Data Infrastructure and Successful Quality Metric Collection: The Last Step in Medicare Shared Savings Shawn Griffin, MD, Quality Reporting Director Memorial Hermann ACO, and Chief Quality and Informatics Officer, Memorial Hermann Physician Network
None Disclosures
Presentation Overview Overview of ACO Organizational Changes Data Management Challenges Data Collection Processes 2013, 2014, and 2015 Questions
OVERVIEW OF MEMORIAL HERMANN ACO
Our Journey to Physician Alignment Medical Staff 1950 Independent Physician Association (IPA) 1983 Clinical Programs Committees (CPC s) 2000 Clinical Integration 2005 Accountable Care Organization 2011
MHMD History 1983-2004: Messenger Model IPA Most Memorial Hermann Physicians are members (now account for 90% of admissions) Arms-length relationship with MH System 2000: Clinical Programs Committees (CPC s) Form Standardized system formulary through CPC structure and given standardization authority 2005: MHMD Board commits to Clinical Integration Clinical Integration (CI) will be model for quality, cost efficiency and managed care contracting
Current CPC Structure (2015) MHMD Board CPC System Quality Board Pathology Radiology Trauma Emergency PM&R Peer Review Pediatrics (APPs) Primary Care (APCPs) Medicine Evidence Based Med Surgery CEPC Orthopedics Cardio- Vascular services Women and Children Critical Care MIC General Surgery Bariatrics Supportive Methods Vendor TF Cardiology Neonatology Nephrology AMIC ENT NSQIP CV Surgery Ob/Gyn Heme/Onc Editorial Robotics Anesthesia Allergy EQC PSH Pain Hospital Documentation Clinic VTE Gastro Diabetes Trauma Infectious Disease
MHMD History 2008: MHMD Compact articulates organizational and physician commitments First contract with hospital system employees for shared savings program with bonus 1200 sign Network Participation Agreements Data collection to support CI model successful. 2012: MSSP ACO formed Based on Clinical Integration Network Some PCP opt-out due to existing relationships with other ACO s. 1850 remain in ACO.
MHMD Physician Compact
ORGANIZATIONAL CHANGES FOR MSSP ACO
Organizational Changes MHHS originally decided to not form ACO. Regulations felt to be too burdensome and benefit too limited planned to leverage CI network going forward New regulations issued Much more favorable for participants Formed as Track One ACO no downside risk Formation of subsidiary based on CI network with required board structures No savings expected from MSSP, but alignment benefits worth the work
Original Application Diagram
Accountable Care Gr Houston >11,000 MHMD 4,000 CI 2,900 ACO 1,900 PCMH 323 Clinically Integrated IPA Private, Employed & Faculty Integration Exclusive Contracting DOJ/FTC Protections Health System 11 Independent Medical Staffs 3 Distinct Practice Models Employment Private >50 Faculty 13
CARE MANAGEMENT DEVELOPMENT
Right Care Right Time Healthy Wellness and Prevention Life in Balance Telemedicine Digital Apps E Medicine Virtual Medicine Fitness Retail Partner(s) Chronic Disease Mgmt Community Health Palliative Care Amb ICU Patient Centered Medical Home Sick Hospice Telephonic Care Management Integrated Care Management 15
Care Management Development New care management infrastructure necessary for population management and to address transitions of care and chronic disease management ACO care management was separate from traditional hospital-centered care management structure own leadership Required negotiation of responsibilities to leverage relationships with providers
Care Management Development First care managers were aligned with regional groupings of physicians along with Practice Facilitators Program key to population management and physician engagement in care gaps and disease management Eventually added social workers and a pharmacist to the care management team Expanding Palliative/Supportive Medicine
PATIENT CENTERED MEDICAL HOME DEVELOPMENT
The Advanced Primary Care Practice: Quality and Contracting Engine Claims Files/Data Advanced Primary Care Practice Single Case Signature Management Contracting Marketing Access HCC Training Document Training Quality Metrics Patient Education Quality Schedule NOW Patient Portal e Notify NCQA Level 3 Practice Assessment Electronic Point Medical Of Record Care Tool Accountable Care Clinical Integration Health Information Exchange Technology 19
Patient Centered Medical Home Growth 325 256 284 177 210 113 47 NCQA 136 NCQA Jan 2012 Mar 2012 Mar 2013 Jun 2013 Sep 2013 Jun 2014 20
95 PCPs 273 Specialists North Region Regional Medical Home Structure 37 PCPs 125 Specialists Northeast Region 158 PCPs 413 Specialists 153 PCPs 311 Specialists West Region Southwest Region 188 PCPs 963 Specialists 98 PCPs 199 Specialists Central Region Southeast Region 21
ACO Technology Environment >20 Electronic Medical Records (EMR s) in use in PCP offices Health Information Exchange (HIE) not comprehensive due to opt-in requirement Overlay registry tool not compatible with all EMR s so data warehouse limited Claims file experience useful for certain quality metrics, care gaps, risk stratification, and physician-level reporting
DATA MANAGEMENT CHALLENGES
Data Management Challenges MSSP very different process from typical Medicare Advantage or commercial claims process Cumbersome claims request process Retrospective attribution only to Tax ID number for clinic (not NPI#) for final assignment of beneficiaries Assignment can change during performance period
Data Management Challenges Files from CMS variable and early process mistakes (file errors requiring file destruction) Already had existing vendor for claims processing and risk stratification, but new process New quality metrics for MSSP ACO program not used by commercial contracts Population churn noted, any Medicare beneficiary could end up being sampled
Claims Request Process Assigned Beneficiaries list received quarterly Required mailing to provider beneficiaries 30 days to opt-out of data sharing, no addresses provided Once 30 days passed, could request claims files on new beneficiaries next monthly load If no mailing, no claims requested Processing of files takes about 3 weeks to put in database
DATA COLLECTION PROCESSES
Quality Reporting Evolution 33 quality measures evolve from pay-forreporting to pay-for-performance Measures divided into 4 domains, one domain based on patient surveys (CAHPS) 25 measures collected by each ACO with successful completion required for receiving shared-saving funds
Evolution of Measures Performance Year 1: Pay-for-reporting applies to all 33 measures. Performance Year 2: Pay-for-performance applies to 25 measures and pay-for-reporting applies to 8 measures. Performance Year 3: Pay-for-performance applies to 32 measures and pay-for-reporting applies to 1 measure.
Points Calculation
Scoring of Measures
General Data Process Collection file received from CMS in early January. File pre-populated with information from claims and EMR-sourced registry data. Prepopulated information given to offices to verify for accuracy since EMR serves as final source of truth Data collected and submitted to CMS by deadline
2013 Process - Paper
2013 Results 3,916 patients information collected on paper 59 Tax ID Numbers involved Transcribed by MHMD staff into internal web portal Completed two days before deadline Web tool was noted to be so helpful, process for next year planned with office access directly to portal New security model built for Tax ID Number access.
Common ACO Collection Process Office Office Office Office Office Office GPRO Web Portal Office
MHMD Collection Process Office Office Office Office Office Office MHMD Portal Office GPRO Portal
2014 Portal
2014 Results 4,042 patients information directly entered into portal Same 59 Tax ID Numbers involved Webinars conducted to assist collection process Practice Facilitators assisted some offices Collection completed two weeks before deadline
Top MSSP ACO Savings ACO States Total Savings ACO Share Memorial Hermann Accountable Care Organization Palm Beach Accountable Care Organization, LLC Catholic Medical Partners- Accountable Care IPA, Inc. Southeast Michigan Accountable Care, Inc. TX $57.83 M $28.34 M FL $39.57 M $19.34 M NY $27.92 M $13.68 M MI $24.68 M $12.09 M RGV ACO Health Providers, LLC TX $20.24 M $11.90 M ProHEALTH Accountable Care Medical Group, PLLC NY $21.91 M $10.74 M Triad Healthcare Network, LLC NC $21.51 M $10.54 M WellStar Health Network, LLC GA $19.88 M $9.74 M Accountable Care Coalition of Texas, Inc. TX $19.10 M $9.36 M 39
National MSSP Performance MHACO 82.8% 40
Fall 2014 Portal Usage Based on review of 2014 collection, portal opened in fall to have focused collection of data on diabetes, ischemic vascular disease, and heart failure patients Provided care management with opportunity to outreach to patients missing care or poorlycontrolled prior to federal data collection.
2015 Collection Calendar January 5-9, 2015 MSSP patient ranking files available from CMS January 9, 2015 MHMD passes patient ranking file to Crimson Notification sent to MHMD providers alerting to MSSP Portal Dates January 12-23, 2015 PCP mapped manually for all attributed patients Deadline for pre-populating patient data from claims January 23, 2015 and registries MHMD readies patient data to open MHMD MSSP January 26-30, 2015 Portal for providers GPRO Web Interface (Group Practice Reporting January 26, 2015 Option) opens for quality reporting February 2-27, 2015 Providers populate MHMD MSSP Portal MHMD readies patient data to upload to GPRO Web March 2-20, 2015 Interface & uploads data to ensure completion March 20, 2015 GPRO Web Interface closes for quality reporting
2015 Portal
Quick Guides Embedded
2015 Results 4,027 patients information directly entered into portal by office staff Expanded to 87 Tax ID Numbers Participating New CMS produced Quick Guides embedded in portal Recorded webinar with directions for process Office submission completed three weeks before deadline Conducted focused audit of results following completion of submission by offices prior to submitting to CMS
Added Measures for Next Year ACO-34: CAHPS for ACOs: Stewardship of Patient Resources ACO-35 Skilled nursing facility 30-day all-cause readmission measures ACO-36 All-cause unplanned admissions for patients with diabetes ACO-37 All-cause unplanned admissions for patients with heart failure
Added Measures for Next Year (cont.) ACO-38 All-cause unplanned admissions for patients with multiple chronic conditions ACO-39 Documentation of current medications in the medical record (replace ACO-12) ACO-40 Depression Remission at 12 months
Changes for 2016 Collection Web portal will need updating for new measures Improve concurrent audit capabilities New practices joining ACO will need education and monitoring All practices will need education on new measures
QUESTIONS?