programs

• Streamlines PQRS, VM, and EHR reporting programs

• Will apply to most Medicare Part B clinicians with a few exceptions

• Generates a MIPS composite performance score (0-100) based on:

– Quality (50%)

– Resource Use (10%)

– Clinical Practice Improvement Activities (15%)

– Advancing Care Information (25%)

Merit-Based Incentive Payment System (MIPS)

• Use certified EHR technology

• Payments based on quality measures similar to what’s listed in MIPS’ quality category

• Entities bear “more than nominal” financial risk ~or~ is a Medical Home Model under CMMI

• Examples of Advanced APMs for 2017 are: MSSP ACO (Tracks 2 & 3), Next Gen ACO Model, Comprehensive

ESRD Care (CEC), Comprehensive Primary Care Plus (CPC+), Oncology Care Model (OCM)

• “MACRA does NOT change how any particular APM functions or rewards value. Instead, it creates extra

incentives for APM participation.”*

Advanced Alternative Payment Models (APM)

Cri

teri

a

* https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-

Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MACRA-NPRM-slides-consumer-version.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/Quality-Payment-Program-MACRA-NPRM-slides-consumer-version.pdf


How to Choose Between MIPS and APMs?

http://www.brookings.edu/research/papers/2016/07/12-how-the-money-flows-under-macra-patel-adler-darling-ginsburg

July 12, 2016

http://www.brookings.edu/research/papers/2016/07/12-how-the-money-flows-under-macra-patel-adler-darling-ginsburg


Timeline for MACRA Implementation

April 2015

MACRA

Signed Into

Law

April 2016

Proposed

MACRA Rule

Fall 2016

MACRA Final

Rule

November 1, 2016

Deadline for Final

Quality Measures

for Performance

Period #1

January 1, 2017

MIPS Data

Collection

Begins*

January 1, 2019

First MIPS Payment

Adjustment

(+/- 4%) or 5%

Incentive Bonus for

APMs


Trend: Risk Bearing Contracts

“There will come a time when the realization occurs that this is a partnership and

that the risk needs to be spread around.”

Two Types of Arrangements:

Upside RiskProvider only shares in the savings (not the losses)

Example: MSSP Track 1

Upside & Downside RiskProvider shares in (a greater) portion of savings but

also responsible for a portion of any losses

Example: MSSP Tracks 2 &3


Trend: Provider Organizational Structures

PCMH

IPA

CINACO

|16©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |

WHAT CAN I DO NOW?


Patient-Centered Medical Home Recognition

Tip: Make Sure The Payers You Work With Accept The Accreditation You Are Applying For

National Committee for

Quality Assurance

(NCQA)

Joint Commission

Accreditation Association

for Ambulatory Health

Care (AAAHC)

Utilization Review

Accreditation

Commission (URAC)


Becoming a Patient-Centered Medical Home

Access to Care

Team-Based Care Population Health

Continuity of Care

Performance Measurement & Quality Improvement

|19©2016 SCIO Health Analytics®. Confidential and Proprietary. All rights reserved. |

6 TIPS TO THRIVE IN VALUE-BASED

REIMBURSEMENT


6 Tips to Thrive in Value-Based Reimbursement

Have a Plan & Set GoalsCultivate an Organization

That is Receptive to Change

Continual & Evolving

Communication

Treat Your Practice Like

Your Own Checkbook

Pay Attention to Your

Quality Measures

Use Technology To

Your Advantage


Tip #1: Have A Plan & Set Goals

Assessments

Gap Analysis

Resources

Budget & operational cost

Evidence-based guidelines

Learning networks & staying up to date

with best practices

Technology

Do you have an EHR?

Does the EHR meet your reporting needs?

Connection to a health information exchange?

Have you optimized your operational workflow with

your technology in mind?

Staff

Is there an EHR “super user”?

Who owns tracking of healthcare trends?

Provider champion and a quality improvement team

Physician alignment on cost / quality reporting

How receptive is your staff to change?

Is your staff consistently working at the top of their

skillset?

Outreach

Do you know your patient panel & demographics?

What options do you have to contact a patient?

What does your patient satisfaction survey say?


Tip #2: Cultivate an Organization That is Receptive to Change

There is no “right answer” for everybody and change doesn’t have to be slow – try

lots of things in rapid succession and see what works for your organization

Plan

DoStudy

Act Plan

DoStudy

Act Plan

DoStudy

Act

• Engage all departments (360◦ view)

• Be transparent internally with providers and give

the feedback necessary to align behavior to

outcomes

• Communicate the impact of changes (good & bad)

• Think outside the box for healthcare opportunities

• All members of the team are important to patients!

Make your staff aware of how they contribute to

achieving the organization’s goals


Tip #3: Continual & Evolving Communication

• Schedule all-staff meetings for education on

trends and quality / referral team activities

• Internal transparency with providers on goals /

impact of actions to drive behavior change

– Validate & communicate their

patient panels

• Pre-visit planning

• Create a patient advisory council and send

patient satisfaction surveys

– Message accomplishments /

mitigation plans

• Develop open communications with hospitals

and community agencies

• Find a cadence and platform(s) that works with

your patient populations

Internal External


Tip #3: Continual & Evolving Communication

It’s never been easier to engage with your patients!

Use your website, portal, and email as a bi-directional

communication tool

• Practice announcements

– Non-traditional hours

• Post-visit report & referral information

• Summary of care

• Patient satisfaction surveys

– Use a CAHPS vendor if possible

• Treatment goal setting

• Appointment scheduling

• New patient forms

• Prescription Refills

To

Pati

en

tF

rom

Pati

en

t


Tip #4: Treat Your Practice Like Your Own Budget

“If you can’t measure it, you can’t improve it”– Peter Drucker

In Network Care

• Fix referrals then leakage

• Increase “after hour” care options

• Consider bringing out-of-network high cost services inside your network

Cost Containment

• Operational costs (workflow, staffing/provider ratio, supplies)

• Enable staff to work at the top of their skill set

• Increase preventative services (well visits including vaccinations & screenings)

Overutilization

• Readmissions within 30 days

Optimize Revenue

• Negotiate competitive pricing

• Increase providers/services


Tip #5: Pay Attention to Your Quality Measures

Ask Yourself: Do you know what your payers are measuring you on?

“If you can’t measure it, you can’t improve it”– Peter Drucker

don’t know what’s being measured

Terri Gonzalez^

^

5 Steps to an Effective Quality Measurement Program

Compile all quality measures across payer contracts into a single place

• Understand what your contracts require for quality measures (what measures are they looking at for your practice?)

Use reporting dashboards for increased visibility into your current performance

Focus on the most achievable measures first

• Patients that haven’t been seen in 2+ years

• Diabetic patients

• BMI gaps

Prioritize remaining gap closure based on which are closest to your contracted threshold

Get creative on the most difficult gaps to close

• e.g., Mobile eye exams, mobile mammography, teen health fair

1

2

3

4

5


Tip #6: Use Technology To Your Advantage

Use analytics to manage your patient populations


Tip #6: Use Technology To Your Advantage

How are we doing as a practice overall?1 What and where is my risk?2

What diagnostic categories are driving my costs?3 What are my quality measure gaps?4


Population

100%

Impactability Prospective Risk

Moderate Impactability

12% of Members

Low Impactability

75% of Members

High Impactability

12% of Members

High

Low

Op

po

rtun

ity

Goal

Close Gaps

and Steerage

to Managed

Networks

Close Gaps

and Steerage

to Managed

Networks

Manage

High Costs

and Risk

Factors

Manage

High Costs

High Risk

10%

Moderate Risk

1.5%

Low Risk

0.5%

High Risk

8%

Moderate Risk

3%

Low Risk

1%

High Risk

13.5%

Moderate Risk

27%

Low Risk

34.5%

High Cost

1% of Members

Stratifying Populations by Financial Risk & Impactability


What To Do Next?

Complete Your

Organizational Assessment

Understand Your Patient

Panel (& Communicate with

Providers)

Form Your Quality Team

• Compile Quality Measures

• Measure Performance

Select Your Industry SMEs &

Technology “Super Users”

Identify Your Most

Vulnerable / High Risk

Patients

Schedule All Staff Meetings

Socialize

PDSA Cycles

Value by Design: A Population Health Primer for Provider Groups

Healthcare

Transcript of Value by Design: A Population Health Primer for Provider Groups