Using PPRNet Reports for Performance Recognition Programs Pre-Meeting Workshop August 23, 2012
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1 Using PPRNet Reports for Performance Recognition Programs Pre-Meeting Workshop August 23, 2012 August 23-25, 2012 PPRNet 2012
2 AGENDA 1:00pm-1:15pm Welcome and Introductions Cara Litvin, MD 1:15pm-2:15pm 2:15pm-3:00pm 3:00pm-3:15pm 3:15pm-4:00pm 4:00pm-5:00pm Using PPRNet Reports to Achieve NCQA Recognition Receiving Bridges to Excellence Recognition with PPRNet Reports Break Receiving PQRS Incentives with PPRNet Reports Hands-On Session: Using Reports for Incentive Programs Cara Litvin, MD Andrea Wessell, PharmD Andrea Wessell, PharmD All Participants August 23-25, 2012 PPRNet 2012
3 WORKSHOP GOALS To introduce PCMH, Bridges to Excellence and PQRI recognition programs To present examples of how PPRNet practices have used reports to achieve recognition and/or incentives To provide hands-on assistance with using your reports to achieve recognition August 23-25, 2012 PPRNet 2012
4 PARTICIPANT INTRODUCTIONS Briefly introduce yourself and your practice. Discuss whether your practice has participated in PCMH, BTE, PQRS and/or other quality recognition programs? What you would like to gain from participation in this workshop? August 23-25, 2012 PPRNet 2012
5 WHY IS THERE A NEED FOR PERFORMANCE RECOGNITION PROGRAMS? Increasing demand for healthcare services Growing aging and chronically ill population Rising healthcare spending without improvement in quality Shortage of primary care physicians Private and public health plans and employers are interested in supporting primary care physicians ability to coordinate care for patients if it improves quality and reduces costs. August 23-25, 2012 PPRNet 2012
6 Using PPRNet Reports to Achieve NCQA Recognition
7 NCQA RECOGNITION PROGRAMS Private, not-for-profit organization dedicated to improving quality Patient-Centered Medical Home Diabetes Heart/Stroke Many health plans pay rewards for NCQA recognition August 23-25, 2012 PPRNet 2012
8 Practice HOW DO PPRNET REPORTS HELP? PPRNet Practices who have used PPRNet Reports to receive NCQA recognition: East Granby Family Practice, East Granby, CT Riverside Family Physicians, Riverside, CA Johnston Family Medicine, Westminster, MD SouthPark Internal Medicine, Highlands Ranch, CO Susan Boyle, St Joseph Medical Group, Duluth, GA NCQA Recognition Level 3 PCMH Level 3 PCMH Level 2 PCMH Level 3 PCMH, Heart Stroke Recognition Program Level 1 PCMH August 23-25, 2012 PPRNet 2012
9 Practice Crete Area Medical Center Crete, NE Hilliard Family Medicine, Hilliard, OH Cayuga Family Medicine, Ithaca, NY Family Medicine of Port Angeles, Port Angeles, WA Family Practice Partners, Murfreesboro, TN Burke Primary Care, Morganton, NC Natural Family Wellness, Glen Dale, MD NCQA Recognition Level 3 PCMH Diabetes Recognition Program Level 3 PCMH Level 3 PCMH, Diabetes Recognition Program Level 3 PCMH Diabetes Recognition Program Level 2 PCMH Diabetes Recognition Program August 23-25, 2012 PPRNet 2012
10 Understanding the Patient Centered Medical Home Health IT August 23-25, 2012 PPRNet 2012
11 Preliminary results of PCMH pilots across the country have demonstrated: Decreased rates of ER visits Decreased rates of hospitalizations Reduced costs Improved performance on preventive and chronic disease quality indicators August 23-25, 2012 PPRNet 2012
12 NCQA PCMH RECOGNITION PROGRAM Widely accepted standards for PCMH recognition developed by National Committee for Quality Assurance (NCQA) Recognition requires completion of survey along with evidence that specific processes and policies are in place. Recognition offered at 3 levels: Level 1 basic Level 2 intermediate Level 3 advanced Over 3300 practices have achieved NCQA PCMH recognition. August 23-25, 2012 PPRNet 2012
13 BENEFITS OF NCQA RECOGNITION Recognition positions practices to take advantage of financial incentives offered by PCMH pilot projects. PCMH Demonstration projects offered by: Multi-payer initiatives and private insurers Medicaid/CHIP Federal efforts (Medicare, Veterans Administration, Department of Defense) August 23-25, 2012 PPRNet 2012
14 WHAT DO YOU HAVE TO DO TO ACHIEVE RECOGNITION?
15 Level 1: points and all 6 mustpass elements Level 2: points and all 6 mustpass elements Level 3: points and all 6 mustpass elements
16 NCQA APPLICATION PROCESS Self-assess level of capability to meet each of the standards Pay application fee ($500/provider) Complete survey tools Respond to questions Complete worksheets/surveys Attach documentation (written protocols, screenshots, performance reports, survey results) Upload documents and submit for scoring August 23-25, 2012 PPRNet 2012
17 NCQA APPLICATION PROCESS 1. The practice submits the Survey Tool with its documentation for NCQA evaluation. 2. NCQA evaluates all data and documents submitted by the practice against the standards, and then scores the practice. 3. For 5% of practices, NCQA conducts an additional, onsite audit. 4. NCQA provides results to the practice. 5. NCQA reports information on the practice, its physicians and its level of performance to the NCQA Web site and to data users, including health plans and physician directory publishers. 6. NCQA does not report information on practices that do not pass at any level. August 23-25, 2012 PPRNet 2012
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19 EXAMPLES OF PCMH REQUIREMENTS: PCMH2- IDENTIFY/MANAGE PATIENT POPULATIONS The practice collects demographic and clinical data for population management The practice assesses and documents patient risk factors The practice identifies patients for proactive and point-of-care reminders August 23-25, 2012 PPRNet 2012
20 EXAMPLES OF PCMH REQUIREMENTS: 2D-USE DATA FOR POPULATION MANAGEMENT Documentation: List of patients (de-identified) within the past 12 months. Factor 1- Pts who need preventive screening or immunizations (at least 3 different immunizations or screenings) Factor 2-Pts who need acute or chronic care services (at least 3 different services) Factor 3-Pts who have not had recent appointment (practice may use own criteria) Factor 4-Pts on specific medications August 23-25, 2012 PPRNet 2012
21 PPRNet PLR reports include lists of patients: With specific diagnoses Needing preventive services Requiring clinician review or action Taking specific medications August 23-25, 2012 PPRNet 2012
22 EXAMPLES OF PCMH REQUIREMENTS: PCMH3- PLAN/MANAGE CARE The practice implements evidence-based guidelines, identifies patients with specific conditions, including high-risk or complex care needs Care management emphasizes: Pre-visit planning Assessing patient progress toward treatment goals Addressing patient barriers to treatment goals The practice reconciles patient medications The practice uses e-prescribing August 23-25, 2012 PPRNet 2012
23 EXAMPLES OF PCMH REQUIREMENTS: 3A- IMPLEMENT EVIDENCE BASED GUIDELINES Practice must 1) Identify 3 important conditions 2) Provide name and source of guideline for each condition 3) Demonstrate how the guidelines for each condition are implemented in patient care, use chart tools, screen shots or workflow organizers Documentation: Paper-based organizers such as algorithms or flow sheets Electronic system organizer (e.g. EHR) screenshots showing templates for treatment plans and documenting progress
24 3A: IMPLEMENT EVIDENCE BASED GUIDELINES Needing preventive services On specific medications Needing specific follow-up Needing chronic care services August 23-25, 2012 PPRNet 2012
25 PRACTICE GUIDELINES
26 HM TEMPLATE FOR DM MANAGEMENT
27 EXAMPLES OF PCMH REQUIREMENTS: 3B- IDENTIFY HIGH RISK PATIENTS Documentation: Factor 1- The practice has a process and criteria used to identify these patients. Factor 2-The practice has a number and percentage of its total population identified as high risk or complex August 23-25, 2012 PPRNet 2012
28 3B: IDENTIFY HIGH RISK PATIENTS
29 EXAMPLES OF PCMH REQUIREMENTS: PCMH6- MEASURE/IMPROVE PERFORMANCE The practice uses performance and patient experience data to continuously improve The practice tracks utilization measures such as rates of hospitalizations and ER visits The practice identifies vulnerable patient populations The practice demonstrates improved performance August 23-25, 2012 PPRNet 2012
30 PPRNET TOOLS: PERFORMANCE REPORTING AND IMPROVEMENT PPRNet reports: Provide performance data across the practice or by physician over time Help practices set goals to improve performance Include NCQA endorsed performance measures August 23-25, 2012 PPRNet 2012
31 EXAMPLES OF PCMH REQUIREMENTS: 6A-MEASURE PERFORMANCE Documentation: The practice provides reports showing performance on the required measures. August 23-25, 2012 PPRNet 2012
32 August 23-25, 2012 PPRNet 2012
33 6A: MEASURE PERFORMANCE August 23-25, 2012 PPRNet 2012
34 EXAMPLES OF PCMH REQUIREMENTS: 6D-DEMONSTRATE CONTINUOUS QUALITY IMPROVEMENT Documentation: Factor 1- Reports or recognition results showing performance measures over time. Factor 2- Reports on improvement activities and the results. Factors 3 and 4- Reports showing improvement on performance measures. August 23-25, 2012 PPRNet 2012
35 Clinical process (e.g., percentage of women 50+ with mammograms) Clinical outcomes (e.g., HbA1c levels for diabetics) August 23-25, 2012 PPRNet 2012
36 EXAMPLES OF PCMH REQUIREMENTS: 6E- REPORT PERFORMANCE Documentation: Factors 1 and 2-Blinded reports showing summary practice or individual clinician performance. Factor 3- Example of reporting method to patients or to public. August 23-25, 2012 PPRNet 2012
37 6E: REPORT PERFORMANCE August 23-25, 2012 PPRNet 2012
38 August 23-25, 2012 PPRNet 2012
39 CASE 1: FMPA PPRNet member and best practice since 2005 Rural locally owned family medicine practice Washington State and Federally Qualified Rural Health Clinic Level 3 NCQA-PCMH since 2009; NCQA Diabetes and Heart/Stroke Recognition 9 MDs and 4 midlevel providers; work as teams with nurses and medical assistants August 23-25, 2012 PPRNet 2012
40 HOW HAS PPRNET MEMBERSHIP HELPED FMPA BECOME A PCMH? Participated in several PPRNet studies Embraced the PPRNet QI model and worked to use their EHR more effectively to improve care Uses PPRNet practice level reports to identify potential areas for improvement Uses PPRNet patient level reports to guide chronic care management and perform outreach Use of note templates, HM tables, and PPRNet reports were instrumental to show how practice met standards for certification August 23-25, 2012 PPRNet 2012
41 CASE 2: WSFM PPRNet Member since 2003 An outpatient department of a local hospital/health system in Michigan 8 MDs and 2 midlevel providers; each practice as a team with dedicated medical assistants; a chronic care manager and pharmacist Participated in the TransforMED study of the AAFP as an intervention practice Health system provided the practice with part time administrative support to assist with the NCQA application August 23-25, 2012 PPRNet 2012
42 HOW HAS PPRNET MEMBERSHIP HELPED WSFM BECOME A PCMH? Active use of PPRNet QI strategies learned from participation in PPRNet projects-they learned how reorganize their team around the EMR to improve care. Use of HM tables, PPRNet reports, note templates vital to satisfying application requirements August 23-25, 2012 PPRNet 2012
43 HOW HAS WSFM BENEFITTED FROM BECOMING A PCMH? Receiving enhanced revenue (>$70,000) from two payers (Priority Health and BCBS of MI) as a result of being a Level 3 PCMH Received multiple quality awards and recognition nationally as a site in TransforMED project Improved patient/provider/staff satisfaction, resulting in low staff turnover August 23-25, 2012 PPRNet 2012
44 Other NCQA Recognition Programs: Diabetes, Heart/Stroke Programs
45 OTHER NCQA RECOGNITION PROGRAMS Use reporting registries for NCQA recognition and PQRS incentives Diabetes Heart/Stroke Physician Practice Connections August 23-25, 2012 PPRNet 2012
46 NCQA RECOGNITION PROGRAMS: BASIC REQUIREMENTS Application Report data on a sample of patients N=25 for diseasespecific programs (or 30 Medicare pts for PQRS program) Tool calculates performance Fees Data collection tool Per-provider fee August 23-25, 2012 PPRNet 2012
47 EXAMPLE: NCQA DIABETES PHYSICIAN RECOGNITION PROGRAM PPRNet 2012
48 USING PPRNET REPORTING TOOLS August 23-25, 2012 PPRNet 2012
49 August 23-25, 2012 PPRNet 2012
50 ACTIVITY: COMPLETE SECTION 2D OF THE PCMH APPLICATION USING YOUR REPORT Documentation: List of patients (de-identified) within the past 12 months. Factor 1- Pts who need preventive screening or immunizations (at least 3 different immunizations or screenings) Factor 2-Pts who need acute or chronic care services (at least 3 different services) Factor 3-Pts who have not had recent appointment (practice may use own criteria) Factor 4-Pts on specific medications August 23-25, 2012 PPRNet 2012
51 Bridges to Excellence (BTE) recognize and reward clinicians who deliver superior patient care.
52 BTE INCENTIVES Fixed annual bonus per patient, preferred network tiering, fee schedule increases and/or other rewards from: Aetna Anthem-Wellpoint Blue Cross and Blue Shield (NC, TX, LA, NM, OK) CDPHP CIGNA MVP Health System Tufts Health Plan United Healthcare August 23-25, 2012 PPRNet 2012
53 BTE RECOGNITION PROGRAMS Asthma Cardiac Congestive Heart Failure COPD Coronary Artery Disease Depression Diabetes Hypertension Physician Office Spine Medical Home August 23-25, 2012 PPRNet 2012
54 BTE: BASIC REQUIREMENTS Pathways to recognition NCQA disease-based or PCMH programs Automated performance assessment EHR, registry, health information exchange Direct data submission Report on at least 25 patients Fees Based on number of providers (starts at $95) August 23-25, PPRNet 2012
55 EXAMPLE: BTE HYPERTENSION LEVEL III
56 August 23-25, 2012 PPRNet 2012
57 EXPERIENCES WITH BTE Diana Lozano, MD Others? August 23-25, 2012 PPRNet 2012
58 ACTIVITY Use your report for a BTE recognition program 1. Sort by selected condition HTN: Y 2. Sort for BP within the last year 3. Sort largest to smallest SQUID or smallest to largest Systolic BP 5. Sort PLR by provider 6. Select at least 25 patients per provider August 23-25, 2012 PPRNet 2012
59 BTE TOOLS AND RECOGNITION CRITERIA August 23-25, 2012 PPRNet 2012
60 Center for Medicaid and Medicare Services (CMS) E-prescribing Incentives Medicare and Medicaid EHR Incentives Medicare Primary Care Incentives Physician Quality Reporting System
61 CMS PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) Incentives : +0.5% of total estimated allowed charges for Medicare Part B Physician Fee Schedule during reporting period 2015: -1.5% penalty if no reporting for : -2% Additional 0.5% incentive for 2012 and 2013 from Maintenance of Certification Program participation August 23-25, 2012 PPRNet 2012
62 PQRS Determine eligibility Eligible professionals Medicare Part B FFS patients At least 3 measures relevant to practice Select reporting mechanism Fees None for general program Potential cost for CMS recognized registry system NCQA tools are recognized Submit by March 2013 August 23-25, 2012 PPRNet 2012
63 PQRS MEASURE GROUPS (22 TOTAL) Diabetes Mellitus Chronic Kidney Disease Preventive Care Coronary Artery Bypass Graft COPD Back Pain Heart Failure Coronary Artery Disease Ischemic Vascular Disease Asthma Elevated blood pressure CV prevention Clinical quality measures from CMS EHR Incentive Program August 23-25, 2012 PPRNet 2012
64 EXAMPLE: PQRS DIABETES MELLITUS MEASURES GROUP August 23-25, 2012 PPRNet 2012
65 EXAMPLE: PQRS PREVENTIVE CARE MEASURES GROUP August 23-25, 2012 PPRNet 2012
66 PQRS REPORTING MECHANISMS Claims Registry EHR Group Practice Reporting Options August 23-25, 2012 PPRNet 2012
67 PQRS REPORTING MECHANISMS Claims Registry EHR Group Practice Reporting Options August 23-25, 2012 PPRNet 2012
68 Registry-Based Reporting Options August 23-25, 2012 PPRNet 2012
69 Registry-Based Reporting Options Larger sample vs reporting by group Fewer total measures Allows for customized selection of measures August 23-25, 2012 PPRNet 2012
70 Registry-Based Reporting Options Small sample of patients required for 12 month option August 23-25, 2012 PPRNet 2012
71 USING PPRNET REPORTS FOR PQRS Select individual measures or measure groups Identify 30 eligible patients by age or insurance fields Use PLR data to supplement required elements for registry completion
72 PRACTICE EXPERIENCES W/PQRS NEIMEF Burke Primary Care Others? August 23-25, 2012 PPRNet 2012
73 PQRS: FUTURE DIRECTIONS Aim to reach 50% of eligible providers by 2015 Proposed rules for Improved alignment across CMS programs Fewer patients (20) for registry reporting Change to a majority of Medicare Part B FFS 2-24 providers eligible for group-reporting option Administrative reporting option added for groups (in addition to claims) August 23-25, 2012 PPRNet 2012
74 ACTIVITY Use your report for PQRS reporting 1. Select measures or measure group - NCQA recognition tools make this easy 2. Sort PLR by selected condition 3. Sort by insurance field or age 4. Supplement PLR data with chart review August 23-25, 2012 PPRNet 2012
75 HOW CAN WE IMPROVE REPORTS? Would this be a better format for patient-level reports? Other suggestions? August 23-25, 2012
76 Hands-on time with your reports! PPRNet 2012
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