high intensity care management november 4, 2014 webinar
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High Intensity Care Management
November 4, 2014Webinar
Additional 2014 Clinical Model Elements
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Clinical Model Goal
Outreach to 100% of patients on the “accepted” list within 90 days of finalizing list (outreach defined as initial attempt to reach patient via telephonic or in-person verbal contact)
Completion of in-person care management assessment within 3 months of successful outreach for at least 50% of Accepted Members patients, and for 100% of Accepted Members within 6 months
Completion of in-person comprehensive health care assessment [for those patients who have not yet received an annual wellness visit in the current calendar year] within 3 months of successful outreach for at least 50% of patients, and for 100% of patients within 6 months
Quarterly review/update of care plan for engaged patientsHospital to home transition phone follow-up for 30 days for engaged patients; frequency of phone calls dependent upon patient
needs
SNF to home transition initial contact within 24-48 hours of discharge for engaged patientsSNF to home transition follow-up w/PCP (or specialist, as appropriate) within 7 days of discharge for engaged patients
SNF to home transition phone follow-up for 30 days, minimum of one call following discharge for engaged patients; frequency of phone calls dependent upon patient needs
The following elements of the clinical model cannot be tracked/measured via the claims system, but are identified as important goals within the clinical model. Physician Organizations should track these metrics. Metrics will be discussed at joint meetings, in addition, Physician Organizations may be asked to submit data to BCBSM.
Phase 1 Launch10-1-14
Full Launch 4-1-15
HICM Common Clinical Model Components Subset of Core
Model
Core Model
Comprehensive Clinical
Model
1.24/7 phone access to clinical decision-maker with electronic access to pt record ● ● ●
2. Comprehensive health care assessment by PCP, NP, or PA with full diagnoses capture, advance planning (75% w/in 2 months; all w/in 4 months; in-home for homebound) – top priority for July 1, 2014 start
● ● ●
3. In-home health care assessment by PCP, NP, or PA for homebound ● ●
4. Daytime home visits by RN, MSW or Care Manager (minimum quarterly), including in-home assessments
● ●
5. Patient-specific comprehensive care plan (updated at least quarterly) ● ● ●
6. Care management team includes pharmacist and nutritionist ● ●
7. Access to in-home PT and OT ● ● ●
8. Care transitions management – Hospitals ● ● ●
9. Care transitions management – SNFs ●
10. Access to palliative care team ●
11. Access to hospice ● ● ●
12. Transportation for non-emergent medical visits and Rx 2016
13. Remote patient monitoring (weight, BP, glucose) 2016
14. Standardized staff training ● ● ●
15. Review of all patients on monthly patient lists, common outreach script (2nd outreach by PCP as needed); POs maintain disposition information on all patients on monthly list
● ● ●
Medicare Advantage STAR Recognition Program
Medicare STAR Ratings
The CMS star rating program is a pay-for-performance program for Medicare Advantage plans
Plans will now receive revenue based on outcomes and the quality of their performance
The higher the quality ranking, the higher the payments and the more competitive the plan is in the marketplace
This is an attempt by CMS to create a new paradigm to bend the cost curve
What’s Measured
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STAR ratings measure a Plan’s performance in delivering quality outcomes
STAR ratings are based on 53 key quality measures (36 related to Medicare and 17 related to prescription drug coverage) across the five following domains (subset of HEDIS measures)
What do CMS STARS Rating Measure
Staying Healthy: screenings, tests, and vaccines Managing chronic (long term) conditions Ratings of health plan responsiveness and care Member complaints, problem getting services, and
choosing to leave the plan Health plan customer service
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What’s It Look Like
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Clinical quality and outcomes
HEDIS
Plan administrative performance and
compliance
Member assessment of their
health (Health Outcomes
Survey)
Member perceptions of Plan, providers and care
CAHPS
2014 Provider Outreach Activities
Diagnosis coding education where DDDS is not part of practice
HEDIS/STARS for all targeted providers Activities include:
• Address and close HEDIS/STARS treatment opportunity gaps
• Address and close Enterprise and BCNA risk adjustment diagnosis gaps
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2014 Provider Outreach Activities
Activities include:• Support HEB education and sign-up • Support provider staff on scheduling member
appointments • Provide education to providers • Provide reference tools and materials to providers • Retrieve medical records related to treatment
opportunity gaps if necessary
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2014 Provider Outreach Activities
Activities include:• Retrieve medical records for BCNA risk adjustment
diagnosis gaps, BCNA only• Complete focus-driven activities as specified• Report on outreach activities completed by practice
unit/providers
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Provider Recognition Program
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Breast Cancer screening 10$ Breast Cancer screening 10$ Breast Cancer screening 10$ Breast Cancer screening 10$
Colorectal cancer screening 10$ Colorectal cancer screening 10$ Colorectal cancer screening 10$ Colorectal cancer screening 10$
Diabetes Retinal Eye Exam 10$ Diabetes Retinal Eye Exam 20$ Diabetes Retinal Eye Exam 10$ Diabetes Retinal Eye Exam 20$
Diabetes HbA1C level <=9% 10$ Diabetes HbA1C level <=9% 20$ Diabetes HbA1C level <=9% 10$ Diabetes HbA1C level <=9% 20$
Diabetes monitoring for nephropathy 10$ Diabetes monitoring for nephropathy 20$ Diabetes monitoring for nephropathy 10$ Diabetes monitoring for nephropathy 20$
Diabetes LDL-C level < 100 mg/dl 10$ Diabetes LDL-C level < 100 mg/dl 20$ Diabetes LDL-C level < 100 mg/dl 10$ Diabetes LDL-C level < 100 mg/dl 20$
Diabetes LDL-C testing 10$ Diabetes LDL-C testing 10$ Diabetes LDL-C testing 10$ Diabetes LDL-C testing 10$
Cardiovascular disease LDL-C testing 10$ Cardiovascular disease LDL-C testing 10$ Cardiovascular disease LDL-C testing 10$ Cardiovascular disease LDL-C testing 10$
Cardiovascular disease LDL-C level <100 mg/dl 10$ Cardiovascular disease LDL-C level <100 mg/dl 10$
BCNA 2013 BCNA 2014
Pay As You GoSame measures as Base PRP but payable for one service per each eligible member per year
Bonus PRP
Base PRPQuality Preventative
Diabetes LDL-C level < 100 mg/dl
Glaucoma testing $20-$40 depending on provider score:
score 70%-74% payment $20 each eligible service
score 75%-100% payment $40 each eligible service
High Risk Medications $20 each eligible service --score 10% or<
Cardiovascular disease LDL-C testing
score 70%-74% payment $125
score 75%-100% payment $300
High Risk Medications $450 depending on prac grp score--score 5% or<
>=80% = $5.00 PMPM
Payable to Provider for each eligible service
Adult BMI $10 each eligible service--score 80% or greater
Diabetes treatment with ACE/ARB for hypertension $20--score 87% or>
Cardiovascular disease LDL-C level <100 mg/dl
0%-71% = $0.00 PMPM
72%-74% = $2.00 PMPM
75%-79% = $3.50 PMPM
Quality Payout
Diabetes monitoring for nephropathy
Diabetes LDL-C testing
Breast Cancer screening
Colorectal cancer screening
Payable to Practice Group based on overall score
Adult BMI $200 to practice group--score 67% or greaterAnnual Monitoring for persistent meds $200 to practice group --score 94% or >
Diabetes treatment with ACE/ARB for hypertension $200 to prac grp--score 87% or>
0%-69% = $0.00 PMPM
70%-74% = $2.00 PMPM
75%-79% = $3.50 PMPM
>=80% = $5.00 PMPM
Diabetes HbA1C level <=9%
Diabetes monitoring for nephropathy
Diabetes LDL-C testing
Diabetes LDL-C level < 100 mg/dl
Cardiovascular disease LDL-C testing
Diabetes Retinal Eye Exam
Diabetes HbA1C level <=9%
Diabetes monitoring for nephropathy
Diabetes LDL-C testing
Diabetes treatment with ACE/ARB for hypertension $20--score 87% or>
Glaucoma testing $20-$40 depending on provider score:
score 70%-74% payment $20 each eligible service
score 75%-100% payment $40 each eligible service
High Risk Medications $20 each eligible service --score 10% or<
0%-69% = $0.00 PMPM
70%-74% = $2.00 PMPM
Glaucoma testing $125-$300 depending on prac grp score:
MA PPO 2014
Payable to Provider for each eligible service
Adult BMI $10 each eligible service--score 80% or greater
Quality Disease Management
0%-71% = $0.00 PMPM
72%-74% = $2.00 PMPM
75%-79% = $3.50 PMPM
>=80% = $5.00 PMPM
Diabetes HbA1C level <=9%
Diabetes monitoring for nephropathy
Diabetes LDL-C testing
Diabetes LDL-C level < 100 mg/dl
Cardiovascular disease LDL-C testing
Cardiovascular disease LDL-C level <100 mg/dl
Diabetes LDL-C level < 100 mg/dl
MA PPO 2013
Breast Cancer screening
Colorectal cancer screening
Breast Cancer screening
Colorectal cancer screening
Diabetes Retinal Eye ExamDiabetes Retinal Eye Exam
Diabetes HbA1C level <=9%
Breast Cancer screening
Colorectal cancer screening
Diabetes Retinal Eye Exam
Annual Monitoring for persistent meds $200 to practice group --score 94% or >
Diabetes treatment with ACE/ARB for hypertension $200 to prac grp--score 87% or>
Glaucoma testing $125-$300 depending on prac grp score:
score 70%-74% payment $125
score 75%-100% payment $300
High Risk Medications $450 depending on prac grp score--score 5% or<
75%-79% = $3.50 PMPM
>=80% = $5.00 PMPM
Payable to Practice Group based on overall score
Adult BMI $200 to practice group--score 67% or greater
Cardiovascular disease LDL-C testing
Measure CodesAdults’ Access to Preventive/ Ambulatory Health Services (AAP)
CPT® codes to identify preventive/ ambulatory health services: Office or other outpatient services: 99201-99205, 99211-99215, 99241-99245 Home services: 99341-99345, 99347-99350 Nursing facility care: 99304- 99310, 99315, 99316, 99318 Domiciliary, rest home or custodial care services: 99324-99328, 99334-99337 Preventive medicine: 99381- 99387, 99391-99397, 99401- 99404, 99411, 99412, 99420, 99429 HCPCS: G0402, G0438, G0439, S0620, S0621Ophthalmology and optom etry: 92002, 92004, 92012, 92014 General medical examination: ICD-9-CM diagnosis codes: V70.0, V70.3, V70.5, V70.6, V70.8, V70.9
Adult Body Mass Index (ABA) Assessment
CPT®: 99201-99205, 99211-99215, 99241-99245, 99341-99345, 99347-99350, 99381-99387, 99391-99397, 99401-99404, 99411, 99412, 99420, 99429, 99455, 99456HCPCS: G0402, G0438, G0439ICD-9-CM Codes to identify BMI: V85.0-V85.5Exclusions: Members with a diagnosis of pregnancy in the measurement year or the year prior to the measurement year.ICD-9-CM: 630-679, V22, V23, V28
Breast Cancer Screening (BCS)
Claims Coding Reference
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Measure CodesAnnual Monitoring for Patients on Persistent Medications (MPM)
Monitoring for ACE Inhibitors or ARBs, Digoxin*, and Diuretics: Drug serum concentration for serum potassium: CPT®: 80051, 84132Drug serum concentration for serum creatinine: CPT®: 82565, 82575Drug serum concentration for blood urea nitrogen: CPT®: 84250, 84525 *Drug serum concentration for Digoxin:CPT®: 80162 Monitoring for Anticonvulsants: Drug serum concentration for phenobarbital: CPT®: 80184Drug serum concentration for carbamazepine: CPT®: 80156, 80157Drug serum concentration for phenytoin: CPT®: 80185, 80186Drug serum concentration for valproic acid and divalproex sodium: CPT®: 80164 Lab panel codes:CPT®: 80047, 80048, 80050, 80053, 80069
Claims Coding Reference
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Claims Coding Reference
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Measure CodesBreast Cancer Screening (BCS)
CPT®: 77055-77057 HCPCS: G0202, G0204, G0206 ICD-9-PCS: 87.36, 87.37Exclusions: Members with a bilateral mastectomy. Any of the following meet criteria for bilateral mastectomy:Bilateral mastectomyICD-9: 85.42, 85.44, 85.46, 85.48Unilateral mastectomyCPT®: 19180, 19200, 19220, 19240, 19303-19307ICD-9-PCS: 85.41, 85.43, 85.45, 85.47Two unilateral mastectomies*50 and 09950 modifier codes indi cate the procedure was bilateral and performed during the same operative session.
Cholesterol Management for Patients with Cardiovascular Conditions (CMC)
CPT®: 80061, 83700, 83701, 83704, 83721 Plus CPT® II: 3048F, 3049F, 3050F
Claims Coding Reference
Claims Coding Reference
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Measure CodesColorectal Cancer Screening (COL)
FOBT Fecal occult blood test between (FOBT) 1/1/2013 and 12/31/2013: CPT®: 82270, 82274 HCPCS: G0328 Flexible sigmoidoscopy between 1/1/2009 and 12/31/2013: CPT®: 45330-45335, 45337-45342, 45345 HCPCS: G0104 ICD-9-PCS: 45.24Colonoscopy between 1/1/2004 and 12/31/2013: CPT®: 44388-44394, 44397, 45355, 45378-45387, 45391,
45392 HCPCS: G0105, G0121 ICD-9-PCS: 45.22, 45.23, 45.25, 45.42, 45.43AND/ORChart documentation of previously performed colorectal cancer screening tests.Exclusions: Members with a history of either of the following: Colorectal cancer HCPCS: G0213-G0215, G0231 ICD-9-CM: 153, 153.0-153.9, 154.0, 154.1, 197.5, V10.05 Total colectomy CPT®: 44150-44158, 44210-44212 ICD-9-PCS: 44.80-45.83
HEDIS Coding Reference
HEDIS Claims Coding Reference
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Measure CodesComprehensive Diabetes Care (CDC) – Eye Exam
CPT®: 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245CPT® II codes: 2022F, 2024F, 2026F, 3072FHCPCS codes: S0620, S0621, S0625, S3000Exclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
HEDIS Claims Coding Reference
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Measure CodesComprehensive Diabetes Care (CDC) – HbA1c
CPT®: 83036, 83037 PLUSCPT® II: 3044F, 3045F, 3046FExclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
Comprehensive Diabetes Care (CDC) – LDL-C
CPT®: 80061, 83700, 83701, 83704, 83721 PLUSCPT® II: 3048F, 3049F, 3050FExclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
Measure CodesComprehensive Diabetes Care (CDC) – Nephropathy Screening
CPT®: 82042, 82043, 82044, 84156 PLUSCPT® II: 3060F, 3061F, 3066F, 4010FICD-9-CM: 250, 403-405, 580-588, 753, 791Exclusions:Identify members who do not have a diagnosis of diabetes, in any setting, during the measurement year or year prior to the measurement year and who meet either of the following criteria:A diagnosis of polycystic ovaries, in any setting, any time during the member’s history through December 31 of the measurement year.ICD-9-CM: 256.4A diagnosis of gestational diabetes or steroid-induced diabetes, in any setting, during the measurement year or the year prior to the measurement year.ICD-9-CM: 249-249.91, 251.8, 648.8, 648.80-648.84, 962.0
Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis (ART)
ICD-9-CM codes to identify rheumatoid arthritis:714.0, 714.1, 714.2, 714.81HCPCS codes to identify pharmacy claims for DMARD in the measurement year:J0129, J0135, J0718, J1438, J1600, J1745, J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J9310
Use of Spirometry Testing in the Assessment and Diagnosis of COPD (SPR)
COPD:Chronic bronchitis: 491Emphysema: 492COPD: 493.2, 496 CPT® codes to identify spirometry testing:94010, 94014-94016, 94060, 94070, 94375, 94620
HEDIS Claims Coding Reference
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Measure CodesOsteoporosis Management in Women Who Had a Fracture (OMW)
Codes to identify bone mineral density test:CPT®: 76977, 77078-77083, 78350, 78351HCPCS: G0130ICD-9-CM: 88.98AND/OR pharmacy claims for osteoporosis drug therapy:HCPCS: J0630, J0897, J1000, J1740, J3110, J3487, J3488
HEDIS Claims Coding Reference
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Open Discussion
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