Michigan Primary Care Transformation

Demonstration Project

March 6, 2013 Webinar

Six Month Incentive Disbursements

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12 Month Incentive

Assess care manager utilization (moderate,

complex, hybrid)

Assess status of patient registry

Status of 2012 metric attainment

• HEDIS measures

• Data per physician

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Care Managers

Each discipline

• PA/NP/APN

• RN

• PhD/LLPsych

• MSW/LMSW

• Pharmacist

• Dietitian

• Health Educator

• Health Coach

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Care Manager Activity Reporting

Beginning with the financial report for 2013

Quarter 1 (due March 31), a new feature added to

collect care manager activity data

Care Manager Activity reporting requires that the

specific information be reported for every care

manager at every practice and by payer

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Care Manager Activity Reporting

Two reporting options available:

• Manual data entry directly into the financial reporting template

• Upload of standardized files

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Care Manager Reporting Activity

Option One

• Template downloaded from the MPCC website that includes a list of the care manager and practices for the current quarter

• Tab-delimited file downloaded after completion

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Care Manager Reporting Activity

Option Two

• PO generates a file that conforms to specific file requirements (e.g., tab-delimited text file) and contains practice unit and care manager IDs

• MNO submitted appropriate file for testing

• MNO generates file electronically, making it much easier and more accurate than typing the information into the web application

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Care Manager Reporting Activity

PCMH Practice

PCMH Practice ID

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Care Manager Reporting Activity

Care Manager Provides

• Patient Last Name (pre-populated)

• Patient First Name (pre-populated)

• Patient Date of Birth (pre-populated)

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Care Manager Reporting Activity

Face-to-Face Encounters

• Medicaid

• Medicare

• Medicare Advantage

• BCBSM

• BCN

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Care Manager Reporting Activity

Telephonic Encounters

• Medicaid

• Medicare

• Medicare Advantage

• BCBSM

• BCN

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Care Manager Reporting Activity

Unique Patients

• Medicaid

• Medicare

• Medicare Advantage

• BCBSM

• BCN

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Additional Patient Population

Priority

BCBSM Self insured plans

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PCMH-MiPCT Learning Activities

Each Care Manager must complete a total of

twelve hours of Care Manager education per year

• This can be satisfied through twelve hours of MiPCT-led Care Manager webinars/sessions

• Eight hours of MiPCT-led Care Manager webinars/sessions

• Four hours of PO-led Care Manager training per year

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PCMH-MiPCT Learning Activities

Each Practice Team (including at least one

physician from the practice, and at least one other

practice team member) must complete eight

hours of learning activity requirements during

calendar year 2013

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PCMH-MiPCT Learning Activities

Town Hall dinners

MiPCT Learning Collaboratives

Monthly practice PCMH meetings

Attendance at Annual MiPCT Summit

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PCMH-MiPCT Learning Activities

MNO led activities

PTI led activities with CME and IACET credits

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Education Programs

Certified coder workshops for physicians and

teams

Appropriate use of ICD-9 Codes

Advanced Care Planning

Durable power of attorney

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Webinars

Volunteers for best practices to be presented at

the webinars

Any team member may provide “best practice”

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Medicare Advantage

CMS Risk Adjustment Model

CMS Star Quality Bonus Program

New Medicare Preventive Services & Health Risk

Assessment

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Why Care About Risk Adjustment?

Compliance with CMS diagnostic submission

requirements

Compliance with CMS diagnostic submission

requirements Compliance with CMS diagnostic

submission requirements

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Why Care About Risk Adjustment?

Receive proper reimbursement from CMS to keep

premiums as low as possible for our patients and

improve the health of the Michigan economy

The projection of CMS funding directly impacts

member premiums

A 1 percent improvement in risk scores can lower

member premiums by roughly 10 percent

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Ten Most Missed Opportunities

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15 Diabetes with Renal, Peripheral Circulatory Manifestations: 249.4x, 249.7x, 250.4x, and 250.7x

16 Diabetes with Neurologic or Other Specified Manifestations: 249.6x, 249.8x, 250.6x, and 250.8x

55 Major Depressive, Bipolar, Paranoid Disorders: 296.xx, 297.x, and E950.x – E9593

71 Polyneuropathy: 337.xx (excludes 337.0, 337.01), 356.x, 357.xx (excludes 357.8), 358.xx (excludes 358.0), and 359.22 – 359.9 (359.8)

80 CHF: 402.x1, 404.x1, 415.0, 416.x (excludes 416.2), 417.x, 425.x, 428.xx, 429.0, and 429.1

92 Specified Heart Arrhythmias: 426.0, 427.0 – 427.32, and 427.81

105 Vascular Disease: 440.0, 440.1, 440.20, 440.21, 440.22, 440.29, 440.3x, 440.4, 441.2, 441.4, 441.7, 441.9, 442.xx, 443.1, 443.8x, 443.9, 447.x, 448.0, 451.11, 451.19, 451.81, 451.83, 453.0, 453.2, 453.3, 453.4x, 453.5x, 453.72 – 453.77, 453.82 – 453.87, 557.1, and 557.9

108 COPD: 491.xx, 492.x, 493.2x, 496, 518.1, and 518.2

131 Renal Failure: 403.x1, 404.x2, 404.x3, 584.x, 585.x (excludes 585), 586, and 753.14

132 Nephritis: 078.6, 580.xx, 581.xx – 583.xx

This information can be accessed at CMS.gov

Star Quality Bonus Payments

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HEDIS

(Health Effectiveness

Data and Information

Set)

CMS administrative

measures

CAHPS

(Consumer Assessment of

Healthcare Providers and

Systems)

Health Outcomes

Survey

Measures Fall into Four Categories

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Stars Measures

Title Description Data

Source Dates of Service

BCN Advantage

Medicare Plus Blue

PPO

Breast Cancer Screening

Ages 40 to 74, one or more mammograms during the measurement year or the year prior

HEDIS 2011 4 4

Colorectal Cancer Screening

Ages 50 to 75, one or more appropriate screenings for colorectal cancer

HEDIS 2011 5 4

Cholesterol Screening for patients with Heart Disease

Ages 18–75, discharged alive for Acute Myocardial Infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from the year prior who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior, who had an LDL-C screening test performed

HEDIS 2011 5 5

Cholesterol Screening for patients with Diabetes

Ages 18-75 with diabetes, who had an LDL-C screening test performed

HEDIS 2011 5 4

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Stars Measures

Title Description Data

Source Dates of Service

BCN Advantage

Medicare Plus Blue

PPO

Glaucoma Screening

Ages 65 years and older, without a prior diagnosis of glaucoma or glaucoma suspect, who received a glaucoma eye exam by an eye care professional

HEDIS 2011 3 4

Annual Flu Vaccine

Received an influenza vaccination CAHPS 2012 4 4

Improving or Maintaining Physical Health**

Sampled Medicare enrollees whose physical health status was the same or better than expected

HOS 2009 1st Survey 2011 2nd Survey

5 Plan too new to have data

Improving or Maintaining Mental Health**

Sampled Medicare enrollees whose mental health status was the same or better than expected

HOS 2009 1st Survey 2011 2nd Survey

3 Plan too new to have data

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Stars Measures

Title Description Source of

Data Dates of Service

BCN Advantage

Medicare Plus Blue

PPO

Monitoring Physical Activity

Sampled ages 65 years or older, who had a doctor‘s visit in the past 12 months and who received advice to start, increase or maintain their level exercise or physical activity

HOS 2009 1st Survey 2011 2nd Survey

2 2

Adult BMI Assessment

Ages 18-74 years, who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior

HEDIS 2011 4 3

Osteoporosis Management

Females ages 67 and older, who suffered a fracture during the measurement year and subsequently had either a bone mineral density test or were prescribed a drug to treat or prevent osteoporosis in the six months after the fracture

HEDIS 2011 1 1

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Stars Measures

Title Description Source of

Data Dates of Service

BCN Advantage

Medicare Plus Blue

PPO

Diabetes Care

Eye Exam Ages 18-75 with diabetes, who had a retinal eye exam

HEDIS 2011 4 4

Kidney Disease Monitoring

Ages 18-75 with diabetes, who had medical attention for nephropathy

HEDIS 2011 5 3

Blood Sugar Controlled**

Ages 18-75 with diabetes, whose most recent HbA1c level is greater than 9%, or who were not tested (This measure is reverse scored so higher scores are better.)

HEDIS 2011 4 2

Cholesterol Controlled**

Ages 18-75 with diabetes, whose most recent LDL-C level was less than 100

HEDIS 2011 5 3

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** Weighting is three times the Star measure.

Stars Measures

Title Description Source of

Data Dates of Service

BCN Advantage

Medicare Plus Blue

PPO

Controlling Blood Pressure**

Ages18–85, who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90)

HEDIS 2011 5 2

Rheumatoid Arthritis Management

Diagnosed with rheumatoid arthritis during the measurement year, who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD)

HEDIS 2011 4 4

Improving Bladder Control

Ages 65 or older, who reported having a urine leakage problem in the past six months and who received treatment for their current urine leakage problem

HOS 2009 1st Survey 2011 2nd Survey

3 3

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** Weighting is three times the Star measure.

Stars Measures

Title Description Source of Data

Dates of Service

BCN Advantage

Medicare Plus Blue

PPO

Reducing the Risk of Falling

Ages 65 or older, who had a fall or had problems with balance or walking in the past 12 months, who were seen by a practitioner in the past 12 months and who received fall risk intervention from their current practitioner

HOS 2009 1st Survey 2011 2nd Survey

4 3

Drug Plan Members 65 and Older Who Receive High Risk Meds**

Ages 65 or older, who received two or more prescription fills for a high risk medication

PDE 2011 5 5

Blood Pressure Meds for Diabetes**

Received an ACE/ARB medication among those who were dispensed at least one prescription for an oral hypoglycemic agent or insulin and at least one prescription for an antihypertensive agent

PDE 2011 3 2

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PDE = Prescription drug event records ** Weighting is three times the Star measure.

Stars Measures

Title Description Source of

Data Dates of Service

BCN Advantage

Medicare Plus Blue

PPO

Medication Adherence for Diabetes**

Ages 18 or older, who adhere to their prescribed drug therapy across four classes of oral diabetes medications: biguanides, sulfonylureas, thiazolidinediones, and DiPeptidyl Peptidase (DPP)-IV Inhibitors.

PDE 2011 4 5

Medication Adherence for Hypertension**

Ages 18 or older, who adhere to their prescribed drug therapy for renin angiotensin system (RAS) antagonists (angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or direct renin inhibitor medications).

PDE 2011 5 5

Medication Adherence for Cholesterol**

Ages 18 or older, who adhere to their prescribed drug therapy for statin cholesterol medications.

PDE 2011 5 5

33 ** Weighting is three times the Star measure.

New Preventive Services

Quick Reference Guide on CMS website

Annual Wellness Visit (AWV is a separate service

from the Initial Preventive Physical Examination)

Welcome to Medicare Preventive Visit aka Initial

Preventive Physical Examination (IPPE)

Personalized prevention plan with advice, screening

schedules, referrals and education based on your

specific health situation

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New Preventive Services

Colorectal cancer screening (colonoscopy)

Bone mass measurement for osteoporosis and

other bone issues

Glaucoma screening

Immunizations (including flu shots and pneumonia

and hepatitis B vaccinations)

Mammograms and pap smears

Prostate screening

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Ew Preventive Exams

Annual alcohol misuse screening

Brief face-to-face behavioral counseling for

alcohol abuse

Annual depression screening

Counseling for sexually transmitted infections

Face-to-face behavioral counseling for obesity

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Reimbursement

CMS established a billing code that physicians

must use to bill for a first AWV service, G0438, and

a subsequent AWV service, G0439.

The 2011 Medicare payment—not adjusted for

geography—is approximately $172 for G0438 and

$111 for G0439. Medicare will pay the full

amount, meaning that the beneficiary does not

have to pay the typical 20 percent copayment nor

toward a yet-to-be reached deductible

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Five Things To Remember

No rule outs

Appropriate signatures

Supportive documentation of diagnosis

Face-to-face visit

Star measurements

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Open Discussion

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