Thomas W. Wells, MD FACP
What Providers Need to Know About Outpatient Quality Measures
2
• I have no financial interests or conflicts to disclose.
Disclosures
3
• Understand the history of healthcare quality
• What are the likely directions to come related to healthcare quality
over next 2-5 years
• Understand the need to be successful for you and your patients
• Become familiar with several preventative health and at risk
population measures
Objectives
4
• Limitations of Measurement
– Claims data
– Clinicians want to see OUTCOMES data…
• For meaningful outcomes (death, infections, complications) …
» That are RISK adjusted….(and show that my patients ARE sicker)
• Adequately sized sample…..(but not require volume for credentialing – unless I
want)
• That measure the part that I am responsible for…
• AND are timely (like yesterday)
– Left with what is “measureable and obtainable” for large volume diagnosis
mostly centered around HOSPITAL CARE – Hard for MDs to link cause
and effect of their practice to reported metrics (limited attribution model,
“yeah but what about…”)
History of Quality
5
While MDs argue about non-validity…• Payers , employers and patients complain about continued COST
of care and inconsistent quality - with CMS driving the agenda…
6
The United States continues to have poorer outcomes and higher costs that other developed countries…
7
All while health care spending continues to grow…
8
… and all payors are pushing for TRANSPARENCY into provider quality and service
9
• What cant go on forever will eventually STOP” - Herbert Stein
• Pressure will continue to address increased costs of care, lack of access to care
for some, consistent care for all
• Will need to PROVE you are a good doctor …with data
• Data Attributes will be defined for us (MIPPS, MACRA, etc)
– Expect multiple iterations with some justice and some injustice
– VERY MESSY
– LOCUS of measurement move OUT of hospital to YOUR INDIVIDUAL PRACTICE
– Measurement likely to focus on POPULATIONS of patients
• Patient voice growing LOUDER (paying for larger portion out of pocket)
– Patient voice will be OUTSIDE of our control – twitter, yelp, facebook, etc
– Ignore this AT YOUR PERIL
– Expect to see LESS “VALID” measures of quality to be reported BY patients FOR
PATIENTS (think Amazon reviews)
• No longer able to hide behand “the data are flawed” as data moves from
OUTCOMES to PROCESS measures (you used the protocol yes or no)
Where does this all leave us…
10
ACO – Accountable Care Organization
APM – Alternative Payment Model
MACRA –Medicare Access and CHIP
Reauthorization Act
MIPS APM
MSSP, Track 1
Etc.
APM
MSSP, Tracks 2 and 3
Comprehensive Primary Care+
Oncology Care Model
NextGen ACO, etc.
MACRA/ QPP Components
MIPS
MIPS APM
APM
ACO
MIPS APM
APM
MIPS – Merit-Based Incentive Payment System
QPP – Quality Payment Program
MSSP – Medicare Shared Savings Program
CMS and other payors are responding
11
• In the final MACRA rule released by CMS in November 2016, all quality programs were integrated
under a single MACRA umbrella
• Piedmont has committed to help ACO participants achieve success on the quality portion of the
MSSP, which includes 23 patient-centric measures
Quality scores in can impact future Medicare Part B reimbursement by +/- 5% in PY2018 and +/-
7% in PY2019. This puts revenues at risk for the providers in the MSSP and providers in the MIPS
program.
Maximum Provider Penalties and Bonuses
… and increasing risk on physicianreimbursement
12
MSSP Program OverviewArea Description
Attribution • Original Medicare beneficiaries based on provider participation
• CMS looks at use of primary care services by primary care providers and by
specialists
Risk • Costs and quality adjusted using HCC (hierarchical condition category) methodology
Quality • 23 quality measures
• Quality measured at population level – not provider specific
• All providers in the ACO receive the same quality score
Cost • “Cost” = costs to CMS as paid through medical claims
• Costs can occur both within and outside of Piedmont (SNFs, non-PHC hospitals)
• ACOs are rewarded when they are able to lower growth in Medicare Parts A and B
fee-for-service costs (relative to their unique target) while, at the same time, meeting
quality performance standards
• Current cost benchmark/target is in lowest 25th percentile in country
13
BOLD = Impact MIPS quality score
MSSP Program OverviewPatient-centric population health metrics
Domain Measures Measurement
Patient-
Caregiver
Experience
10 ACO CAHPS measures:
Survey
1. Getting Timely Care
2. How Well Providers Communicate
3. Patients’ Rating of Provider
4. Access to Specialists
5. Health Promotion and Education
6. Shared Decision Making
7. Health Status/ Functional Status
8. Stewardship of Patient Resources
9. Courteous and Helpful Office Staff
10. Care Coordination
Care
Coordination/
Patient Safety
4 Care Coordination/Safety measures:
1. Risk-Standardized, All Condition Readmission Claims
2. All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions Claims
3. Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator (PQI) #91) Claims
4. Falls: Screening for Future Fall Risk Web Interface
Preventive
Health
6 Preventive Health measures:
Web interface
1. Preventive Care and Screening: Influenza Immunization
2. Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
3. Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan
4. Colorectal Cancer Screening
5. Breast Cancer Screening
6. Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
At-Risk
Populations
3 At-risk Population measures:
Web interface1. Depression Remission at Twelve Months
2. Diabetes Mellitus: Hemoglobin A1c Poor Control
3. Hypertension (HTN): Controlling High Blood Pressure
14
Measure can have quality and cost impacts…
Measure Description Patient Benefits Economic Positive
Colorectal Cancer
ScreeningPatient aged 50-75 with
colorectal cancer screening
(FOBT, colonoscopy, FIT-
DNA, flex sigmoidoscopy)
Early detection of cancer • Prevents downstream costs
• Bonus payments for MA
contracts
• Impacts Part B payment
adjustment
Breast Cancer Screening Patients 50-74 who had had a
mammogram between
10/1/2017 and 12/1/2019
Early detection of cancer • Prevents downstream costs
• Bonus payments for MA
contracts
• Impacts Part B payment
adjustment
Statin Therapy for the
Prevention and
Treatment of
Cardiovascular Disease
Patients with ASCVD, LDL>
190, or hypercholesterolemia
who received an order
(prescription) for statin therapy
at any point during the 2019
Lower the risk of recurrent
ASCVD
• Prevents downstream costs
• Bonus payments for MA
contracts
• Impacts Part B payment
adjustment
Hypertension (HTN):
Controlling High Blood
Pressure
Patients whose blood
pressure is adequately
controlled (<140 systolic AND
< 90 diastolic) at their most
recent visit in 2019
By focused concentration on
the blood pressure lower the
risk of end organ damage from
hypertension
• Prevents downstream costs
through avoidable
hospitalizations and other
health issues
• Bonus payments for MA
contracts
• Impacts Part B payment
adjustment
15
Measure can have quality and cost impacts…
Measure Description Patient Benefits Economic Positive
Screening for Future
Falls Risk
Patients who were screened
for future falls risk at least
once during 2019
Intervening before falls. As
falls are the leading cause of
both fatal and nonfatal
accidents in older adults.
Avoid downstream costs by
lowering ED and Hospital
costs
Have older adults maintain
their productivity
Influenza Immunization Patients who received a flu
vaccine OR who reported
previous receipt of a flu
vaccine between August 1,
2018 and March 31, 2019
Prevents potential severity of
flu
Avoid downstream costs of
avoidable ED and Hospital
admissions
Diabetes Mellitus:
Hemoglobin A1c Poor
Control*
Patients whose most recent
HbA1c level in 2019 is <=
9.0%
Focused concentration on
HbA1c to lower this and avoid
end organ
Avoid downstream costs by
lowering risks of end organ
damage
16
Need to Accurately Reflect the Risk of the Patient
• In the ongoing world of Value Based contracting need to have accurate diagnosis to adjust for the Total medical cost in addition to closing care gaps
What CMS thinks your patient looks like… … vs. what your patient actually looks like.
17
1,450 providers – entire
Clinic primary care
network
69,721 Medicare
beneficiaries
10th largest ACO in the
nation
Bottom 20th percentile
for patient risk
MSSP Patient Origin
MSSP Program Overview
18
Piedmont’s cost benchmark is lower than national FFS average. This benchmark was
calculated looking at historical spend of MSSP patients from 2014-2016.
$9,257
$10,462
$9,500
$10,291 $10,133
$9,329
PiedmontMSSP ACO
National FFSAverage
Georgia FFSAverage
Methodist(TX) MSSP
ACO
Wellstar (GA)MSSP ACO
UW(Wisconsin)MSSP ACO
PMPY Benchmark
Earned $4.4M in
shared savings in
2017
Earned $7.8M in
shared savings in
2017
Earned $6.7M in
shared savings in
2017
Piedmont is already lower in cost as compared to the market
19
• Some success achieved in value-based arrangements, but lots of money left on the table
• Historic focus has been on quality, but costs are integral to picture
• Piedmont’s total cost/utilization has been lower relative to market, but must have strategies to
maintain
• Out-of-network utilization continues to be an opportunity across all contracts
• Coding is cited as an issue from all payors
• Limited provider awareness of and engagement in many of our value-based programs
• Opportunity to continue to streamline programs and enter into program designs that benefit
Piedmont and partner
Many common themes emerge…
20
Discussion
&
Questions