Transitions of Care: Deep Dive. Objectives. Overview. Kelli Graziano, MD

Transcription

1 Transitions of Care: Deep Dive Kelli Graziano, MD Objectives Measure Overview Changes to TRC Review of challenges and strategies by indicator: Notification of Inpatient Admission Receipt of Discharge Information Patient Engagement Medication Reconciliation Post-Discharge Overall challenging Overview Intent communication and continuity of care 4 Indicators 1

2 Hybrid hits must come from same chart Overview PCP or managing provider Change to validation process Measure Changes Notification of Inpatient Admission Receipt of Discharge Communication 2

3 Notification of Inpatient Admission May happen in PY Communication must be about inpatient stay Tests/treatments anytime during IP stay Receipt of Discharge Information Not limited to examples Instructions for pt care must be to PCP/ongoing care provider No allergies required Identifying discharge date Strategies and Challenges 3

4 Notification of Inpatient Admission Time sensitive Must come from provider Must be clear the provider knew the patient was admitted ED referral not enough Notification of Inpatient Admission Numerator Options: Fax Automated admission/discharge/transfer Phone note Preadmission exam Shared EMR PCP admitted or treated Non-Compliant Example 4

5 Non-Compliant Example Compliant Example Potential Source: Provider Inbox 5

6 Receipt of Discharge Information Must occur in the correct timeframe Must include all required information Allergies! Must be in the record, but not limited to the DC summary Receipt of Discharge Information Start with discharge summary Evaluate the record for additional requirements Become familiar with the EMR 6

7 Any outpatient visit Patient Engagement Can include telehealth/telephone visits Cannot include date of discharge Look for MRP visit!! Medication Reconciliation Remember current medication list is required Provider type requirement Focus on compliance details Questions? Thank you! 7

8 Hybrid Pursuit Strategies Amy Hammer Plan It Out AGENDA Prepare Your Data Execute A Strong Process REVIEW HISTORY Review Past Performance Chase Completion Report Review chase counts per member per measure Successful chase completion definition Late completion of chart pursuit Task Execution Provider Contact Chart abstraction Data Entry 8

9 HYBRID PROJECT TIMELINE Keep Specific to Hybrid Process Identify start date and end date Identify Key Milestones Recognize Impact of Delays Feb 11 May 3 = 11 weeks March 4 May 3 = 8 weeks Collaborate with Vendors MEASURE KNOWLEDGE Identify Eligible Measures Understand Measure Changes Understand Reporting Requirements State Specific Medicare Marketplace NCQA VENDOR COMMUNICATION Debrief about Experience Identify Successes Acknowledge Challenges Make Recommendations and Requests 9

10 Evaluate Past Performance Orphans or Small Yield? PCP Dependent Chases Logic for No Assigned PCPs MRP/TRC/CBP/CDC FQHC Volume and Prioritization CHASE LOGIC PHYSICIAN INFORMATION Vendor Provider Data File Provider Contact Information Source of Data Accurate Phone & Fax Contact Person EMR? Normalize Data File and QA MRSS and Over-Samples Minimum Record Sample Size (MRSS) 411 or 548 CDC or Reduced Oversample >20% must be approved If exhausted must contact NCQA Initiation of Oversample- How & When 10

11 Measure Progress & Trouble Shoot Set Milestones Require Weekly Reports & Discuss Results Number of providers scheduled Calculate records received vs. records expected Monitor Rates Review IRR Reports Communication is Key Schedule Standing Meetings Be engaged and Keep Fact Based Write Concise s Agree on Escalation Process Questions 11

12 Troublesome Administrative Measures Michael Williams Measures to Review BCR, UOP, MPT, Risk Adjusted Utilization For each measure: Measure Summary Common Issues Thresholds & Expectations Strategies/QA Measure Summary: BCR Board Certification 3-Year Cycle Roadmap Section 3 Table 3.4 Attachment 3.2 (flowchart) Attachment 3.5 (source code) 12

13 BCR: Common Issues Programming logic Mapping errors Incomplete/bad data Multiple source systems Outdated/missing board certification dates or specialties Measure Summary: UOP Use of Opioids From Multiple Providers The proportion of members 18 years and older, receiving prescription opioids for 15 days during the measurement year who received opioids from multiple providers 3 Rates: Multiple Prescribers Multiple Pharmacies Multiple Prescribers and Multiple Pharmacies UOP: Common Issues Pharmacy Benefit Flags Days Supply NPI Missing = Overstated Rates Default Codes = Understated Rates 13

14 Let s Review! *Rates as a percentage. Rates were per 1,000 in HEDIS 2018 Prescriber Rate > Pharmacy Rate > Combined Rate UOP: Strategies Validate all pharmacy files are loaded Confirm NPI mappings Share/compare rates with internal pharmacy staff Measure Summary: MPT Mental Health Utilization The number and percentage of members receiving the following mental health services during the measurement year: Inpatient Intensive outpatient or partial hospitalization Outpatient ED Telehealth Any service 14

15 Counting Services: For Each Member HEDIS 2018 Count only first encounter Report age based on DOS or discharge Report only once in Any Services category HEDIS 2019 Count only first encounter in each category Report age based on DOS or discharge Report only once in Any Services category Digging into the Details Member #1 Visit Date Type of Visit Reporting Category Jan 5, 2018 Outpatient Outpatient Jan 5, 2018 ED ED Mar 3, 2018 Inpatient Inpatient Aug 10, 2018 Outpatient Not counted Aug 10, 2018 Telehealth Telehealth Aug 29, 2018 Telehealth Not counted Dec 8, 2018 ED Not counted Digging into the Details Member #2 Visit Date Type of Visit Reporting Category Jan 5, 2018 ED (resulted in IP Stay) Not counted Jan 5, 2018 Inpatient Inpatient Mar 3, 2018 Inpatient Not counted Aug 10, 2018 Outpatient Outpatient Aug 10, 2018 Telehealth Telehealth Aug 29, 2018 Telehealth Not counted Dec 8, 2018 ED ED 15

16 MPT Benchmarking Expectations Slight increase in all categories Telehealth near 0% IOP, ED, IP ~0-2% Any Service consistent with HEDIS 2018 Rate doubled. Please validate Risk Adjusted Utilization Measures PCR HFS AHU EDU HPC 16

17 Risk Adjusted Utilization Measures PCR Acute IP readmissions vs. expected HFS Unplanned acute hospitalizations after SNF stay AHU Acute & observation discharges vs. expected For Nonoutliers EDU ED visits vs. expected HPC Acute & observation discharges vs. expected for certain conditions Risk Adjusted Utilization: Common Issues Complex measures Paid vs. expected to be paid vs. denied Definitions Calculations Tables Full rates only after data refresh PLD variances Significant rate change. Please research Benchmark & Research Early Understand complexities If/how data is collapsed in software GG 44 Always review source or warehouse data Review at member level Compare to counts from software Paid/ Denied Exclusion criteria Other sources? 17

18 Final Thoughts Map Early Review Rates Prior to Submitting Communicate with Audit Team How To QA Your Rates Alaina Warfield Who QA s their rates prior to sending them over for initial benchmarking? Who trends their rates? Who utilizes the Outlier Toolbox to research rate concerns? Who does a visual review of the IDSS prior to final rate submission? Quick Poll 18

19 Agenda What to look for after you have run preliminary rates How to investigate concerns prior to sending preliminary rates for benchmarking What to look for? How do you investigate? What should you send? Agenda What does your auditor look at? How should you respond? What s different for Final IDSS submission? Looking at Your Rates Reasonable Changes Trends Benefits Utilization Practitioner Type Vendor Data Prospective Runs 19

20 Looking at Your Rates Understand the Technical Specifications Research must be meaningful You can QA new measures Appendix 2 Technical Considerations for New Measures Looking at Your Rates Helpful items to send with your initial rates Enrollment breakdown (ENP reports) Major changes to overall population Addition of an age/sex group New members sicker Internal process changes SDS Change in vendors Significant mapping changes Plan Vendor Example 1 What s Wrong? Prior Var Submitt Year Yr3 Var from Percentage CY from Measure Name ed Data Rate Data Prior Year Diff EP Mean Mean Low High Comments th to 90th percentile, > 5% SPC Adherence Rate 72.7% 62.5% 61.9% 10.2% 16% % % % change from Prior Yr, th to 90th percentile, > 5% SPD Adherence Rate 66% 56.7% 55.8% 9.2% 16% % % % change from Prior Yr, th to 75th percentile, > 5% AMM Acute Rate 55.3% 49.6% 51% 5.7% 11% % % % change from Prior Yr, th to 90th percentile, > 5% AMM Continuation Rate42.5% 34.1% 35.6% 8.4% 25% % % % change from Prior Yr, ABX Average Days > 90th percentile by 1.7, > 10% Supply % change from Prior Yr, 20

21 Example 2 What s Wrong? Measure Name Submitted Data CY EP Mean Var from Mean Low High Comments ABA Rate 34.60% % % 94.90% 10th to 25th percentile, ABA EP from Bnch, BCS Rate 7.50% % % 83.20% BCS EP < 10th Percentile by -52.2%, Expect slight increase due to spec change -44 from Bnch, Now Excludes ISNP and LTI COL Rate 11.70% % % 81.70% < 10th Percentile by -37.8%, COL EP from Bnch, Now Excludes ISNP and LTI SPR Rate 0% % % 49.30% < 10th Percentile by -22.2%, SPR EP from Bnch, Example 3 What s Wrong? Measure Name Submitted Data Prior Year Rate Var Yr3 Var from Percentage from Data Prior Year Diff CY EP Mean Mean Low High Comments < 10th Percentile by -4.4%, > 5% CAP Age Months Rate 86.8% 95.5% 96.2% -8.7% -9% % % 98.8% change from Prior Yr, < 10th Percentile by -7.8%, > 5% CAP Age 25-6 Years Rate 73.5% 85.3% 86.3% -11.8% -14% % % 93.8% change from Prior Yr, 50th to 75th percentile, > 5% change PPC Prenatal Admin Rate 69.3% 83% 82% -13.7% -17% 058.6% % 79.2% from Prior Yr, 10th to 25th percentile, > 5% change W15 Six+ Visits Admin Rate 47% 52.8% 55.2% -5.8% -11% % % 70.3% from Prior Yr, Eligible Populations Matter Too Internal Membership Reports Warehouse Checks Overall Enrollment Benefit Flags Membership Events Adds/Terms Linking Spans 21

22 Example 4 What s Wrong? Example 4 What s Wrong Cont.? What Does Your Auditor Look At? Changes in Rate and Eligible Populations from PY Effectiveness of Care Measures +/- 5% Utilization Measures +/- 10% Spec Changes New Measures Trends across measures 22

23 What Does Your Auditor Look At? Var Prior from Var Submitted Year Yr3 Prior Percentage from Measure Name Data Rate Data Year Diff CY EP Mean Mean Low High Comments % 47.7% 75th to 90th percentile, > 5% change from Prior Yr, ABA Admin Rate 44.4% 15.9% 8.6% 28.5% 179% % ABA EP % Within Range, th to 90th percentile, > 5% WCC BMI 38.4% 20.3% % 18% 89% % % 51.2% change from Prior Yr, Admin Rate 11.4 % WCC Nutr Admin Rate 19.8% 17.3% 2.6% 15% % % 33% 75th to 90th percentile, 7.8% 2.9% 745% % % 8.7% 50th to 75th percentile, WCC Phys Admin Rate 3.3% 0.4% WCC EP % Within Range, Rate Research Tool Troubleshooting High / low rates High / Low populations Plan Action Validation Outlier Toolbox Outlier Toolbox Process Steps Categories and Measure Domains Ideas for researching trends 23

24 Example 1 Rx Data Measure Identifier SPC Measure Name Statin Therapy for Patients With Cardiovascular Disease Rate Benchmarking High/ Large Increase Verify counting members, not dispensing events Confirm members only counting once Confirm appropriate logic for days covered by statin medication in treatment period Confirm days supply does not extend beyond the MY Determine treatment period calculation is number of days from the IPSD (inclusive) to the end of MY *Pulled from HEDIS 2018 Outlier Toolbox Example 2 Missing Claim Measure Identifier Measure Name BCS Breast Cancer Screening EP Benchmarking Low/ Rate Benchmarking Low/ Large Decrease Large Decrease Confirm age range women years Confirm counting services in appropriate of age) time frame (on or between Oct 1 two years Confirm all enrollment segments linked prior to MY and Dec 31 of MY correct, applies to in-house and plans that Confirm using CPT or DX or rev code (not 'normalize' enrollment data prior to loading and logic) in software Confirm no specialty logic is applied Confirm optional exclusion criteria so that Confirm exclusions lookback as far back two unilateral mastectomies must have in history as possible service dates 14 or more days apart. Added digital breast tomosynthesis as a Confirm codes on the same claim for method for meeting numerator criteria. Unilateral mastectomy (NEW MY2017) with a bilateral modifier for optional exclusions *Pulled from HEDIS 2018 Outlier Toolbox Example 3 Provider Mapping Measure Identifier CAP Measure Name Children and Adolescents Access to Primary Care Practitioners Rate Benchmarking Low/Large Decrease Confirm compliant visits not limited to assigned PCP Confirm using 2 year lookback for older age groups Examine specialty mapping of urgent / convenience care centers and clinics Confirm PCPs correctly identified Confirm use of ambulatory visit CPT & UB Rev codes *Pulled from HEDIS 2018 Outlier Toolbox 24

25 Source System Operational Reports Membership Trends Utilization Provider Information Warehouse Reports Source System Source System Internal Utilization Trends Warehouse Checks Payment Status Homegrown Codes Lag Confirm data loaded Plan Changes = Data Changes HEDIS Reporting Engine HEDIS Software Vendor Layouts and Reports Mapping data correctly View load reports HEDIS Engine and Investigation My HEDIS Engine is certified Please validate 10 numerator positives/negatives 25

26 Final IDSS Tier Warnings Tier 1 Validations Basic Data Checks LBP: Reporting Method must be A, NR, or NQ Measure Specific: All Measures Tier 2 Validations Subset to Total Comparisons GUID Checks Tier 3 Validations Measure Specific: Utilization & Risk Adjusted Rates Established Thresholds Final IDSS Visual Review Missing Data BCR Excluded Required for MCR TLM (Total Membership) RDM cannot be 100% unknown Utilization Measures for Medicaid: Category Reporting Final IDSS Visual Review Erroneous Data Dental, Mental Health, Pharmacy Not Offered / Carved Out NB for Impacted Measures Incorrect Measure Set Missing Required Measures Appendix 1 Doesn t Match 26

27 Final IDSS Submission Communicate to Audit Team Tier Warnings have been reviewed Why or why aren t they an issue? Submit supporting documentation Export/screenshot from HEDIS software engine Tier 2 Warning Review Measure Type ID Message ahu Warning ahu v : Surgery F O/E Ratio (Observed Discharges/Expected Discharges) Value should be greater than or equal to 0.2. hpc Warning hpc v : Acute ACSC M O/E Ratio (Observed Discharges/Expected Discharges) Value should be greater than or equal to 0.2. hpc Warning hpc v : Acute ACSC M O/E Ratio (Observed Discharges/Expected Discharges) Value should be greater than or equal to 0.2. hpc Warning hpc v : Acute ACSC 85+ M O/E Ratio (Observed Discharges/Expected Discharges) Value should be greater than or equal to 0.2. vendormanualdataentry Warning The health plan edited the following vendor certified measure(s): BCR, IET, TLM, MRP, LDM, TRC, CBP Please review data for all measures, especially the Medicare Star Measures (ABA, ART, BCS, CBP, CDC, COA, COL, MRP, OMW, PCR). No medicarestarmeasurecheck Warning resubmissions are accepted after the HEDIS deadline. Questions? 27