Transformation Management & Data Metrics for Preparation and Participation: The New Age of Healthcare Reimbursement

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Stephany Tucker
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1 Transformation Management & Data Metrics for Preparation and Participation: The New Age of Healthcare Reimbursement Tennessee Primary Care Association October 5, 2017 Curt Degenfelder Today s Agenda Getting Ready For Pay For Performance (P4P) - Patients - Data - Contracts Alternative Payment Methodology - Why? - APM Basic Elements 1 1

2 Current Status of Tennessee FQHCs Health centers of various size and organizational infrastructure No Medicaid expansion; thus the impact of Medicaid P4P may be limited Some commercial business, but not enough to change behavior Difficulty recruiting and retaining providers Assigned but not seen managed care patients not a large issue Current Tenncare PCMH program with Transformation Payment, risk-adjusted Activity Payment, and Outcomes Payment 2 Getting Ready for Pay For Performance 3 2

3 The Triple Aim Total Cost of Care Improving Health of Populations Improving Patient Experience 4 FQHC Revenue Today & In The Future TODAY PPS/APM BASED ON VISITS MINIMAL SERVICE PAYMENT TRIPLE AIM PAYMENT APM BASED ON PATIENTS PCMH/CASE MANAGEMENT ADD ON SHARED SAVINGS QUALITY BONUS PATIENT ENGAGEMENT BONUS FUTURE 5 3

4 Rate Setting Data - Sources - Data anomalies Making rate model consistent with APM design model Rate specificity 6 Where Is The Marketplace Going HHS Goals for Medicare 30% of fee-for-service payments convert to payments for quality or value through alternative payment models such as ACOs or bundled payments by the end of 2016; 50% by the end of % of Medicare payments subject quality or value measures by 2016, and 90% by For 2017, physicians can receive a bonus of 4%, or a penalty of 4%, for quality scores. The percentages will increase over time. 7 4

5 The Balancing Act Changes Required for the Future PPS primary payment system P4P payments minimal Limited buy in 8 Pay for Performance Pay For Performance Patients 9 5

6 Key Elements of APM/Pay for Performance Attribution The key question, for APM, pay-for-performance, population health, etc. is Who Are Our Patients? Current UDS definition (patients seen in a calendar year) is not consistent any of these systems - Patients who didn t need to be seen in a year - Patients who visited multiple PCPs - Assigned but not seen (this figure is 70% at some CHC sites) Many health centers experience large patient turnover (30% +) per year, that is 30% of their patients are new even when they don t grow 10 Key Elements of APM/Pay for Performance Attribution Managed care organizations often have patient lists, especially in capitated systems. These lists may partly be based on service experience, but are also based on patient choice (which may not be consistent with care seeking patterns) or autoassignment In managed care, every patient is assigned to a primary care provider. There is a provider responsible for the quality scores, engagement, total cost of care, etc. for every patient, including patients not seen by a provider. Difficult to get patients off your assigned list 11 6

7 Patient Attribution Who Are Your Patients? The payor s assignment list is used for all calculations what were the costs of patients, who used the ED, what are the quality measures It takes substantial infrastructure to get it right, i.e. for the patient list to match the population that the health center feels they can manage: Some health centers have indicated that these patients constitute up to half of their managed care members Little financial impact in fee-for-service, and are not shown on UDS quality measures These patients will be included in the denominator for HEDIS quality measures Need to obtain correct demographic data for these patients. Work with MCO to determine if they are actually seen by another PCP. If health center can get historical claims information, perhaps prioritize patients: 1. ED and inpatient follow-up, 2. patients who are not well and need to seen, 3. patients needing a health maintenance service, 4. healthy patients 12 Patient Attribution Who Are Your Patients? Infrastructure (cont): - List of seen but not assigned. What is the process for reassigning them to us, and can it be done outside a patient visit? - List management: does the MCO send us the list electronically? Are changes highlighted? List management may require an individual spending full time reconciling the list at the beginning of each month - Should also be tied into the CHC s provider paneling both policies and in the EHR 13 7

8 Data Driven Metrics - Quality 14 Data in Pay For Performance Data in pay for performance is from the payor s system. Thus the data is not self-reported, even if health center reports (bills) are a source of some of the data Payors may also have supplemental data reporting means; these systems might be different for each payor. There might also be a greater lag in entry into the database In pay for performance, the data may be as important as the performance; i.e. bad data can misrepresent good performance 15 8

9 Potential Points of Data Failure Provider not recording the service Provider not recording the service with code (chart only) Provider not using code required by HEDIS or other analytics system Provider not recording code in PM/EHR FQHC not billing/recording code on claims (for example PAP immunizations) Reported code not making it into MCO s system 16 What is HEDIS? The Health Effectiveness Data and Information Set (HEDIS) is a measurement system developed by the National Committee for Quality Assurance (NCQA) used by health plans nationwide HEDIS focuses on process measures for an assigned patient population Generally, the source of data for Medicaid HEDIS is the MCO claims system. Thus MCO quality payments are likely to be based on HEDIS (not UDS) 17 9

10 HEDIS Medicaid Quality Measures Children immunization Adolescent immunization HPV for female adolescents Lead screening in children Breast cancer screening Cervical cancer screening Chlamydia screening Pharyngitis testing for children URI treatment for children Antibiotic avoidance adlt bronchitis Spirometry testing for COPD Pharmacotherapy mgmt of COPD Initiation & engagement for AOD Timeliness of prenatal & postpartum Frequency of adolescent care ED visits Follow up on ADHD meds Use of asthma meds Asthma med mgt Asthma medication ratio Cholesterol mgmt for CV conditions Beta blocker after heart attack Comprehensive diabetes care DMARD therapy Imaging studies for low back pain Antidepressant med mgmt MH hospitalization f/u Monitoring for persistent meds Adult access to preventive/ambulatory Child access to PCP Frequency of prenatal care Frequency of well child visits Annual dental visits Developmental screening 18 Methodology Numerator services from claims database. HEDIS criteria looks for specific CPT and ICD codes Denominator attributed patients (see explanation next page) meeting criteria for each measure Measures are not use rates, i.e. services per patient, but rather a measure of % of patients who received indicated service. Calculation is called administrative measure MCO may calculate hybrid measures, using chart reviews for certain measures. Hybrid measure performance is usually better than the administrative measure. However sampling methodology allows for limited chart review Not outcomes measures such as diabetic or hypertension control 19 10

11 UDS vs. HEDIS Sample Attributed Not Seen Timely Entry Into Prenatal Care Childhood Immunzation* UDS HEDIS UDS HEDIS Health Center A 11% 74% 48% 68% 1% Health Center B 11% 85% 66% 93% 0% Health Center C 12% 86% 60% 84% 0% Health Center D 9% 56% 53% 97% 1% Statewide Administrative 59% 4.7% Statewide Hybrid 64.7% *Combination of Dtap, IPV, MMR, HiB, HepB, VZV, PCV 20 UDS vs. HEDIS Sample Cervical Cancer Screening Asthma Pharm Therapy UDS HEDIS UDS HEDIS Health Center A 61% 47% 79% 84% Health Center B 43% 72% 90% 84% Health Center C 60% 66% 75% 86% Health Center D 70% 69% 91% 92% Statewide Administrative 66% 87% 21 11

12 STAR Measures Plan Based Staying healthy: screening tests and vaccines Managing chronic conditions Member experience with health plan Member complaints and changes in healthplan performance Health plan customer service 22 Data Driven Metrics - Total Cost of Care 23 12

13 What Drives Total Cost of Care? SumOfPaid_Amount Cumulative Cost % of Total Count of Pts $ 1,536,800 $ 1,536, % 1 $ 585,072 $ 2,121, % 2 $ 564,305 $ 2,686, % 3 $ 502,359 $ 3,188, % 4 $ 480,759 $ 3,669, % 5 $ 461,517 $ 4,130, % 6 $ 441,076 $ 4,571, % 7 24 What Drives Total Cost of Care? SumOfPaid_Amount Cumulative Cost % of Total Count of Pts $ 3 $ 893,869, % 115,291 $ 2 $ 893,869, % 115,292 $ 2 $ 893,869, % 115,293 $ 2 $ 893,869, % 115,294 $ 1 $ 893,869, % 115,295 $ 1 $ 893,869, % 115,296 $ 1 $ 893,869, % 115,

14 What Drives Total Cost of Care? Top (Costs): 10% 20% 30% $ 89,386,928 $ 178,773,855 $ 268,160,783 # of Pts: 422 1,234 2,570 % of Total Patients: 0.37% 1.07% 2.23% Range (High): $ 1,536,800 $ 151,691 $ 84,269 Range (Low): $ 151,777 $ 84,342 $ 54, What Drives Total Cost of Care? Top (Costly Pts): 10% 20% Everyone Else # of Pts: 11,539 23,078 92,311 % of Total Costs: 59.3% 75.1% 24.9% 27 14

15 A CHC Provider s Take on High Cost Patients There were 101 high cost patients. Of these, 25 are "not currently attributed" to this CHC. Of the 76 attributed patients, 14 were children, 62 adults. All of the 14 children were high need/intrinsically high cost 2 with hemophilia (one with physical and sexual abuse), 5 complicated preemies, 2 cancers (malignancies), 2 severe autism/developmental delay, 1 cystic fibrosis with liver transplant, 1 severe ulcerative colitis with colectomy. The only one with asthma also has psychosis. We can identify the 62 adults by the clusters of conditions which are the highest cost: HIV, Hep C, Substance Abuse Cancer Advanced Age with multiple conditions Severe mental illness plus or minus other health conditions Neurodegenerative disorders Dialysis, transplants I find it hard to imagine how to impact their costs. There are about 2 3 adults who have problem lists and medication lists that are not huge, and for whom it is not totally evident why their costs are high. Each of these has home care services, which may be a major contributor to their cost. 28 Risk Adjustment of Total Cost of Care Predicted Risk Score Predicted Total Cost PMPY Actual Total Cost PMPY Actual % of Predicted Actual Total Cost PMPY Health Center A 1.52 $ 7,894 $ 7,700 98% $ 6,860 Health Center B 1.21 $ 6,307 $ 5,419 86% $ 5,026 Health Center C 1.59 $ 8,276 $ 8,233 99% $ 7,420 Health Center D 1.03 $ 5,370 $ 5,318 99% $ 4,775 Health Center E 1.54 $ 8,007 $ 7,417 93% $ 6,781 Health Center F 1.08 $ 5,605 $ 5, % $ 5,167 Health Center G 1.21 $ 6,267 $ 5,654 90% $ 5,052 Health Center H 1.37 $ 7,101 $ 6,810 96% $ 6,393 Health Center I 1.30 $ 6,756 $ 6,299 93% $ 5,496 Health Center J 0.98 $ 5,086 $ 5, % $ 5,160 Health Center K 1.78 $ 9,245 $ 8,784 95% $ 8,275 Health Center L 1.25 $ 6,471 $ 6,004 93% $ 5,121 Health Center M 1.94 $ 10,099 $ 9,583 95% $ 8,683 Health Center N 0.99 $ 5,137 $ 4,758 93% $ 4,593 FQHC Average $ 6,663 Statewide Average 1.00 $ 5,

16 Key Elements of APM/Pay for Performance Payment For Touches/Quality/Social Determinants CHCs may not be ready for this Taxonomy needs to be fully formed and tested for touches and social determinants CHCs need to capture this information in their EHR Relativity needs to be developed for touches and social determinants if they are going to be worked into a payment system If quality is a basis of payment, need to understand and resolve HEDIS vs. UDS calculation methodologies 30 P4P Contract/Operational Issues 31 16

17 Identifying Timing of Pay For Performance Revenue Managed care/ipa usually after a quarter/fiscal year for the managed care organization. Often based on total managed care organization profit, total cost care for health center patients, and/or quality Process based rewards: - Engagement for new patients - Follow up on inpatient - Other gaps in care incentives - Appointment availability standards 32 Thinking About Pay For Performance (P4P) Pay = revenue Current P4P revenue is typically a small portion of a health center s revenue. How much does P4P need to be to move the needle? Current payments from managed care organizations and IPAs seem to be arbitrary and capricious 33 17

18 Earning P4P Changing operations to earn performance based rewards Infrastructure - Personnel for quality and data management - EHR - IT infrastructure 34 Infrastructure - The Ongoing Economics of the EHR New licenses/depreciation of license cost Maintenance fees IT infrastructure Provider productivity hit Staff productivity/work Meaningful use $ Using integrated EHR/PM to make practice more efficient PPS change in scope 35 18

19 Contract Structure - Direct Payor Services P4P Provider 36 Contract Structure - Group Payor Clinical Services P4P IPA Provider Provider Provider 37 19

20 Considerations In Group Contracting Is the IPA, or other contract entity, a shared risk pool, or a pass through? How is risk amongst different providers grouped? What is the management entity? 38 Contract Structure Management Infrastructure Payor Clinical Services P4P IPA Admin Services MSO Provider Provider Provider 39 20

21 Contract Structure Management Infrastructure Payor Clinical Services P4P Admin Services IPA Admin Services Provider Provider Provider 40 Sample Managed Care Pay for Performance Measures Targets When Total Cost Not Used Operational Discharges per 1,000 members per year (vs. average) ER visits per 1,000 members per year (vs. average) Timely submission of capitated encounters (vs. MCO standard) HEDIS measures (vs. MCO target) 41 21

22 Sample Payment Report Incentive Category MCO Standard CHC Score CHC Against Standard P4P Earned Discharges per 1,000* (4) $ ER Usage Per 1, $ 10,000 Encounter Reporting 81% 87% 6% $ 10,000 HEDIS Measures Breast cancer screening 21% 28% 7% $ 4,000 Well visits 80% 89% 9% $ 4,000 Cervical cancer screening 10% 14% 4% $ 4,000 Total $ 32,000 * Excludes maternity 42 Financial/Operational/IT Concerns on Pay-For-Performance P4P revenue is insufficient to generate a positive return in a cost-benefit analysis P4P payment pool may be based on factors other than CHC performance (such as healthplan profitability), thus payment is not guaranteed P4P measures may not be tied to the primary driver of revenue (i.e. maximizing billable visits) and in fact may be at odds (longer preventive visits vs. easy visits) Often requires monitoring HEDIS in addition to UDS quality measure (without ability to vet accuracy of data in healthplan s claim system) 43 22

23 Financial/Operational/IT Concerns on Pay-For-Performance It appears to be difficult to change the outcomes that impact P4P measures - Much of the data is external with a managed care plan - That data is not received on timely basis that allows for actionable change - That data does not reside in the CHC s primary clinical data system (the EHR) - Patient assignment often includes patients who have never been to the health center - Staff (both the health center s and the healthplan s) don t understand the P4P program Therefore, in preparation for P4P, and the first year of the program, the emphasis should be on getting the data right 44 Strategic Considerations For Tennessee CHCs What is the total amount of pay for performance revenue that the health center can earn in the Year 2020? How does payor mix impact pay for performance investment? Will Medicaid payments shift, and will this impact the participation of other providers? How causal/guaranteed are investments in quality? Is investment infrastructure best done at the individual health center level, or at a network level? 45 23

24 Strategic Considerations For TN CHCs What is the future of the ACO model in Tennessee? Do health centers need to control their own ACO? What does a heath center network have to sell? Should investment in pay for performance be proactive or reactive? How do changes at the Federal level impact all of this? 46 Alternative Payment Methodology 47 24

25 Payment Reform Why? 48 The Unified Theory of the Patient Centered Medical Home Primary care providers are difficult to recruit PCPs are difficult to retain PCPs have trouble reaching visit productivity targets PCPs don t like doing non provider work PCPs want more variety in their work day PCPs don t like constant interruptions The providers are saying... Payors & market are saying... PRACTICE TRANSFORMATION Payors want to pay on Triple Aim Payors want population health for assigned patients FQHC payment reform envisions payments per patient 49 25

26 Investment in Practice Transformation Positive Cash Flow through Productivity & Payor Mix Investments in Infrastructure to Improve Quality & Efficiency ( ) Working Capital to Fund Expansion Increased Coverage of Base Administrative Costs More Sites, More Patients, More Revenue ( ) 50 Regulators Perspective Medicaid Directors seeking to change reimbursement systems CMS and Medicaid Directors want: Alignment with value-based pay, and/or Movement away from FFS Pressure continues to increase FQHCs continue to grow in state budgetary impact NACHC is suggesting that APMs may be a way to minimize legislators concerns about PPS 51 26

27 The Billable Visit PPS as a volume driven and cost-based system does not appear to be aligned with current policy goals Providers do not like being held accountable for productivity based on billable visits. In a competitive recruitment environment, this focus may be detrimental to health centers Differential PPS rates amongst health centers may not reflect additional services, higher quality, or better outcomes Volume based systems based on a narrow definition of services are not consistent with PCMH 52 Using the Team to Change Work Task List Proposed With Second MA DONE BY PROVIDER MA1 (with provider) Front Desk Clerk TASKS DONE BY RN 2nd MA Allergy & real medicine reconciliation pharmacy choice x x Answer flashing phone lines x X Answer phones x X X Assist patients w. paperwork x X Assist procedures x X Assist w/ making appointments x X Bed bug screening X BP checked not associated with med change x BP Monitoring X Call patients x x X X 53 27

Financial Implications of PCMH Under PPS Pre- PCMH Post- PCMH Encounters

4 $ 420 4 $ 420 Physician 99203 1 $ 105 Nurse 1 Care Coordinator 2 Total

Physician $ 300 $ 300 Nurse/MA $ 141 $ 141 Care Coordinator $ 47 Overhead

Provider Recruitment and Retention in 2017 1973 1972 Chevy Impala 1982

28 Financial Implications of PCMH Under PPS Pre- PCMH Post- PCMH Encounters Revenue Encounters Revenue Physician $ $ - Physician $ $ 420 Physician $ 105 Nurse 1 Care Coordinator 2 Total 6 $ $ 525 Grant Revenue $ 85 $ 85 Total Revenue $ 715 $ 610 Physician $ 300 $ 300 Nurse/MA $ 141 $ 141 Care Coordinator $ 47 Overhead $ 270 $ 270 Total Cost $ 711 $ 758 Net Income $ 4 $ (148) 54 Thoughts on Provider Recruitment and Retention in Chevy Impala 1982 Ford Escort 1974 In 2017, what is expensive and in short supply in the future? 55 28

29 PCMH Cost/Benefit Analysis Physician - $170, ,000 RN - $65,000 Medical assistant 1 - $12/hr Medical assistant 2 - $14/hr Medical assistant 3 - $20/hr Care coordinator - $20/hr Front desk - $13/hr Scribe 56 How Patient Engagement Links to Value Based Payment Based on a defined/assigned population Moves away from encounter-based payment and patient definition model Moves towards Triple Aim measures Success in Triple Aim requires active patient engagement In other words, PCMH, pay for performance, and APM all work well in a population health context 57 29

30 Cost of Losing A Provider Recruitment Cost $ 10,000 Length of Vacancy 3.5 Months Annual Productivity 3,600 Visits Lost Visits 1,050 Net Revenue/visit $ Lost Revenue $ 126,000 Provider Comp $ 54,900 $180K, 22% fringe Marginal Cost Coverage $ 71,100 Months to Full Rampup 6 Lost Visit % 10% Lost Visits 180 Lost Revenue $ 21,600 Total Financial Impact $ 102, APM Basic Elements 59 30

31 Alternative Payment Methodology (APM) Under Prospective Payment System (PPS) PPS allows for APMs The APM must result in an amount at least equal to what the FQHC would have received under PPS APM must be agreed upon individually by each health center 60 Key Elements of an APM Budget Neutrality State pays the same amount in the APM as they would under PPS. APM could also contain an add-on for PCMH payment May be perceived as a win-win to pay the same amount in a better way In Oregon APM, budget neutrality was defined on a per-patient, not a per-visit basis Not a requirement for an APM; in fact, the State could pay more 61 31

32 Key Elements of an APM Reconciliation Necessary to determine if at least what FQHC would have gotten under PPS threshold is met May also determine budget neutrality In Oregon, APM health centers fill out a quarterly reconciliation (frequency required by CMS) 62 Key Elements of an APM Attribution As in pay for performance, which patients are attributed to the health center is very important Can be attributed by: - Payor assignment - Actual utilization 63 32

incorporated. Community rates do need risk adjustment The risk in a capitated system is variation, i.e. where future utilization is different from the past.

33 Key Elements of an APM Rate Basis Sample Rate Set 64 Key Elements of an APM Rate Basis - Risks Experienced based capitated rates do NOT need to be risk adjusted if they are done on a health center specific basis, as the utilization experience of the population is already incorporated. Community rates do need risk adjustment The risk in a capitated system is variation, i.e. where future utilization is different from the past. Actuarial data sets for FQHC populations probably are not highly accurate, partially because of patient movement 65 33

34 Key Elements of an APM Health Center Qualification Not all health centers are good candidates for APM - Financially unstable: even though an APM can potentially improve/speed up cash flow, there are potential disruptions, especially at the beginning - Unable to report data. Any health center that has trouble reporting current data is going to have more trouble with enhanced reporting in an APM - Need to have EHR Meaningful Use and PCMH certification. The organization does NOT have to be far along in transitioning to new models of care - Oregon APM health centers send a monthly list to the State. State uses their claims database to do historical reattribution; this process requires sophisticated systems 66 Key Elements of an APM Reporting APM requires enhanced reporting, potentially along two dimensions: - Touches: services other than those delivered by billable providers. Enabling services capture some touches, but there are other services around patient management that should be captured under an APM - Patient engagement: how soon/often a patient is seen. Currently MCOs have incentives to see patients within a certain interval from assignment (typically days) 67 34

35 APM Actual Visits to Touches 68 Readiness Steps For Health Centers Identify assigned patient population Outreach to assigned not seen. Does health center have capacity to full panel of assigned patients? Measure % of assigned patients with no visits/never seen May require counting of enabling services/patient touches. Is PM/EHR set up to do this? May require quality measures (HEDIS?) for assigned patient population. Can health center track and influence? Fully panel all patients to an active provider Calculate current/baseline visits PMPY Create revenue model/projections for APM and/or VBP Propose a risk adjustment model for VBP 69 35

PAY FOR PERFORMANCE: NAVIGATE THE RISKS, MAXIMIZE THE BENEFITS, PREPARE FOR THE FUTURE. About Vista Community Clinic

PAY FOR PERFORMANCE: NAVIGATE THE RISKS, MAXIMIZE THE BENEFITS, PREPARE FOR THE FUTURE Michele Lambert CFO Vista Community Clinic About Vista Community Clinic OUR MISSION: To advance community health and