CMS Data What s In It & How To Use It. Kimberly Kauffman Executive Director Summit Health Solutions
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1 CMS Data What s In It & How To Use It Kimberly Kauffman Executive Director Summit Health Solutions
2 2 Summit Health Solutions ACO w/ July 1, 2012 start date Wholly owned by Summit Medical Group Two hospital systems as participant providers 21 RN Care Coordinators, 6 Social Workers 2 Care Navigators 36,000 attributed beneficiaries 44,000 pts in Med Adv or Mcare FFS
3 3 Summit Medical Group 150 PCPs + 50 hospitalists + 20 specialists (pul, rheum & card l) + 80 physician extenders 55 practice sites, 12 county market Ancillaries lab, imaging, sleep, PT / OT, urgent care & wellness 100% primary care sites recognized by NCQA as Patient Centered Medical Home AllScripts EMR in all sites
4 4 What Keeps You Night? Goal Three Part Aim Process Ready Shoot Aim
5 5
6 6 Feel like you re building it while flying it?
7 7 Clear Action Plan Define Measure Action Plan Build Use
8 8
9 9 Data Schedule Monthly Months of service: 12 months prior to effective date thru current
10 10 Claim type, not coverage Part A Part B - not only claims for services covered by Part A - includes institutional outpt claims (covered by Part B) - not all claims covered by Part B
11 11 Part A Inpatient hospital Skilled nursing facility Institutional outpatient Home health agency Hospice
12 12 Part B Physicians Outpatient lab DME and other suppliers
13 13 Key Fields HICN Provider ID Claim id Dx DOS Pd $ w/o co-share Claim type HCPCS
14 14 Define Measure Action Plan Build Use
15 15 Build determine its use Pt Practice ACO
16 16 Patient Level Organize & prioritize staff activity Engage physicians & providers
17 17 Staff Activity Risk stratification Predictive modeling Disease registries
18 18 Risk Stratification & Predictive Modeling based on paid claims data Optum Actuarial Symmetry Episode Risk Groups ( ERGs )
19 19 Optum Actuarial Member Key Primary Diagnosis Total ER Visits Diagnosis Specific ER Visits Chest pain, unspecified Abdominal pain, unspecified site Chest pain, other Painful respiration Lumbago Concussion with no loss of consciousness Sciatica Gouty arthropathy, unspecified Contusion of knee Abdominal pain, right lower quadrant Head injury, unspecified Headache Anxiety state, unspecified Migraine, unspecified without mention of intractable migraine without mention of status migrainosus Sprain and strain of unspecified site of back Chest pain, unspecified Nasal bones, closed fracture Lumbago Headache Shortness of breath Other dyspnea and respiratory abnormalities Anxiety state, unspecified Urinary tract infection, site not specified Unspecified essential hypertension Nausea with vomiting Panic disorder without agoraphobia Generalized anxiety disorder Other acute pain Unspecified constipation 35 1
20 Patient Detail 20
21 21 Episode Treatment Grouper
22 22 Optum Symmetry ERGs Built on top of ETGs Determines an ETG per claim line & estimates RISK for (i.e., predicts) resource usage (cost) Assigns weight to different ETGs Adds weights to determine risk score
23 Sample ERG 23
24 24 Disease Registries Name Risk Score Patient HICN DOB SiteC ode ProvName XXXXX, JACQUELINE Primary Care Phy XXXXX, WILLIAM Primary Care Phy XXXXX, PANSY Primary Care Phy XXXXX, CATHY Primary Care Phy XXXXX, JAMES Primary Care Phy XXXXX, DAVID Primary Care Phy XXXXX, BETTY Primary Care Phy XXXXX, ALVIN Primary Care Phy XXXXX, JAMES Primary Care Phy
25 25 Pt Practice ACO
26 26 Engage Physicians PCPs SCPs
27 27 Primary Care Physicians Reports must be Credible Actionable Timely Trendable Relevant
28 PCP Dashboard 28
29 29 Creating open dialogue with SCPs Medical Neighborhood Utilization & steerage Share practice pattern data w/ individual specialty practices Identify opportunities to understand & improve components of care delivery Identify opportunities to get pts the right care, at the right location, at the right time
30 Drilldown Area of Focus 1 Specialty Type Comparison Against Benchmarks Benchmark ACO (Attributed State of TN, % Sample) Provider Specialty Code Description Procedures Cost per Procedure Total Cost PMPM Procedures Cost per Procedure Total Cost PMPM 11 Internal Medicine 345,971 $28.59 $ ,261 $38.64 $ Ophthalmology 42, , Family Practice 222, , Hematology/Oncology 41, , Ambulance Service Supplier 28, , Independent Clinical Laboratory 117, , Diagnostic Radiology 86, , Cardiology 71, , Ambulatory Surgical Center 8, , Orthopedic Surgery 33, , Medical Oncology 16, , Nurse Practitioner 63, , Dermatology 38, , Drill down into cardiologists: potential $1.34+ PMPM savings opportunity? Compare to regional benchmarks 30
31 Drilldown Area of Focus 1 Specialty Type Cardiologist: Cost and Use Report Service Type Procedures Cost per Procedure Cost PMPM Cost Distribution Benchmark Paid PMPM Benchmark % of Paid Professional All Other 65 $ $ % Allergy Tests/Treatments $ % Cardiovascular 31, $ % $ % Emergency Room Visits $ % Inpatient Visits 6, $ % $ % Lab/Pathology 9, $ % NPRV-Physical/Well Child $ % Office Visits 17, $ % $ % Other HCPCS $ % Other Injectibles/Infusions $ % Other Medicine $ % PRV-Colorectal Cancer Screening $ % PRV-Influenza Vaccine $ % PRV-Prostate Cancer Screening $ % Pulmonary $ % Radiology 2, $ % $ % Surgery 3, $ % Professional Total 71,239 $ $ % Determine services with high utilization and cost for cardiologists. 31
32 Drilldown Area of Focus 2 TINS Specific TINS with Assigned Cardiologists Normalized Cost Per Patient is an efficiency metric indicator TIN Summary TIN Prodecures Patients Cost per Procedure Total Cost Total Cost per Patient Average HCC Score of TIN Panel Normalized Cost per Procedure Normalized Cost per Patient 71,629 15,910 $ $ 3,155,249 $ $ $ ,487 3,681 $ $ 773,047 $ $ $ ,671 1, , ,218 1, , , , , , , , , , , , , , , , ,772 2, , , , , , Identify clinics with high procedure counts and/or high normalized costs / procedures
33 Drilldown Area of Focus 2 TINS Cost and Use Report for Specific TIN TIN: Specialty Code 06 Specialty Code Description Cardiology Service Type Procedures Cost per Procedure Total Cost Total Cost Professional All Other 3 $ $ 721 0% Cardiovascular ,106 33% Emergency Room Visits % Inpatient Visits ,582 11% Lab/Pathology ,581 2% NPRV-Physical/Well Child % Office Visits 1, ,408 29% Other Medicine % Radiology ,685 18% Surgery ,077 2% Professional Total 3,077 $ $ 176,067 96% Identify service areas within the TIN that have room for possible savings. 33 *Note that other service categories (e.g. Part B drugs) are not shown and make up the remaining 4% of cardiology services.
34 Drilldown Area of Focus 3 Providers Specific Cardiologists Within TIN Normalized Cost Per Patient is an efficiency metric indicator Identify physicians or clinics within the TIN with high procedure counts and/or high normalized costs / procedures 34 Identify physicians or clinics within the TIN with good performance
35 Drilldown Area of Focus 3 Providers Cost and Use Report for Specific Provider Above Average Below Average 35 Identify areas of focus for particular physicians and opportunities for savings
36 36 Pt Practice ACO
37 Process Improvement ER use access issues Readmit coordination opportunities Low utilizers proactive contact High cost education indicated 37
38 38 Define Measure Action Plan Build Use
39 39 Questions? Contact info: Kimberly Kauffman Summit Health Solutions (865)
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