CureMD & Physician Quality Reporting Programs. Presented by Sara Irshad Consultant,

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Tamsin Woods
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2 CureMD & Physician Quality Reporting Programs Presented by Sara Irshad Consultant,

3 OPENING WORDS Quality is not an accident. It is always the result of an intelligent effort.

4 AGENDA Overview Healthcare Challenges Physician s Perspective Incentive Program Overview Current Programs Incentive Programs in Depth Questions

5 OVERVIEW The US spends 18% of the economy on healthcare Third of the $3,000,000,000,000 spent on health care in the US is wasted Bottom line: The healthcare quality in United States has reached a plateau with no end in sight to reducing healthcare costs

6 YSICIAN S PERSPECTIVE Clinicians are not allowed to practice to the full extent Not enough time to treat patient and document and report Need to free up clinicians to focus on care Bottom line: Physicians need more freedom and rewards to assist in revolutionizing health care in the US

7 CHALLENGES

8 THE PROBLEM The ultimate conflict is Cost vs. Quality

9 PAST SOLUTIONS Fee for Service Capitated Payments Bundled Payments Quality and Cost Treated Quality is the Solution to Cost! Separately Shared Savings Programs

10 NEW SOLUTIONS Focus on Cost as a function of Quality Fee for Service decreasing - increasing Fee for Quality Government & Private payers developing Incentive Programs as a solution

11 INCENTIVE PROGRAMS What is an incentive program?

12 INCENTIVE PROGRAMS An incentive program is a specified path for providers to earn additional revenue while improving quality

13 INCENTIVE PROGRAMS Incentive Programs come in many shapes and sizes Maryland EHR Adoption - $7,500 BCBS Enhanced Patient Healthcare 20% FS Horizon PCMH Program - $8 PMPM

14 TYPES OF PROGRAMS Government Incentive Programs -Meaningful Use, ACO, PQRS Private Payer Incentive Programs -Humana Star Quality, Meridian HEDIS Bonus Program National Quality Initiatives/Recognition Programs -Bridges to Excellence

15 GOVERNMENT INCENTIVES What is Physician Quality Reporting Program?

16 VERNMENT INCENTIVES PQRS is a reporting program that provides an incentive payment to practices that report data on quality measures for covered Physician Fee Schedule (PFS) services furnished to Medicare Part B beneficiaries

17 PQRS IN DEPTH PQRS Measures= 287 Group Measures = 25 Report PQRS measures for at least 50% of Medicare Part B patient encounters Incentive Payment 2014: 0.5% of allowables for Medicare Part B Failure to participate incurs penalty of 2% starting 2016

18 PRIVATE PAYER INCENTIVES Most Incentive Programs are State-Specific and Non- Exclusive Mostly Primary Care Three common forms of reimbursement Lump Sum Fee Schedule Increase Per Member Per Month (PMPM) No expiration date

19 PRIVATE PAYER INCENTIVES Quality Measures Process Measures (Conduct Lipid Panel) Outcome Measures (LDL > 100 mg/dl) Efficiency Measures Generic Prescribing, Low-cost Labs External Certifications MU, Bridges to Excellence (BTE)

20 PROGRAM EXAMPLES Humana Medicare Advantage Program Medical Mutual of Ohio Value Based Program Priority Health PCP Incentive Program BCBS of Texas Diabetes/Cardiac/Asthma Meridian HEDIS Bonus Program BCBS Horizon PCMH Incentive Program BCBS Primary Care Incentive Program Michigan Paramount Diabetes Program

PROGRAM EXAMPLES Humana Medicare Advantage Program Medical Mutual of Ohio Value Based Program Priority Health PCP Incentive Program BCBS of Texas

21 PROGRAM EXAMPLES Humana Medicare Advantage Program Medical Mutual of Ohio Value Based Program Priority Health PCP Incentive Program BCBS of Texas Diabetes/Cardiac/Asthma Meridian HEDIS Bonus Program BCBS Horizon PCMH Incentive Program BCBS Primary Care Incentive Program Michigan Paramount Diabetes Program

22 PROGRAMS IN DEPTH Humana Medicare Advantage Program Bridges to Excellence Empire BCBS Quality-in-Sights BCBS Horizon PCMH Incentive Program

HUMANA Need to achieve targeted goals for 6 out of the 9 quality measures Patients eligible for this program: MA Preferred Provider Organization (PPO) MA

23 HUMANA Need to achieve targeted goals for 6 out of the 9 quality measures Patients eligible for this program: MA Preferred Provider Organization (PPO) MA Health Maintenance Organization (HMO) MA Private Fee-for-Service (PFFS) Payment equal to 10 percent of total primary care allowed Humana Claims US wide for all PCPs

HUMANA MEASURES All HEDIS measures: Breast Cancer Screening Glaucoma Screening Colorectal Cancer Screening Cholesterol Management Comprehensive

24 HUMANA MEASURES All HEDIS measures: Breast Cancer Screening Glaucoma Screening Colorectal Cancer Screening Cholesterol Management Comprehensive Diabetes Care Osteoporosis Management in Women Diabetes Treatment Measure Body Mass Index Disease Modifying Anti-Rheumatic Drug Therapy For Arthritis

25 BTE BACKGROUND BRIDGES TO EXCELLENCE Created by Healthcare Incentives Improvement Institute, Inc. (HCI3) BTE is not an incentive program, it is a recognition process. A BTE certification can either be used as part of an incentive program or for direct payments from insurance companies

26 NATIONAL QUALITY INITIATIVE BRIDGES TO EXCELLENCE Cardiac Care (5 Quality Measures) Diabetes Care (8 Quality Measures) Asthma Care (7 Quality Measures)

27 EMPIRE QUALITY IN SIGHTS Set of 6 Care Categories 6% fee schedule increase across the board Preferred recognition on BCBS website

28 HORIZON INCENTIVE PROGRAM Focuses on Preventive measures ~ 8 Incentive Reward Type is PMPM Maximum ~ $8 PMPM (based on performance) Preferred recognition on Horizon website

29 CUREMD CONSULTING Determine Eligible Incentive Programs Outline the most efficient ways to maximize incentive payments from all programs Come speak to us at the Meaningful Use Table for further questions!

30 SUMMARY Wide range of incentives available across the country Growing trend, new opportunities available frequently Opportunities geared towards PCPs Industry focusing on improving quality and keeping cost low CureMD will be providing services to clients to make additional revenue per year

31 Thank You

32 Questions Company Name - Presentation 32

Enhanced PCMH Payment Models and Mechanisms

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