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Value-Based Payment Lessons from a Michigan FQHC
Kathleen J. Dunckel, MD
Alcona Citizens for Health, Inc.
Keep the Triple Aim in mind…
Improved health – clinical quality measures, which ones?
Enhanced patient experience – patient satisfaction surveys
Lower cost - compared to what?
benchmarks, risk scoring
total expenditures
ED, inpatient, post-acute care utilization
Of your population – attribution, assignment
Alcona Citizens for Health, Inc.
dba Alcona Health Centers
7 counties in northern lower Michigan and the UP
Alpena, Alcona, Iosco, Emmet, Cheboygan, Chippewa and
Mackinac
13 medical clinics, 2 dental clinics, 1 MDCH school-based
clinic, 13 Behavioral Health school clinics, 2 pharmacies
30,000+ patients
7,000+ Medicare beneficiaries
Our Story Begins…
Experience with chronic disease management for 17+ years
Health Disparities Collaboratives in the early 2000’s
Michigan Primary Care Transformation (MiPCT) Demonstration
Project 2011-2016
Bureau of Primary Health Care requirements for FQHCs
Electronic charting and practice management since 2008
Extensive internal IT network
All sites PCMH designated
Experience with Integrated care initiatives, e.g. Behavioral Health
& Primary Care
Challenges
2012 – tried to form an MSSP ACO with local Michigan providers
Minimal interest from potential partners
Other FQHC’s – mostly Medicaid patients
Non-affiliated hospitals – no incentives
Lack of data sharing with CMS
Lack of understanding of patient barriers
1/3 on disability
Limited community resources, e.g. transportation
#1 Challenge
Unable to achieve minimum attribution numbers
In 2016:
total Medicare 7069, Medicare FFS 5601, attributed 2168
To play the game, we needed to better understand the rules!
From the CMS rule book:
Assigning beneficiaries – Track 1 & 2 ACO’s
Final retrospective assignment at the end of the year, using the
most recent claims, i.e. the past 3 months
Preliminary prospective assignment quarterly; lists are
provided to each ACO
A beneficiary assigned this year may not have been assigned in
a preceding year, and may not be assigned next year
Assignment Criteria
A. Record of Medicare enrollment
B. At least 1 month of enrollment in Part A & B, and no
months of Part A only or Part B only
C. No months of Medicare Advantage or PACE*, i.e. only
traditional Medicare Fee-for-Service
D. Not assigned to another Medicare shared savings
initiative
E. U.S. resident
*Programs of All-Inclusive Care for the Elderly
Assignment Criteria (continued)
F. Received at least 1 primary care service from a physician
utilized in assignment* within the ACO
*Primary care physicians utilized in assignment: internal
medicine, general practice, family medicine, geriatric medicine,
pediatrics
FQHC’s/RHC’s – only beneficiaries who had at least 1 primary
care service from a physician NPI (MD/DO) are eligible for
assignment
Assignment Policy Steps
If screening criteria A through F are met,
a beneficiary is eligible to be assigned to an ACO
Step 1:
At least 1 primary care service furnished by a primary care
practitioner, or ACO professional at FQHC’s/RHC’s
AND, the plurality of the primary care services were
furnished by the ACO
i.e. more allowed charges by all ACO participants than by
other ACO’s or non-ACO providers of the same type
Impact on AHC’s attribution
High mid-level provider to physician ratio, i.e. no physician visit
Patients receiving care elsewhere
Snowbirds
Referral patterns to tertiary centers, e.g. the old Burns Clinic
Turnover of attribution
No physician visit – 1st reason
Plurality of care elsewhere – 2nd reason
Medicare Advantage enrollment – distant 3rd
Back to Our Story…
Joined National Rural Accountable Care Organization (NRACO), now
Caravan Health, in 2014
Reorganized in 2016 with ACO Investment Model funding, now in one
of 2 Michigan ACO’s
8-9 partners, mostly small rural hospital systems, to achieve
attribution numbers
Access to CMS claims data thru Lightbeam
Identification of highest cost patients
Awareness of inpatient and SNF utilization
Our Story, continued…
Effective use of our EMR registry and report functions
Health Information Department – combines EMR and Billing staff
Improved working relationships:
Hospitals – MMMC-Alpena, TSJH, McLaren NM
Home care agencies – medical director is AHC provider
SNFs – our internist sees nearly all AHC pts
Strong physician champion who can effectively reach providers
Impact – Care Coordination
Expanded care coordination/care management to all pts
Strong Care Management Department leadership
High rate of patient enrollment in care management
RN Care Managers located at all sites
Patient self-management of chronic disease
5+ chronic conditions account for 80% of the cost
Coordination of care and services
Patient navigation of healthcare maze
Prevention of unnecessary ED use and hospitalizations
Transition of Care Management – GLHC provides ADT’s
Tele-Care Management
Care Coordination of the Sick & Expensive;
Wellness Visits for the rest
15
The Care Model revisted!
Care Coordination, continued…
LPN Care Connectors
Work insurance lists to close gaps in care
Educate re: appropriate use of ED – letters, rack cards, fridge
magnets
Expanded care-team service delivery
Behavioral Health Consultants
Behavioral Health Patient Navigators
Community Health Workers
ED Patient Education – Rack Card
!
Before you go to the Emergency Room!
Have you called our Alcona Health Center
provider on-call?
An AHC provider is available by phone for after-hours care: nights (5pm – 8am), weekends, and holidays.
Call Alpena Hospital at
356-7390
to contact the on-call provider for our patients.
Call the on-call provider for:
Cold or flu symptoms
Fever
High blood pressure
High or low blood sugar
Minor injuries, aches, pains
Changes in mood
Nausea, vomiting, diarrhea
Burning with urination
“I don’t feel right” (shaky, weak, dizzy)
Swelling of feet/ankles
Call 911 or go to the ER for:
Severe pain or headache
Chest pain
Signs of stroke
Difficulty breathing
Fainting or seizures
Major injuries (cuts, broken bones)
Bleeding that won’t stop or throwing up blood
Feeling suicidal
ED Patient Education – Refrigerator Magnet
Impact – Annual Wellness Visits
AWV for all Medicare patients
Retrospective assignment precludes targeting assigned pts
Preliminary prospective assignment is a moving target
Use of EMR function (Clinical Events Manager) for Point-of-Service
reminders
Less staff time, e.g. calling from lists
Greater patient acceptance
Pre-visit assessment via phone by clinical support staff
More efficient use of time
Better prepared for the face-to-face visit
Annual Wellness Visits, continued…
Focus on evidence-based preventative care, e.g. USPSTF
Advanced Care Planning can be included
Capture clinical quality measures
Increase attribution numbers
Quality Measures
Multiple initiatives, grants, programs with their own requirements
“They-to-whom-we-must-report”
UDS, PCMH, MSSP, etc.
Consistency
Across sites – clinical support staff training
Across providers – peer training
Within EMR – work with system administrators
Clinical Quality Measures Crosswalk
Borrowed from Ohio Primary Care Association
Quality Measure Crosswalk
ADOLESCENT/ CHILDCARE PCMH UDS HEDIS MU MSSP MIPCT
ADHD Percentage of children 6-12 years of age and newly dispensed a medication for attention
deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care YES YES
LEAD SCREENING Percentage of children 2 years of age who had one or more blood tests for lead poisoning by their 2 nd
birthday YES
PHARYNGITIS Percentage of children 2-18 years of age who were diagnosed with pharyngitis and dispensed an
antibiotic, and received a group A streptococcus test for the episode YES YES
UPPER RESPIRATORY INFECTION (URI) Percentage of children 3 months-18 years of age who were given a diagnosis of URI and were not
dispensed an antibiotic prescription YES YES
WELL CHILD EXAMS Access to care: Percentage of children and adolescents 12 months-19 years of age who had a visit with
a PCP. The measure reports on four separate percentages: Children 12-24 months who had a visit with
a PCP during the measurement year; Children 25 months-6 years who had a visit with a PCP during the
measure year prior to the measurement year; Adolescents 12-19 years who had a visit with a PCP
during the measurement year or the year prior to the measurement year
YES YES
Well-Child Visits in the First 15 Months of Life- Percentage of children who turned 15 months old during
the measurement year and had from no well-child visits to six well-child visits with a primary care
physician during their first 15 months of life
YES YES YES
>= 6 VISITS
Well-Child visits in the third, fourth, fifth, and sixth years of life- Percentage of children 3-6 years of age
who received one or more well-child visits with a primary care practitioner during the measurement
year
YES YES YES
Adolescent Well-Care Visit – Percentage of enrolled adolescents and your adults 12-21 years of age who
had at least one comprehensive well-care visit with a primary care practitioner or an OB/GYN
practitioner during the measurement year
YES YES
Percentage of children and adolescents 3-17 years of age who had an outpatient visit with a PCP or
OB/GYN during the measurement year and who had evidence of: BMI percentile documentation;
counseling for nutrition; counseling for physical activity
YES YES YES
Quality Measure Crosswalk
ASTHMA Asthma Treatment: percentage of patients with a diagnosis of persistent asthma (either mild, moderate, or severe) who were prescribed accepted pharmacologic therapy
YES YES YES YES
Medications Management: Percentage of people aged 5-64 years of age who were identified as having persistent asthma and were dispensed appropriate asthma controller medications that they remained on for at least 75% of their treatment period
YES (regardless of age)
YES
ATRIAL FIBRILLATION Percentage of time in which patients aged 18 and older with atrial fibrillation who are on chronic warfarin therapy have International Normalized Ratio (INR) test results within the therapeutic range during the measurement period
YES
BACK PAIN Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis
YES YES
BRONCHITIS Percentage of adults 18-64 years of age with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription
YES
CANCER Percentage of patient visits, regardless of patient age, with a diagnosis of cancer currently receiving chemotherapy or radiation therapy in which pain intensity is quantified
YES
BREAST CANCER Percentage of women 50-74 years of age who had at least one mammogram to screen for breast cancer in the past two years
YES YES (40-69)
YES YES 27 MONTHS
YES
Percentage of female patients aged 18 years and older with Stage IC through IIC, ER or PR positive breast cancer who were prescribed tamoxifen or aromatase inhibitor (AI) during the 12-month reporting period
YES
CERVICAL CANCER Percentage of patients 21-64 years of age who received one or more Pap tests to screen for cervical cancer
YES YES YES YES YES
COLORECTAL CANCER Percentage of patients 50-75 years of age who had appropriate screening for colorectal cancer
YES YES YES YES YES
Percentage of patients aged 18-80 years of age with AJCC Stage III colon cancer who are referred for adjuvant chemotherapy, prescribed adjuvant chemotherapy, or have previously received adjuvant chemotherapy within the 12-month reporting period
YES
PROSTATE CANCER
2017 ACO Quality Measures
I 25
Timely Care
Provider Communication
Patient’s Rating of Provider
Access to Specialists
Health Promotion and Education
Shared Decision Making
Health Status/Functional Status
Stewardship of Pt. Resources
CARE COORDINATION & PT SAFETY Fall Risk
Medication Recon Post Discharge
AT RISK POPULATIONS Diabetes - A1c Poor Control
Diabetic Eye Exam
Hypertension Control
Aspirin for IVD
Depression Remission
PREVENTION Breast Cancer Screen
Colon Cancer Screen
Flu Vaccine
Pneumonia Vaccine
BMI
Tobacco Use
Depression Screen
Statin Therapy for CVD
PATIENT EXPERIENCE - ACO-CAHPS Survey
Claims Based
Use of Imaging for Low Back Pain
Unplanned Admissions – DM, HF, CC+
Readmissions – All conditions, SNF 30-day
Admissions – Ambulatory sensitive conditions
Use of Certified EHR (Meaningful Use)
Risk Adjustment
CMS compares the ACO’s spending to a benchmark:
an estimate of what FFS expenditures under Parts A & B would have
been in the absence of the ACO
Benchmark is adjusted
Patient demographics, e.g. age, gender
Level of risk
Risk Adjustment, continued…
Risk adjustment in the MSSP
Adjusts the benchmark based on the expected costs of assigned
beneficiaries
Is prospective – predicts future expenses based on diagnoses
from the prior year
Compares the benchmark to the actual expenditures for
beneficiaries assigned to the ACO in each performance year
The ACO will only receive shared savings if the expenditures are
lower than the benchmark
Risk Level
Diagnosis codes submitted on a claim – the primary way Medicare
assigns risk
Providers must accurately capture and code all relevant diagnoses,
i.e. chronic conditions, every year
Code to the highest ICD-10 specificity, complexity or severity
Diagnoses and treatment codes claimed should be supported by
documentation in the medical record (of course!)
Cost and Utilization for 2016
Risk-adjusted total expenditures
Alcona well below CMS benchmark, but trending up
Greater Michigan Rural ACO just above the benchmark
Inpatient discharges per 1,000
Alcona below the average for ACO and Caravan Health, but trending up
ACO saw an increase in PPPY cost, but decrease in discharges
Cost and Utilization, continued…
ED discharges
Alcona slightly above the ACO and CH averages, but trending down
ACO well above CH average, but trending down
SNF days per 1,000
Alcona below ACO and CH averages, and trending down
ACO cost and utilization well above CH average, but trending down
NACHC Fact Sheet – May 2016
Health Centers and Medicare: Caring for America’s Seniors
Lessons and On-going Challenges
Ensure patients see a physician once a year
Impact on attribution
High mid-level to physician ratio
Keep patients in the community to achieve plurality of care
Expand same-day and after-hours access
Walk-in hours, especially at sites close to hospitals
Reduce ED utilization and preventable admissions
Care Management and Transition of Care Management
Patient education re: appropriate ED use
Educate providers re: ICD-10 coding and risk scoring
QI re: patient survey responses, and quality measure results
Additional Resources
Fiesinger, T. Patient Attribution: Why It Matters More Than Ever. Family Practice Management, Nov/Dec 2016.
www.aafp.org/fpm
No Dollar Left Behind: Maximize Medicare Payments for Your Practice. Michigan Family Physician, Winter 2016-2017
www.mafp.com
CMS Specifications: Medicare Shared Savings Program, Shared Savings and Losses and Assignment Methodology, Applicable beginning Performance Year 2016, Version 4, December 2015
