“preparing for payment reform - strategies shared by a ... · “preparing for payment reform -...
TRANSCRIPT
April 13, 2017
“Preparing for Payment Reform - Strategies Shared by a Rural Iowa Healthcare Organization”
This material was prepared by Telligen, the Medicare Quality Innovation Network Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-QIN-D1-04/05/17-2069
2
• Telligen: Quality Innovation Network-Quality Improvement Organization (QIN-QIO) for Colorado, Illinois and Iowa
• Subject Matter Experts for CMS Quality Performance Initiatives
Telligen QIN QIO
Sandy Swallow, CMA Program Specialist Iowa
Linda Brewer Sr. QI Facilitator Illinois
Temaka Williams HIT Advisor Illinois
Courtnay Ryan QI Facilitator Colorado
3
Welcome!
Ron Kloewer
• Montgomery County Memorial Hospital
• Chief Information Officer for Healthcare (CHCIO)
• Master of Healthcare Administration (MHA)
• Certified Professional in Health Information Technology (CPHIMS)
S T R A T E G I E S – T A C T I C S – M E A S U R E M E N T
MEDICAL PRACTICE STRATEGIES TO IMPROVE VALUE
For Presentation at Telligen’s “QPP Coffee Talk” Webinar
April 13, 2017
LEARNING OBJECTIVES
• Understand the forces of change that are affecting medical
practices, from payment reform, to quality improvement
requirements, and the relentless march of technology
• Describe how a small rural health system developed easy to
understand strategies to drive process improvement in their medical
practices.
• Describe how the organization is implementing those strategies using
tools like “value chain analysis” to identify critical workflow steps,
ensuring that consistent quality is delivered.
• Show how these strategies helped this organization’s medical clinics
provide better care and demonstrate value.
ABOUT MCMH
• Montgomery County Memorial Hospital (MCMH)
• Critical Access Hospital and Clinics- Red Oak, Iowa
• Iowa Code Chapter 347 County Public Hospital
• $73 million Gross Revenue - 80+% Outpatient
• 335 Employees – Largest Employer in Montgomery County
• 55% Medicare 13%Medicaid – Non RHC
• 22,000 Primary Care Visits - 47,000 Specialty & OP Visits
• Welmark BCBS ACO Member – At Risk in 2017
• CEO David Abercrombie – 51% Revenue Growth in 2 Years
The Medicare Access and CHIP Reauthorization Act (MACRA), a bill
passed overwhelmingly by Congress and supported by doctors, and
MIPS the Merit-based Incentive Payment System combines:
LEGISLATION
MU – The Meaningful Use of Health Information Technology (HIT) using certified Electronic Medical Record (EMR) systems.
PQRS - The Physician Quality Reporting System, quality data used
to negatively adjust payments for non-compliance.
eCQM – The electronic Clinical Quality Measures used for quality reporting compliance under MU.
VBM – The Value Based Modifier program used to negatively adjust payments that were outside of government parameters.
PAYMENT REFORM
Value Based Physician Reimbursement is a method of
paying physicians for value rather than volume.
The fee for service payment system is being replaced with one where payments are based on value.
The value is determined by performance against evidence based quality and performance measures.
Payments are adjusted based on the performance of a previous period, sometime months in the past.
Medicare, Medicaid, and all major payers are moving to value-based physician reimbursement.
MIPS AND PAYMENT REFORM
The Merit-based Incentive Payment System (MIPS) allows a physician to earn a
performance-based adjustment to their Medicare payments.
Payments are adjusted by using practice-specific quality data compared
to evidence-based standards, this determines if a reward or penalty is due.
Rewards are earned by demonstrating high quality, efficient care,
supported by information technology in in the following categories.
PROBLEM STATEMENT AND QUESTION
• The Problem • MIPS requires evidence-based quality and performance standards be met
to avoid penalties.
• The penalties become increasingly harsh, diminishing the level of care for
patients, and increasing the possibility of practice failure.
• Medical practices should develop strategies, tactics, and measurement
tools to demonstrate compliance with new standards.
• The Question • What strategies, tactics, and measurement tools will best prepare the
MCMH medical practices for operating under the MIPS payment model?
PREPARING FOR REFORM
• MCMH Medical Practices • Red Oak Internal Medicine
• Surgical Services
• Women’s Health Clinic
• Villisca Medical Clinic
• Heartland Oncology Clinic
• Heartland Mobile Health
• Heartland Occupational Medicine
• Preparing for payment reform • Meets the standards of the Physician
Quality Reporting System (PQRS)
• Attested for Stage 2 of the Meaningful Use
of Health Information Technology (HIT)
• Meets the standard for the electronic
Clinical Quality Measures (e-CQM)
• To successfully navigate the changes of payment reform, MCMH:
• Uses strategic management techniques with common vision.
• Uses high performance incentive programs to drive change.
• To provide a solid foundation on which to build for payment reform,
MCMH has sought talent and invested resources in:
• Leadership
• Medical Staff
• Mid-level Providers
• Human Resources
• Quality Management
• Information Technology
MONTGOMERY COUNTY MEMORIAL HOSPITAL
Our Mission Working together to improve health
with dignity, compassion, and respect.
Every person. Every time.
Our Vision Montgomery County Memorial Hospital
will be the proven regional leader in
improving health.
Inspired
Ethical
Leadership
Evidence
Based Criteria
For Success
Progressive
Unambiguous
Actionable
Training
Knowledge
Competence
The Will To
Execute
New Ideas
WHY STRATEGIC MANAGEMENT? IT’S A RESULTS ORIENTED PROCESS!
Mission Driven
Strategic Goals
Measured
Performance
Incentivized
Motivation
Continuous
Improvement
THE GOAL OF HEALTHCARE REFORM THE TRIPLE AIM
Patient
Experience Access
Population
Health Results
Lower
Cost Value
(Beasley, 2009)
Literature Review
EXPERIENCE OF CARE
• Use innovative methods of access that go beyond the traditional settings of clinic, hospital, rehab center, etc. Retail centers, business locations, schools, etc.
• Use nontraditional settings to help populations considered at risk. Mobile clinics
and telemedicine are a great examples.
• Use nontraditional hours of availability that cut down on emergency visits. This saves a significant amount of money.
• Use technology to transform medical care. A convergence of technologies has been occurring for 30 years, setting the stage for a “super convergence.”
• Use team based care coordination, combined with patient engagement, fueled
by technology; it is shown to improve outcomes.
To improve the experience of care, an organization must:
Literature Review
POPULATION HEALTH MANAGEMENT
• Realize that no single entity can be totally responsible. Multiple actions across a spectrum of community services is required. Healthcare organizations can lead in coordinating:
• Medical Care – Education – Social Services – Community Assistance – Government Assistance
• Identify negative social determinants that impede medical care. The absence of preventative care and chronic care raises the health risk of a population.
• Unemployment – Housing – Stress – Life Experience – Social Exclusion – Addiction – Transportation
• Understand the importance of referral management and transition of care management.
These are the points of highest potential risk for patients.
• Care Team Approach – Closed Loops – Seamless Communication– EMR Driven – Medication Reconciliation
To improve the health of a population, an organizations must:
Literature Review
COST CONTROL AND VALUE
• Providers unable to demonstrate quality will receive lower reimbursement.
• Risk is quickly being shifted to the providers and healthcare organizations.
• Providers that deliver higher quality tend to be more financially successful.
• EMR technology combined with data analytics improves efficiency.
• Costs must be cut, services must be integrated, and efficiencies created.
• Value driven organizations coordinate, cooperate, and are accountable.
To improve value, quality must rise or costs must drop, or both.
Consider that:
Literature Review
STRATEGY DEVELOPMENT
Focus groups at MCMH were asked to identify activities critical
to the success of a patient’s experience in four areas.
Preventative
Care
Management
Chronic
Care
Management
Referral
Care
Management
Transition
Care
Management
Patient
Focus groups of providers, nurses, HIT, administration.
• The value chain analysis was Introduced by
Michael E. Porter in his
influential book,
“Competitive Advantage.”
• The activities conducted can be divided into
primary activities and
support activities.
• The information from the
focus groups was collected and
summarized.
• The summary was used to
develop the strategies,
and outline the tactics and measurement tools.
Figure 2 : Porter’s Value Chain Model
Porter’s Value Chain Model
Value Chain Analysis
A value chain analysis was used by the focus groups to identify the
activities critical to the success of the four areas.
VALUE CHAIN ANALYSIS
Inbound Patient Flow : Getting patients into the practice, engaging them, making them feel at home, collecting accurate information, etc.
Clinic Operations : Activities to collect accurate and complete clinical information, creating and documenting the plan.
Outbound Patient Flow: Activities to help the patient on to the next step in their care journey, i.e., ensuring that the plan is carried out.
Patient Engagement : Activities that keep the patient informed, guided, and engaged in their own health and healthcare.
Services : Activities required to keep the patient effectively cared for after being treated and released.
The focus groups looked at these primary activities.
For Preventative, Chronic, Referral, and Transition Care
VALUE CHAIN ANALYSIS
The focus groups looked at these support activities.
Procurement : Resources essential to operate at peak efficiency.
Technology Development : Technical excellence for value creation.
Human Resource Management : Hire, train, motivate, reward, and retain.
Support Systems: Management and infrastructure that create value.
For Preventative, Chronic, Referral, and Transition Care
STRATEGIES TO IMPROVE VALUE
1. Focus on the patient and their experience in four key areas; preventative care,
chronic care, referrals of care, and transitions of care, making it the best
experience possible.
2. Surround providers with a competent support staff led by individuals who
understand the principles of the Triple Aim, population health management, and
the new roles in the expanding continuum of care.
3. Fully utilize a highly functional and certified EMR that collects information across
the expanded continuum, is available to anyone on the care team, and is
capable of producing added value in the form of analytics.
4. Be mindful that the effort to improve the health of a population does not start and
stop at the clinic door, it reaches to the extent of the organization’s capabilities
to deliver a better experience of care, with a better quality of care, at a lower
cost.
RECOMMENDED TACTICS AND TOOLS
Demographic accuracy, education for staff and patients, verify eligibility.
Health maintenance, reminders, care team review, anticipate before visit.
Complete documentation, follow-up appointments, after visit summary.
Patient portal, interactive communication with provider, marketing.
Accuracy, NeHII HIE, State IRIS, EMR Queries, PPRNet Reporting
Preventative Care
Management
The focus group recommended the following:
RECOMMENDED TACTICS AND TOOLS
Portal appointments, visit preparation, registry verification, engagement survey.
Accurate histories, prep for referral, team communication, complete charts.
After visit summary, teach back, literacy help, team assignments with intro.
Provider guided protocols, care manager assignment, med rec, home monitoring.
Support groups, psychosocial needs, benchmarks against evidence, PPRNet.
Chronic Care Management
The focus group recommended the following:
Demographic accuracy, portal appointments, referral anticipation, patient messaging.
Complete histories, med rec, every referral must be ordered. Query verified.
After visit summary review with patient Q&A. Verify patient commitment and capacity.
Patient messaging follow up, query anticipation and patient contact. CCDA to provider.
Referral closure effectiveness via EMR query. Agreements with providers to receive reports.
Referral Care Management
RECOMMENDED TACTICS AND TOOLS The focus group recommended the following:
Notification is vital, shared accountability, preplanning for chronic patients.
EMR access, CCDA, preplanning for high risk patients, provider update.
Med rec, customized follow up, accurate documentation, provider update.
Health promotion visit, portal use, patient messaging, support system engagement.
Med rec, generic vs brand, care team debrief, summary to patient.
Transition Care
Management
RECOMMENDED TACTICS AND TOOLS The focus group recommended the following:
SURROUND PROVIDERS WITH WELL TRAINED & COMPETENT STAFF
• Clinical informatics professionals help the transformation process succeed!
• Administration, leadership and management - project management cannot be underestimated.
• Analysis - using data to synthesize knowledge, inform decision support, and manage outcomes.
• Compliance and integrity management - helping make sure organizations are meeting all the
national laws.
• Coordination, facilitation, and integration - serving as the translator between end-users and IT
experts
• Development - translating user requirements into solutions. Managing the user experience (UX)
• Education and professional development - teaching the end-user to use a device or application to
educating the next generation of nurses and the general public
• Policy development and advocacy - being an advocate for consumers, providers, and staff.
• Research and evaluation - conducting research in topics that impacts both caregivers and
consumers
-HIMSS 2012
EMR SUCCESS – 3 MAJOR FACTORS
• Workflow re-engineering must occur to harness the power of automation. • Computers are not just a new filing system, they are transformative
tools.
• Continuously improve the user experience and user interface of the tools. • What we see today is crude compared to what we will see tomorrow,
don’t get stuck.
• Analytics will convince you to change and improve, for you are not as good as you think you are. • Use the power of data to constantly improve.
Your patients and your organization will benefit.
-Barry Chaiken, MD
MEASUREMENT
• Improved Clinical Quality and Documentation. • 63% rise in diabetes foot exams • 103% rise in A-Fib patients on anti-coagulant Rx • 88% rise in heart failure patients on Ace inhibitor • 148% rise in osteoporosis screening
• 289% rise in breast cancer screening • 121% rise in pneumococcal for high risk patients • 47% rise in shingles vaccines
• MIPS Related Performance Activities. • Over 35% of MIPS Table “H” CPIA items underway • All Stages of MU met = MIPS ACI compliance on target
• Welmark Blue Cross & Blue Shield ACO Performance • Regional quality score is 15% above the group average • ACO performance improvement in tertiary prevention and in chronic
and follow-up care
SUMMARY
• Value based payment models are now a fact in healthcare.
• Evidence suggests that value-based models deliver better patient care.
• Easy to understand strategies, implemented well, will lead to success.
• Therefore… • Improve preventative care, chronic care, referral care, and transition care.
• Surround providers with well-trained and competent staff.
• Utilize a high functioning EMR for every possible process.
• Be mindful of the the patient’s need beyond the clinic door.
• MCMH can succeed under payment reform because the recommended
strategies are easy to understand, the tactics and measurement tools are
achievable, and the organization has the will to act.
REFERENCES
Advisory Board (2013). Playbook for population health: Building the high-performance care management
network. Advisory Board Company. Retrieved from https://www.advisory.com/research/health-care-
advisory-board/studies/2013/playbook-for-population-health
Beasley, C. (2009). The Triple Aim. Healthcare Executive, 24(1), 64-66. Retrieved from
http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com/docview/200378333?accountid
=28125
Birk, S. (2014). Quality, cost and accountable care: Models for the journey. Healthcare Executive. May/June
21-28
Bosko, T., Dubow, M., & Koenig, T. (2016). Understanding Value-Based Incentive Models and Using
Performance as a Strategic Advantage. Journal of Healthcare Management, 61(1), 11-14.
Gooch, J. (2011). PPO Evolution. Managed Healthcare Executive, 21(4), 21-23. Retrieved from
http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com.ezproxy.bellevue.edu/docview/
870059644?accountid=28125
Heller, B. R., & Goldwater, M. (2004). The governor's wellmobile: Maryland's mobile primary care clinic.
Journal of Nursing Education, 43(2), 92-94. Retrieved from
http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com.ezproxy.bellevue.edu/docview/
203924817?accountid=28125
Iowa Code (2016). Chapter 347 County Hospitals. Retrieved from
https://www.legis.iowa.gov/law/iowaCode/sections?codeChapter=347&year=2016
Jonas, S., Knickman, J.R., Kovner, A.R., (2015). Jonas & Kovner’s Health Care Delivery in the United States.
New York, NY: Springer Publishing Company
Kessler, C., Tsipis, E. M., Seaberg, D., Walker, G. N., & Andolsek, K. (2016). Transitions of care in an era of
healthcare transformation. Journal of Healthcare Management, 61(3), 230-240.
REFERENCES (CONT.)
Kindig, D. A., & Isham, G. (2014). Population health improvement: A community health business model that
engages partners in all sectors. Frontiers of Health Services Management, 30(4), 3-20,56-57. Retrieved
from
http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com.ezproxy.bellevue.edu/docview/
1554331139?accountid=28125
Ly, D. P., Jha, A. K., & Epstein, A. M. (2011). The association between hospital margins, quality of care, and
closure or other change in operating status. Journal of General Internal Medicine, 26(11), 1291-1326.
doi:http://dx.doi.org.ezproxy.bellevue.edu/10.1007/s11606-011-1815-5
O'connell, E., Zhang, G., Leguen, F., & Prince, J. (2010). Impact of a mobile van on prenatal care utilization
and birth outcomes in Miami-Dade County. Maternal and Child Health Journal, 14(4), 528-34.
doi:http://dx.doi.org.ezproxy.bellevue.edu/10.1007/s10995-009-0496-8
Perry, F. (2014). The Tracks We Leave: Ethics & Management Dilemmas in Healthcare. Chicago, IL: Health
Administration Press.
Porter, M. E., & Teisberg, E. O. (2006). Redefining Healthcare: Creating Value-Based Competition on Results.
Boston, MA: Harvard Business School Press.
Topol, E. (2012). The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health.
New York, NY: Perseus Books Group.
Walston, S. L. (2014). Strategic Healthcare Management. Chicago, IL: Health Administration Press
Wofford, D. (2016). Paving the way for Medicare reform. Healthcare Financial Management, 70(1), 52-55.
Retrieved from
http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com.ezproxy.bellevue.edu/docview/
1760361659?accountid=28125
Zeis, M. (2014). Connecting patient engagement and patient experience. Health Leaders, 17, 30-34.
Retrieved from
http://ezproxy.bellevue.edu:80/login?url=http://search.proquest.com.ezproxy.bellevue.edu/docview/
1550172493?accountid=28125
35
News Flash!
• Registration for MIPS Group Web Interface and CAHPS Reporting by June 30, 2017 – Registration required if you intend to utilize the CMS Web
Interface and/or administer the CAHPS for MIPS survey
– MIPS Group is defined as a single TIN with two or more eligible clinicians (including at least one MIPS EC), as identified by their individual NPI, who have reassigned their billing rights to the TIN.
– Groups will be assessed at group level across all 4 categories and receive one payment adjustment for group performance.
– Groups in a Shared Savings Program ACO are not required to register or report
36
Q & A Session!
Contacts: • Iowa – Sandy Swallow
– 515-223-2105
• Illinois – Linda Brewer
– 630-928-5819
• Illinois -Temaka Williams
– 630-928-5825
• Colorado – Courtnay Ryan
– 720-554-1711
www.TelligenQINQIO.com
37
Q & A Session!
Q. When can we expect eligibility letters from CMS? And who will receive the letters?
All TINs should receive the letter no later than May 31st.
Letter will go directly to TIN representative
Informs at the individual (TIN/NPI) level and group (TIN) level if an EC is included in MIPS
A sample letter will be posted to www.qpp.cms.gov
38
Telligen QIN-QIO is Here to Help!
• Experienced quality improvement advisors to provide expert technical assistance and quality improvement support for participating providers across the state
• Join the monthly webinars “Coffee Talks” with subject matter experts:
– Focused QPP topic
– Open discuss with Q & A – dedicated to your questions
– 2nd Thursday every month
– 11:00 a.m. CST for 1 hour
May 11th: Pros & Cons of Group/Individual Reporting and Intro to SURS
June 8th: TBA
• Partner with Telligen QIO on practice improvement activities
– Participation with a QIO in a self-management training program (diabetes)
– Implementation of antibiotic stewardship program
– Implementation of a cardiac quality improvement program
