Michigan Primary Care   TransformationDemonstration Project     March 6, 2013       Webinar
Six Month IncentiveDisbursements                      2
12 Month Incentive   Assess care manager utilization (moderate,    complex, hybrid)   Assess status of patient registry...
Care Managers   Each discipline    • PA/NP/APN    • RN    • PhD/LLPsych    • MSW/LMSW    • Pharmacist    • Dietitian    •...
Care Manager Activity Reporting   Beginning with the financial report for 2013    Quarter 1 (due March 31), a new feature...
Care Manager Activity Reporting   Two reporting options available:    • Manual data entry directly into the financial    ...
Care Manager Reporting Activity   Option One    • Template downloaded from the MPCC website that      includes a list of ...
Care Manager Reporting Activity   Option Two    • PO generates a file that conforms to specific file      requirements (e...
Care Manager Reporting Activity   PCMH Practice   PCMH Practice ID                                           9
Care Manager Reporting Activity   Care Manager Provides    • Patient Last Name (pre-populated)    • Patient First Name (p...
Care Manager Reporting Activity   Face-to-Face Encounters    • Medicaid    • Medicare    • Medicare Advantage    • BCBSM ...
Care Manager Reporting Activity   Telephonic Encounters    • Medicaid    • Medicare    • Medicare Advantage    • BCBSM   ...
Care Manager Reporting Activity   Unique Patients    • Medicaid    • Medicare    • Medicare Advantage    • BCBSM    • BCN...
Additional Patient Population   Priority   BCBSM Self insured plans                                          14
PCMH-MiPCT Learning Activities   Each Care Manager must complete a total of    twelve hours of Care Manager education per...
PCMH-MiPCT Learning Activities   Each Practice Team (including at least one    physician from the practice, and at least ...
PCMH-MiPCT Learning Activities   Town Hall dinners   MiPCT Learning Collaboratives   Monthly practice PCMH meetings   ...
PCMH-MiPCT Learning Activities   MNO led activities   PTI led activities with CME and IACET credits                     ...
Education Programs   Certified coder workshops for physicians and    teams   Appropriate use of ICD-9 Codes   Advanced ...
Webinars   Volunteers for best practices to be presented at    the webinars   Any team member may provide “best practice...
Medicare Advantage   CMS Risk Adjustment Model   CMS Star Quality Bonus Program   New Medicare Preventive Services & He...
Why Care About Risk Adjustment?   Compliance with CMS diagnostic submission    requirements   Compliance with CMS diagno...
Why Care About Risk Adjustment?   Receive proper reimbursement from CMS to keep    premiums as low as possible for our pa...
Ten Most Missed Opportunities 15 Diabetes with Renal, Peripheral Circulatory Manifestations: 249.4x, 249.7x, 250.4x, and 2...
Star Quality Bonus Payments                              25
Measures Fall intoFour Categories        HEDIS        (Health          CMS     Effectiveness   administrative       Data a...
Stars Measures                                                                                                 Medicare   ...
Stars Measures                                                                                    Medicare                ...
Stars Measures                                                                                                    Medicare...
Stars Measures                                                                                                     Medicar...
Stars Measures                                                                                                  Medicare  ...
Stars Measures                                                                                                            ...
Stars Measures                                                                                                   Medicare ...
New Preventive Services   Quick Reference Guide on CMS website   Annual Wellness Visit (AWV is a separate service    fro...
New Preventive Services   Colorectal cancer screening (colonoscopy)   Bone mass measurement for osteoporosis and    othe...
Ew Preventive Exams   Annual alcohol misuse screening   Brief face-to-face behavioral counseling for    alcohol abuse  ...
Reimbursement   CMS established a billing code that physicians    must use to bill for a first AWV service, G0438, and   ...
Five Things To Remember   No rule outs   Appropriate signatures   Supportive documentation of diagnosis   Face-to-face...
Open Discussion                  39
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MiPCT Webinar 03/06/2013

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MiPCT Webinar 03/06/2013

  1. 1. Michigan Primary Care TransformationDemonstration Project March 6, 2013 Webinar
  2. 2. Six Month IncentiveDisbursements 2
  3. 3. 12 Month Incentive Assess care manager utilization (moderate, complex, hybrid) Assess status of patient registry Status of 2012 metric attainment • HEDIS measures • Data per physician 3
  4. 4. Care Managers Each discipline • PA/NP/APN • RN • PhD/LLPsych • MSW/LMSW • Pharmacist • Dietitian • Health Educator • Health Coach 4
  5. 5. Care Manager Activity Reporting Beginning with the financial report for 2013 Quarter 1 (due March 31), a new feature added to collect care manager activity data Care Manager Activity reporting requires that the specific information be reported for every care manager at every practice and by payer 5
  6. 6. Care Manager Activity Reporting Two reporting options available: • Manual data entry directly into the financial reporting template • Upload of standardized files 6
  7. 7. Care Manager Reporting Activity Option One • Template downloaded from the MPCC website that includes a list of the care manager and practices for the current quarter • Tab-delimited file downloaded after completion 7
  8. 8. Care Manager Reporting Activity Option Two • PO generates a file that conforms to specific file requirements (e.g., tab-delimited text file) and contains practice unit and care manager IDs • MNO submitted appropriate file for testing • MNO generates file electronically, making it much easier and more accurate than typing the information into the web application 8
  9. 9. Care Manager Reporting Activity PCMH Practice PCMH Practice ID 9
  10. 10. Care Manager Reporting Activity Care Manager Provides • Patient Last Name (pre-populated) • Patient First Name (pre-populated) • Patient Date of Birth (pre-populated) 10
  11. 11. Care Manager Reporting Activity Face-to-Face Encounters • Medicaid • Medicare • Medicare Advantage • BCBSM • BCN 11
  12. 12. Care Manager Reporting Activity Telephonic Encounters • Medicaid • Medicare • Medicare Advantage • BCBSM • BCN 12
  13. 13. Care Manager Reporting Activity Unique Patients • Medicaid • Medicare • Medicare Advantage • BCBSM • BCN 13
  14. 14. Additional Patient Population Priority BCBSM Self insured plans 14
  15. 15. PCMH-MiPCT Learning Activities Each Care Manager must complete a total of twelve hours of Care Manager education per year • This can be satisfied through twelve hours of MiPCT-led Care Manager webinars/sessions • Eight hours of MiPCT-led Care Manager webinars/sessions • Four hours of PO-led Care Manager training per year 15
  16. 16. PCMH-MiPCT Learning Activities Each Practice Team (including at least one physician from the practice, and at least one other practice team member) must complete eight hours of learning activity requirements during calendar year 2013 16
  17. 17. PCMH-MiPCT Learning Activities Town Hall dinners MiPCT Learning Collaboratives Monthly practice PCMH meetings Attendance at Annual MiPCT Summit 17
  18. 18. PCMH-MiPCT Learning Activities MNO led activities PTI led activities with CME and IACET credits 18
  19. 19. Education Programs Certified coder workshops for physicians and teams Appropriate use of ICD-9 Codes Advanced Care Planning Durable power of attorney 19
  20. 20. Webinars Volunteers for best practices to be presented at the webinars Any team member may provide “best practice” 20
  21. 21. Medicare Advantage CMS Risk Adjustment Model CMS Star Quality Bonus Program New Medicare Preventive Services & Health Risk Assessment 21
  22. 22. Why Care About Risk Adjustment? Compliance with CMS diagnostic submission requirements Compliance with CMS diagnostic submission requirements Compliance with CMS diagnostic submission requirements 22
  23. 23. Why Care About Risk Adjustment? Receive proper reimbursement from CMS to keep premiums as low as possible for our patients and improve the health of the Michigan economy The projection of CMS funding directly impacts member premiums A 1 percent improvement in risk scores can lower member premiums by roughly 10 percent 23
  24. 24. Ten Most Missed Opportunities 15 Diabetes with Renal, Peripheral Circulatory Manifestations: 249.4x, 249.7x, 250.4x, and 250.7x 16 Diabetes with Neurologic or Other Specified Manifestations: 249.6x, 249.8x, 250.6x, and 250.8x 55 Major Depressive, Bipolar, Paranoid Disorders: 296.xx, 297.x, and E950.x – E9593 71 Polyneuropathy: 337.xx (excludes 337.0, 337.01), 356.x, 357.xx (excludes 357.8), 358.xx (excludes 358.0), and 359.22 – 359.9 (359.8) 80 CHF: 402.x1, 404.x1, 415.0, 416.x (excludes 416.2), 417.x, 425.x, 428.xx, 429.0, and 429.1 92 Specified Heart Arrhythmias: 426.0, 427.0 – 427.32, and 427.81105 Vascular Disease: 440.0, 440.1, 440.20, 440.21, 440.22, 440.29, 440.3x, 440.4, 441.2, 441.4, 441.7, 441.9, 442.xx, 443.1, 443.8x, 443.9, 447.x, 448.0, 451.11, 451.19, 451.81, 451.83, 453.0, 453.2, 453.3, 453.4x, 453.5x, 453.72 – 453.77, 453.82 – 453.87, 557.1, and 557.9108 COPD: 491.xx, 492.x, 493.2x, 496, 518.1, and 518.2131 Renal Failure: 403.x1, 404.x2, 404.x3, 584.x, 585.x (excludes 585), 586, and 753.14132 Nephritis: 078.6, 580.xx, 581.xx – 583.xx This information can be accessed at CMS.gov 24
  25. 25. Star Quality Bonus Payments 25
  26. 26. Measures Fall intoFour Categories HEDIS (Health CMS Effectiveness administrative Data and measures Information Set) CAHPS (Consumer Health Assessment of Outcomes Healthcare Survey Providers and Systems) 26
  27. 27. Stars Measures Medicare Data Dates of BCN Title Description Plus Blue Source Service Advantage PPOBreast Cancer Ages 40 to 74, one or more mammograms HEDIS 2011 4 4Screening during the measurement year or the year priorColorectal Cancer Ages 50 to 75, one or more appropriate HEDIS 2011 5 4Screening screenings for colorectal cancerCholesterol Ages 18–75, discharged alive for Acute HEDIS 2011 5 5Screening for Myocardial Infarction (AMI), coronarypatients with artery bypass graft (CABG) or percutaneousHeart Disease coronary interventions (PCI) from the year prior who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior, who had an LDL-C screening test performedCholesterol Ages 18-75 with diabetes, who had an LDL- HEDIS 2011 5 4Screening for C screening test performedpatients withDiabetes 27
  28. 28. Stars Measures Medicare Data Dates of BCN Title Description Plus Blue Source Service Advantage PPOGlaucoma Ages 65 years and older, without a HEDIS 2011 3 4Screening prior diagnosis of glaucoma or glaucoma suspect, who received a glaucoma eye exam by an eye care professionalAnnual Flu Received an influenza vaccination CAHPS 2012 4 4VaccineImproving or Sampled Medicare enrollees whose HOS 2009 5 Plan tooMaintaining physical health status was the same 1st new toPhysical or better than expected Survey haveHealth** 2011 data 2nd SurveyImproving or Sampled Medicare enrollees whose HOS 2009 3 Plan tooMaintaining mental health status was the same 1st new toMental or better than expected Survey haveHealth** 2011 data 2nd Survey 28
  29. 29. Stars Measures Medicare Source of Dates of BCN Title Description Plus Blue Data Service Advantage PPOMonitoring Sampled ages 65 years or older, who had a HOS 2009 1st 2 2Physical doctor‘s visit in the past 12 months and who SurveyActivity received advice to start, increase or maintain 2011 2nd their level exercise or physical activity SurveyAdult BMI Ages 18-74 years, who had an outpatient visit HEDIS 2011 4 3Assessment and who had their body mass index (BMI) documented during the measurement year or the year priorOsteoporosis Females ages 67 and older, who suffered a HEDIS 2011 1 1Management fracture during the measurement year and subsequently had either a bone mineral density test or were prescribed a drug to treat or prevent osteoporosis in the six months after the fracture 29
  30. 30. Stars Measures Medicare Source of Dates of BCN Title Description Plus Blue Data Service Advantage PPO Diabetes CareEye Exam Ages 18-75 with diabetes, who had a retinal eye HEDIS 2011 4 4 examKidney Ages 18-75 with diabetes, who had medical HEDIS 2011 5 3Disease attention for nephropathyMonitoringBlood Sugar Ages 18-75 with diabetes, whose most recent HEDIS 2011 4 2Controlled** HbA1c level is greater than 9%, or who were not tested (This measure is reverse scored so higher scores are better.)Cholesterol Ages 18-75 with diabetes, whose most recent HEDIS 2011 5 3Controlled** LDL-C level was less than 100 ** Weighting is three times the Star measure. 30
  31. 31. Stars Measures Medicare Source of Dates of BCN Title Description Plus Blue Data Service Advantage PPOControlling Ages18–85, who had a diagnosis of HEDIS 2011 5 2Blood hypertension (HTN) and whose BP wasPressure** adequately controlled (<140/90)Rheumatoid Diagnosed with rheumatoid arthritis during the HEDIS 2011 4 4Arthritis measurement year, who were dispensed at leastManagement one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD)Improving Ages 65 or older, who reported having a urine HOS 2009 3 3Bladder leakage problem in the past six months and who 1stControl received treatment for their current urine Survey leakage problem 2011 2nd Survey ** Weighting is three times the Star measure. 31
  32. 32. Stars Measures Medicare Source Dates of BCN Title Description Plus Blue of Data Service Advantage PPOReducing the Ages 65 or older, who had a fall or had problems HOS 2009 4 3Risk of with balance or walking in the past 12 months, 1stFalling who were seen by a practitioner in the past 12 Survey months and who received fall risk intervention 2011 from their current practitioner 2nd SurveyDrug Plan Ages 65 or older, who received two or more PDE 2011 5 5Members 65 prescription fills for a high risk medicationand OlderWho ReceiveHigh RiskMeds**Blood Received an ACE/ARB medication among those PDE 2011 3 2Pressure who were dispensed at least one prescription forMeds for an oral hypoglycemic agent or insulin and at leastDiabetes** one prescription for an antihypertensive agent PDE = Prescription drug event records ** Weighting is three times the Star measure. 32
  33. 33. Stars Measures Medicare Source of Dates of BCN Title Description Plus Blue Data Service Advantage PPOMedication Ages 18 or older, who adhere to their prescribed PDE 2011 4 5Adherence for drug therapy across four classes of oral diabetesDiabetes** medications: biguanides, sulfonylureas, thiazolidinediones, and DiPeptidyl Peptidase (DPP)-IV Inhibitors.Medication Ages 18 or older, who adhere to their prescribed PDE 2011 5 5Adherence for drug therapy for renin angiotensin system (RAS)Hypertension* antagonists (angiotensin converting enzyme* inhibitor (ACEI), angiotensin receptor blocker (ARB), or direct renin inhibitor medications).Medication Ages 18 or older, who adhere to their prescribed PDE 2011 5 5Adherence for drug therapy for statin cholesterol medications.Cholesterol** ** Weighting is three times the Star measure. 33
  34. 34. New Preventive Services Quick Reference Guide on CMS website Annual Wellness Visit (AWV is a separate service from the Initial Preventive Physical Examination) Welcome to Medicare Preventive Visit aka Initial Preventive Physical Examination (IPPE) Personalized prevention plan with advice, screening schedules, referrals and education based on your specific health situation 34
  35. 35. New Preventive Services Colorectal cancer screening (colonoscopy) Bone mass measurement for osteoporosis and other bone issues Glaucoma screening Immunizations (including flu shots and pneumonia and hepatitis B vaccinations) Mammograms and pap smears Prostate screening 35
  36. 36. Ew Preventive Exams Annual alcohol misuse screening Brief face-to-face behavioral counseling for alcohol abuse Annual depression screening Counseling for sexually transmitted infections Face-to-face behavioral counseling for obesity 36
  37. 37. Reimbursement CMS established a billing code that physicians must use to bill for a first AWV service, G0438, and a subsequent AWV service, G0439. The 2011 Medicare payment—not adjusted for geography—is approximately $172 for G0438 and $111 for G0439. Medicare will pay the full amount, meaning that the beneficiary does not have to pay the typical 20 percent copayment nor toward a yet-to-be reached deductible 37
  38. 38. Five Things To Remember No rule outs Appropriate signatures Supportive documentation of diagnosis Face-to-face visit Star measurements 38
  39. 39. Open Discussion 39

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