Improving the Health Outcomes of Both Patients AND PopulationsCHC Connecticut
NCA Clinical Workforce Development, Team-Based Care 2019 Webinar Series
Webinar broadcast on: May 23, 2019 | 2 p.m. EST
In this webinar experts will share their journey in planning, preparing and launching a population health initiative. With the goals of impacting population health outcomes while ensuring cost effectiveness, our experts designed interventions to eliminate gaps in care, particularly among special populations.
How to Engage Physicians in Quality/Safety Improvement Using MetricsWellbe
The unsustainable rising cost of medical care is creating financial pressures that will critically alter the way that health care is both paid for and delivered. Limited resources dictate that we become more efficient at providing high quality care. In an effort to provide financial incentive for delivering quality care the Federal government instituted Value Based Purchasing (VBP) and Bundled Payments. In order to maximize reimbursement under these programs, providers of health care must follow to the basic tenants of the quality principles.
Lorraine Hutzler, Associate Director of the Center for Quality and Patient Safety at NYU Hospital for Joint Diseases at the NYU Langone Medical Center, will discuss:
• How to build a quality infrastructure for your orthopedic program
• What quality metrics to measure and how to engage surgeons using them
• Lean and Six Sigma principles to use to accelerate improvement
About the Speaker:
Lorraine100Lorraine Hutzler is the Associate Director of the Center for Quality and Patient Safety at NYU Hospital for Joint Diseases at the NYU Langone Medical Center and a Principal of Labrador Healthcare Consulting. She designed, built and maintains a robust quality infrastructure for the Department of Orthopaedic Surgery. Lorraine has extensive expertise in quality metrics management and reporting as well as Lean and Six Sigma Certification.
Improving the Health Outcomes of Both Patients AND PopulationsCHC Connecticut
NCA Clinical Workforce Development, Team-Based Care 2019 Webinar Series
Webinar broadcast on: May 23, 2019 | 2 p.m. EST
In this webinar experts will share their journey in planning, preparing and launching a population health initiative. With the goals of impacting population health outcomes while ensuring cost effectiveness, our experts designed interventions to eliminate gaps in care, particularly among special populations.
How to Engage Physicians in Quality/Safety Improvement Using MetricsWellbe
The unsustainable rising cost of medical care is creating financial pressures that will critically alter the way that health care is both paid for and delivered. Limited resources dictate that we become more efficient at providing high quality care. In an effort to provide financial incentive for delivering quality care the Federal government instituted Value Based Purchasing (VBP) and Bundled Payments. In order to maximize reimbursement under these programs, providers of health care must follow to the basic tenants of the quality principles.
Lorraine Hutzler, Associate Director of the Center for Quality and Patient Safety at NYU Hospital for Joint Diseases at the NYU Langone Medical Center, will discuss:
• How to build a quality infrastructure for your orthopedic program
• What quality metrics to measure and how to engage surgeons using them
• Lean and Six Sigma principles to use to accelerate improvement
About the Speaker:
Lorraine100Lorraine Hutzler is the Associate Director of the Center for Quality and Patient Safety at NYU Hospital for Joint Diseases at the NYU Langone Medical Center and a Principal of Labrador Healthcare Consulting. She designed, built and maintains a robust quality infrastructure for the Department of Orthopaedic Surgery. Lorraine has extensive expertise in quality metrics management and reporting as well as Lean and Six Sigma Certification.
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
CPHQ certification is “world class” in the field of healthcare quality. Which certify that as a professional you are privileged to take the lead for Healthcare Quality Management Structure, Process and Evaluation within a healthcare organization. CPHQ is beneficial for both quality professional and managerial position in healthcare facility
Hospitals in India have a high burden of infection in their Intensive Care Unit and general wards,many of which are resistant to antibiotic treatment.In antibiotic resistant infections are difficult and sometimes impossible to treat.They lead to longer hospital stays,increased treatment cost and in some cases death.
Quality assurance is one of the important topic for our Nursing field this is important for M.Sc. Nursing Final Year students for the subject of management that will also help to all nurses either in the filed of clinical as well as education
The CMS Innovation Center hosted a special webinar featuring Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer, on Monday, November 10, 2014 from 10:30am – 11:30 am ET. Dr. Conway will provided an update about the work of the CMS Innovation Center and the models being tested to improve better care for patients, better health for our communities, and lower costs through improvement for our health care system. Opportunities for questions were provided.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The healthcare transformation from fee for service to fee for outcomes just got an adrenaline shot in the arm April 27th when the Department of Health and Human Services surprised many in the market by announcing a Quality Payment Program, a proposed set of new rules to take effect in 2019 based on key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
An introductory overview of the basic concepts of Healthcare Quality, a starter for beginners.
Prepared in 2014 for the new staff of the Quality Management Department in King Saud University Medical City in Riyadh as a part of their capacity building plan.
Acknowledgments:
*Dr. Magdy Gamal Yousef, MBBCh, MS, CPHQ - for his contribution in the scientific content
**Ms. Maram Baksh, MS, CPHQ - for the design of the full HCQ capacity building plan in KSUMC
CPHQ certification is “world class” in the field of healthcare quality. Which certify that as a professional you are privileged to take the lead for Healthcare Quality Management Structure, Process and Evaluation within a healthcare organization. CPHQ is beneficial for both quality professional and managerial position in healthcare facility
Hospitals in India have a high burden of infection in their Intensive Care Unit and general wards,many of which are resistant to antibiotic treatment.In antibiotic resistant infections are difficult and sometimes impossible to treat.They lead to longer hospital stays,increased treatment cost and in some cases death.
Quality assurance is one of the important topic for our Nursing field this is important for M.Sc. Nursing Final Year students for the subject of management that will also help to all nurses either in the filed of clinical as well as education
The CMS Innovation Center hosted a special webinar featuring Dr. Patrick Conway, CMS Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer, on Monday, November 10, 2014 from 10:30am – 11:30 am ET. Dr. Conway will provided an update about the work of the CMS Innovation Center and the models being tested to improve better care for patients, better health for our communities, and lower costs through improvement for our health care system. Opportunities for questions were provided.
- - -
CMS Innovation Center
http://innovation.cms.gov
We accept comments in the spirit of our comment policy:
http://newmedia.hhs.gov/standards/comment_policy.html
CMS Privacy Policy
http://cms.gov/About-CMS/Agency-Information/Aboutwebsite/Privacy-Policy.html
The healthcare transformation from fee for service to fee for outcomes just got an adrenaline shot in the arm April 27th when the Department of Health and Human Services surprised many in the market by announcing a Quality Payment Program, a proposed set of new rules to take effect in 2019 based on key provisions of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
Are you:
Keeping up to date with your risk scoring?
Missing out on reimbursement premiums?
Ensuring accurate health profiles for your patients?
Proper risk adjustment is important, not only to ensure your patients' quality of care, but also to improve your bottom line. This CareOptimize presentation will take you from the basic tenets of risk adjustment to specific ways you can increase your risk scores and get the highest premium payments.
The Design of Accountable Care OrganizationsCJ Fulton
Pillars for Accountable Care
PCMH versus ACOs
Core competencies
Six core structural components of successful ACO deployment
Pioneer ACO burn and learn lessons
Barriers & root cause analysis
Patient attribution
Five modes of Accountable Care
Early value-based adopters
Value discovery assessment
Modified Triple Aim
GPRO
Breakdown by 33 Measures
Revenue at Risk: Understanding Financial Impacts of Quality ReportingBill Presley
Jodi Frei, Northwestern Medical Center Vermont, and I co-presented at the MUSE Executive Institute on Revenue at Risk: Understanding Financial Impacts of Quality Reporting. The Executive Institute featured many amazing CXO's discussing the changing landscape of revenue cycle management and how finance, quality, and IT departments are converging on revenue cycle.
Though pay for performance is the common theme, the logistics of programs including Value Based Purchasing (VBP), Inpatient Quality Reporting (IQR), Hospital Acquired Condition (HAC) Reduction Program, Readmission Reduction, MACRA, MIPS and APMs, are very different. In this session, the specifics of each Quality Program including reporting requirements, scoring methodologies, and associated incentives and penalties will be covered. In addition, tools to track performance and quantify financial risk will be shared.
Reimbursement in this era of health care reform is challenging. We all seek success under this new normal in health care. Optimizing revenue capture in a quality reimbursement model requires acquisition of new knowledge and the use of new tools and strategies. Join us in the conversation; share your strategies; learn from others.
4508 Final Quality Project Part 2 Clinical Quality Measur.docxblondellchancy
4508 Final Quality Project
Part 2: Clinical Quality Measures for Hospitals
Overview
This activity focuses on Quality Measures for Hospitals. The activity uses online resources from
the CMS website. The Clinical Quality Measures for Hospitals activity focuses on the Hospital
Value Based Purchasing (VBP) Program
Background
The National Quality Strategy (NQS) was first published in March 2011 as the National Strategy
for Quality Improvement in Health Care, and is led by the Agency for Healthcare Research and
Quality on behalf of the U.S. Department of Health and Human Services (HHS). Today, the NQS
serves as a guide for identifying and prioritizing quality improvement efforts, sharing lessons
learned, and measuring the collective success of Federal, State, and public‐ and private‐sector
healthcare stakeholders across the country.
The Aims of the NQS are threefold:
Better Care: Improve the overall quality by making health care more patient‐centered,
reliable, accessible, and safe.
Healthy People/Healthy Communities: Improve the health of the U.S. population by
supporting proven interventions to address behavioral, social, and environmental
determinants of health in addition to delivering higher‐quality care.
Affordable Care: Reduce the cost of quality health care for individuals, families,
employers, and government.
To align with this, CMS has set goals for their Quality Strategy. These include:
• Make care safer by reducing harm caused in the delivery of care
– Improve support for a culture of safety
– Reduce inappropriate and unnecessary care
– Prevent or minimize harm in all settings
• Strengthen person and family engagement as partners in their care
• Promote effective communication and coordination of care
• Promote effective prevention and treatment of chronic disease
• Work with communities to promote best practices of healthy living
• Make care affordable
CMS’s vision states that if we can find better ways to pay providers, deliver care, and distribute
information than patients can receive better care, health dollars are spent more wisely, and
there are healthier communities, a healthier economy, and a healthier county. It is with this in
mind that they have created multiple quality payment programs.
In January 2015, the Department of Health and Human Services made an announcement that
set in place measurable goals and a timeline to move the Medicare program towards paying
providers based on the quality of care rather than the quantity. This was the first time in the
history of the program that explicit goals were set. They invited private sector payers to match
or exceed these goals as well. These goals included:
1. Alternative Payment Models
a. 30% of Medicare payments tied to quality or value through Alternative Payment
models by the end of 2016 and 50% by the end of 2018
2. Linking Fee‐For‐Service payments to Quality/Value
a. 85% of all Medi ...
4508 Final Quality Project Part 2 Clinical Quality Measurromeliadoan
4508 Final Quality Project
Part 2: Clinical Quality Measures for Hospitals
Overview
This activity focuses on Quality Measures for Hospitals. The activity uses online resources from
the CMS website. The Clinical Quality Measures for Hospitals activity focuses on the Hospital
Value Based Purchasing (VBP) Program
Background
The National Quality Strategy (NQS) was first published in March 2011 as the National Strategy
for Quality Improvement in Health Care, and is led by the Agency for Healthcare Research and
Quality on behalf of the U.S. Department of Health and Human Services (HHS). Today, the NQS
serves as a guide for identifying and prioritizing quality improvement efforts, sharing lessons
learned, and measuring the collective success of Federal, State, and public‐ and private‐sector
healthcare stakeholders across the country.
The Aims of the NQS are threefold:
Better Care: Improve the overall quality by making health care more patient‐centered,
reliable, accessible, and safe.
Healthy People/Healthy Communities: Improve the health of the U.S. population by
supporting proven interventions to address behavioral, social, and environmental
determinants of health in addition to delivering higher‐quality care.
Affordable Care: Reduce the cost of quality health care for individuals, families,
employers, and government.
To align with this, CMS has set goals for their Quality Strategy. These include:
• Make care safer by reducing harm caused in the delivery of care
– Improve support for a culture of safety
– Reduce inappropriate and unnecessary care
– Prevent or minimize harm in all settings
• Strengthen person and family engagement as partners in their care
• Promote effective communication and coordination of care
• Promote effective prevention and treatment of chronic disease
• Work with communities to promote best practices of healthy living
• Make care affordable
CMS’s vision states that if we can find better ways to pay providers, deliver care, and distribute
information than patients can receive better care, health dollars are spent more wisely, and
there are healthier communities, a healthier economy, and a healthier county. It is with this in
mind that they have created multiple quality payment programs.
In January 2015, the Department of Health and Human Services made an announcement that
set in place measurable goals and a timeline to move the Medicare program towards paying
providers based on the quality of care rather than the quantity. This was the first time in the
history of the program that explicit goals were set. They invited private sector payers to match
or exceed these goals as well. These goals included:
1. Alternative Payment Models
a. 30% of Medicare payments tied to quality or value through Alternative Payment
models by the end of 2016 and 50% by the end of 2018
2. Linking Fee‐For‐Service payments to Quality/Value
a. 85% of all Medi ...
Top 3 Strategic Initiatives for Sustainable Results in Healthcare in Middle EastSTELIOS PIGADIOTIS
This research paper offers insights in three areas:
1. Current Challenges in GCC/Middle East Healthcare sector
2. Future Drivers for Healthcare Excellence
3. Future Strategic Initiatives for Sustainable Results
Patient-Centered Care Requires Patient-Centered Insight: What We Can Do To C...Health Catalyst
Health systems and providers are inundated with measurement systems and reporting. Why would we want to add to the measurement mayhem? The real question is, “Are we measuring what matters?”
Carolyn Simpkins MD, PhD, chief medical informatics officer, will discuss how putting the patient at the center of the measurement matrix can bring coherence and completeness to the picture of care delivery performance across the patient journey, and therefore the performance of the healthcare ecosystem.
She will describe the building blocks for patient-centered measurement and how other metrics, patient-reported outcomes, and patient satisfaction fit into this approach. Carolyn will also review the challenges that have kept health systems from completing a patient-centered outcomes approach and why we are poised to break through. Finally, she will share case studies of organizations who have begun to pioneer the use of patient centered metrics to improve care and outcomes.
Introducing the New Care Management Suite: A Comprehensive, Data-Driven ApproachHealth Catalyst
Because approximately 75 percent of U.S. healthcare costs are attributed to patients with chronic diseases, care management has emerged as a critical improvement strategy. Yet, fragmented workflows, incomplete data sources, and a lack of transparency into typical “black box” solutions leave care teams feeling frustrated and struggling to track success. These challenges are exacerbated in the dynamic, new normal of COVID-19.
Health Catalyst is pleased to introduce our new care management solution. Leveraging a transparent, data-informed approach, the Health Catalyst® Care Management Suite enables quick identification and response to the changing needs of patient populations.
In this webinar, we share the current state of the care management landscape and discuss trends from across the country that highlight risk model biases, the impacts of COVID-19, and the importance of evaluating program ROI. Our Care Management Suite has the capabilities and flexibility to adjust to the ever-changing health environment by identifying the most impactable patients, supporting the entire clinical care pathway, and optimizing program ROI and profitability.
During this webinar, we discuss how our solution does the following:
-Provides a rich, more comprehensive data set—including the ability to look across a wide variety of data sources combining clinical and claims data.
-Offers a patient-centric view—optimized for care management workflows.
-Supports a wide range of analytic capabilities—algorithm transparency and flexibility enabling users to confidently explain, demonstrate, and continuously optimize care management processes.
NCQA’s Accreditation process provides payers with a comprehensive framework to improve quality of care and services. It allows members and employers to compare health plan performance across various plans and against industry benchmarks. NCQA accreditation has 3 parts – HEDIS, Patient experience CAHPS measures and NCQA standards
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
Health Education on prevention of hypertensionRadhika kulvi
Hypertension is a chronic condition of concern due to its role in the causation of coronary heart diseases. Hypertension is a worldwide epidemic and important risk factor for coronary artery disease, stroke and renal diseases. Blood pressure is the force exerted by the blood against the walls of the blood vessels and is sufficient to maintain tissue perfusion during activity and rest. Hypertension is sustained elevation of BP. In adults, HTN exists when systolic blood pressure is equal to or greater than 140mmHg or diastolic BP is equal to or greater than 90mmHg. The
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
2. Agenda
• Industry Background and Overview
• Accrediting Entities
• Quality Program Overview
− Federal Programs
− Local Programs
• Risk Adjustment Overview
• Quality Documentation
3. Background
Paradigm Shift
Volume & Consumption
Value & Quality
Quality-focused care
Care coordination
and transparency
Patient-centric
Cost containment
The US healthcare system is in the midst of a sea change transformation.
Fee for service
Uncoordinated care
Unnecessary utilization
and cost
Siloed work
4. Expansion of Data-Driven Patient Populations
Oregon Health Plan Receives Waiver to
Reimburse Based on Patient-Level Data
ACG Risk Adjustment Model Released
NCQA Releases HEDIS 2.0
NY Launches QARR
HIPAA
CDPS
Created
Balanced Budget Act
Medicare Modernization Act
Medicare Part D
CMS Star Ratings Launch
160
140
120
110
80
60
40
20
0
1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
ACA Passed
Managed Medicaid Medicare Advantage MSSP/Pioneer Accountable Care Organization Commercial ACA
PatientCount(millions)
Aon Hewitt Launches Private Exchange
Blue KC Exchange Launches
Bridges to Excellence Founded
PQRI Launched
Premier
Hospital
Quality
Incentive
Launched
National
Committee
on Evidence-
Based Benefit
Design
Established
California
P4P
Program
Launched
ACO Launch
Commercial HIX Marketplace
Launch
Sears, IBM & Walgreens Move to Exchanges
Medicare + Choice
Launch
E E E E E E
Estimates based upon internal Inovalon analyses and industry sources. Please see the Company’s prospectus filed pursuant to Rule 424 on February 12, 2015.
5. Overview
The Centers for Medicare & Medicaid Services’ (CMS) Center for Clinical Standards &
Quality supported by state health agencies, and numerous oversight and accrediting
bodies such as the NCQA, URAC, American Medical Association (AMA), the American
Heart Association (AHA), the Agency for Healthcare Research and Quality (AHRQ), and
the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) have
developed initiatives to assure quality healthcare for Medicare beneficiaries, Medicaid, and
people participating in the Exchange marketplace through accountability and public
disclosure with the end goal of:
1) Preventing the overuse, underuse, and misuse of healthcare services and ensuring
patient safety;
2) Identifying what works in healthcare—and what doesn’t—to drive improvement;
3) Holding health insurance plans and healthcare providers accountable for providing
high-quality care;
4) Measuring and addressing disparities in how care is delivered and in health outcomes;
and
5) Helping consumers make informed choices about their care.
6. Benefits
Patients benefit from:
• Improved quality of care
• Reduced healthcare costs
• Transparent rating system on health plan
performance
• Improved patient/physician engagement
Physicians benefit from:
• Accurate patient profiles leveraging
technology
• Greater access to patient data that may be
outside of the network
• Improved quality initiatives
• Streamlined cost in the delivery of care
• Improved communication between the
physician and patient
• Better care coordination
Health plans benefit from:
• Improved operational and financial
performance
• Improved communication between
the health plan, physician, and
patient
• Improved competitive stance
7. Accrediting Entities
An independent non-profit organization that works to improve healthcare quality
through the administration of evidence-based standards, measures, programs,
and accreditation. NCQA administers the Healthcare Effectiveness Data and
Information Set (HEDIS®) and Consumer Assessment of Healthcare Providers
and Systems (CAHPS) survey.
An independent, non-profit organization that promotes continuous improvement
in the quality and efficiency of healthcare management through processes of
accreditation, education, and measurement.
The purpose of clinical and quality outcomes accrediting organization is to standardize how quality of care
is measured while driving improvements, and bettering the care and services being dispensed to the
patient population.
Health organizations that acquire and maintain accreditation benefit through:
• Increased enrollment
• Improved quality of care for their members
• Better financial performance
Two key accrediting organizations are:
8. 8
Key Federal Quality Improvement Models:
Medicare and Commercial
Program LOB
CMS Five-Star Quality Rating Medicare Advantage
Quality Rating System (QRS) Commercial ACA
Medicare Shared Savings Program Medicare FFS
In addition to regulatory requirements and standards developed by oversight and accrediting bodies,
there are federal and state-specific programs that incentivize improvements in clinical and quality
outcomes.
9. ASES Quality Retention Fund
• Performance measures to monitor and assure quality of care to all
members across multiple preventive services and chronic
conditions management domains:
• Breast Cancer Screening
• Cervical Cancer Screening
• Cholesterol Management for High Risk Population
• Diabetes Care Management
• Access to Preventive Visits
• Annual Dentist Visit
• Timeliness in Prenatal Care
• Asthma Management
• Disease Management and Emergency Room Utilization metrics
9
INOV PPT Template (1.1.16) v1.0.0
10. Breast Cancer Screening
10
• The number of women 42-69 years of age who had a mammogram to screen breast
cancer
• One or more mammograms any time on or between October 1st two years prior to
the measurement year and December 31st of the measurement year
• Excludes patients with documented:
– Bilateral mastectomy any time during the patient’s history
• Including two unilateral mastectomies at least 2 weeks apart
INOV PPT Template (1.1.16) v1.0.0
11. Cervical Cancer Screening
11
• The number of women 24-64 years of age who receive one or more Pap Tests to
screen for cervical cancer using either:
• Cervical cytology during the measurement year, or the two years prior
• Cervical cytology/HPV co-testing during the measurement year or four years prior
– Document when the cervical pathology and/or the HPV test was performed, and
the results or findings
• Exclusion:
– Hysterectomy with no residual cervix , cervical agenesis, or acquired absence of
the cervix
INOV PPT Template (1.1.16) v1.0.0
12. Cholesterol Management for High Risk
Population
12
• Patients 18-75 years with a high risk diagnoses (Acute MI, CABG, PCI) who have
had a LDL-C screening
• Document when the LDL-C test was performed and the results or finding
INOV PPT Template (1.1.16) v1.0.0
13. Diabetes Care Management
13
Members 18-75 years of age with Diabetes (Type 1 or 2) who had each of the following screening
tests:
• Hemoglobin A1c
• Eye exam
– Retinal or dilated eye exam by optometrist or ophthalmologist in the measurement year
– A negative retinal or dilated eye exam in the year prior to the measurement year
• LDL-C
• Nephropathy screening:
– Microalbumin (24 hour urine, timed urine, spot urine, microalbumin/creatinine ratio, 24 hour
protein, random protein/creatinine ratio)
– Diagnosis of nephropathy by nephrologist
– Renal transplant
– Documentation of chronic kidney disease, including acute renal failure, ESRD, and diabetic
nephropathy
– Positive urine macroalbumin test
INOV PPT Template (1.1.16) v1.0.0
14. Early and Periodic Screening Diagnosis and
Treatment (EPSDT)
14
Members under 21 years old , based on age stages:
• Preventive visit (well child)
• Inmunizations
• Developmental screening
• Counseling for nutrition and physical activity, BMI percentile
• Dental care
• Hearing and vision screening
INOV PPT Template (1.1.16) v1.0.0
15. Medicare Advantage Commercial ACA Managed Medicaid
Payment
Model
CMS-HCC model HHS-HCC model
State-specific model (CDPS,
CRG, ACG, Medicaid Rx, etc.)
Payment
Timeline
Prospective (future payments
adjusted twice per year, plus
one lump-sum reconciliation
payment)
Concurrent (one lump-sum
transfer payment determined
by June 30 each year)
Prospective (future payments
adjusted quarterly)
Risk Score Calculation
Risk score based on age,
gender, diagnosis and
geography
Risk score based on age,
gender, diagnosis and
geography
Varies by state (diagnostic or
demographic-only) and
population (TANF, SSI)
Member or Population
Risk Score
Individual member-level
risk scores
Group, plan-level risk scores
(Average of member-level
scores)
Generally group, plan-level
risk scores by population
(TANF, SSI, etc.)
Submission Schedule
Three annual data submission
deadlines (March, September
and January)
One annual submission
deadline (April 30)
Varies by State
Comparing Risk Adjustment
Programs
16. Medicare Advantage Commercial ACA Managed Medicaid
Diagnosis Grouping
ICD-10 codes grouped
into 79 HCCs*
ICD-10 codes grouped into 127
HCCs, separate risk pools for age
(Infant, Child, Adult) and metal
level (Bronze, Silver, Gold,
Platinum, Catastrophic)
ICD-10 codes grouped into
condition categories specific to
risk adjustment model (CDPS
groups, CRGs, ACGs) and
relevant populations (TANF, SSI,
etc.)
Budget Neutrality
Not budget-neutral, but
risk factors are adjusted
annually based on
Medicare budget
Zero-sum settlement (budget
neutral)
• If one plan’s risk score
changes, all plans’ scores
change
Generally zero-sum settlement
(budget neutral)
• If one plan’s risk score
changes, all plans’ scores
change
Data Submission Format
RAPS and EDS (837/5010)
data format
EDGE Server (XML format) Generally 837/5010 format
Supplemental Data
Supplemental data
permitted (allows for
medical record review)
Supplemental data permitted
(allows for medical record
review)
Supplemental data generally
not accepted
Comparing Risk Adjustment Programs
(cont.)
*Note: 87 HCCs in ESRD model
17. Managed Medicaid Risk Adjustment
Overview
• 37 States have Managed Care programs with a capitated payment model
• Many states expanded Medicaid eligibility under the Affordable Care Act (ACA)
• About half of states use a diagnostic-based risk adjustment model for their
managed care populations
• Most Medicaid risk adjustment programs are budget neutral
• States May Choose from Multiple Risk Adjustment Models
− CDPS – Chronic Disability Payment System
− CDPS + Rx
− CRG – Clinical Risk Groups
− ACG – Adjusted Clinical Groups
− DCG – Diagnostic Cost Groups
− ERG – Episodic Risk Groups
− Medicaid Rx
− Demographic-only Risk Adjustment
18. Monitoring, Evaluation, Assessment or Treatment (MEAT):
• Only diagnoses documented in the patient’s medical record are considered when
calculating a member’s compliance.
• Clinical validation rules require documentation of physical exam findings or
evaluation of symptoms for conditions such as depression, COPD, PVD, heart
failure, rheumatoid arthritis or diabetes.
• Assessment/Plan section requires documentation of evaluation if conditions are
assessed to be stable and specification of recommended treatment plan.
Documentation Support for Compliance
19. Challenges with Diagnostic
Coding
Doctors have a lack
of or limited
knowledge of risk
adjustment
methods
ICD codes must be
documented every
year in a patient-
provider visit
Physicians are often
not incentivized to
improve patient risk
score accuracy
Systems, processes,
and/or training
programs do not stress
the importance of risk
adjustment
Continued use of
CPT codes for
reimbursement
Incomplete and erroneous coding is common and can
affect the accuracy of a managed-care plan’s risk score
and resulting reimbursement.
Factors contributing to inaccurate diagnostic coding by
providers:
20. Initial Priorities for Measure Development by
Quality Domain
Clinical Care
• Measures incorporating patient preferences and shared decision-making
• Cross-cutting measures that may apply to more than one specialty
• Focused measures for specialties that have clear gaps
• Outcome measures
Safety
• Measures of diagnostic accuracy
• Medication safety related to important drug classes
Care Coordination
• Assessing team-based care (e.g., timely exchange of clinical information)
• Effective use of new technologies, such as telehealth
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21. Initial Priorities for Measure Development by
Quality Domain
Patient and Caregiver Experience
• Patient-reported outcome measures (PROMs)
• Additional topics that are important to patients and families/caregivers (e.g., knowledge, skill, and
confidence for self-management)
Population Health and Prevention
• Developing or adapting outcome measures at a population level, such as a community or other
identified population, to assess the effectiveness of the health promotion and preventive services
delivered by professionals
• IOM Vital Signs topics (e.g., life expectancy, well-being, addictive behavior)
• Detection or prevention of chronic disease (e.g., chronic kidney disease)
Affordable Care
• Overuse measures (e.g., overuse of clinical tests/procedures)
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22. Quality Documentation
Important aspects of documentation:
• Utilization of proper codes in claims and encounters
• Submit all related codes accurately
• Submit all service encounters timely
• Progress notes in record that evidence the submitted codes
• Use of technology, specially electronic health records
• It reflects your work, compliance and quality of care offered
• Supports contracted requirements of quality activities
• HEDIS
• EPSDT
• Performance Measures
• Disease Management
• Wellness Program
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For decades quality has been the center of focus for the healthcare industry, but has also provided significant challenges:
Care coordination
Cost and utilization
Disparate data
Technology and reporting
Patient insight
As result the healthcare industry is undergoing a sea change transformation from volume and consumption to value and quality. Government and state entities have put programs in place to support and incentivize quality-focused initiatives that:
Improve patient health
Avoid costly mistakes and readmissions
Increase financial outcomes
…and throughout the years as quality of care has gained importance, so has the need for increased data for the patient population that’s being served
CMS’ center for clinical standards and quality coupled with a host of quality care oversight organizations and agencies are working together to devise a standardized plan on how to measure and evaluate the quality care for health entities throughout the U.S. with the goal of
Preventing the overuse, underuse, and misuse of health care services and ensuring patient safety;
Identifying what works in healthcare—and what doesn’t—to drive improvement;
Holding health insurance plans and health care providers accountable for providing high-quality care;
Measuring and addressing disparities in how care is delivered and in health outcomes; and
Helping consumers make informed choices about their care.
Standardizing the quality of care that’s being dispensed, health plans, physicians and the like can look forward to (ramble off some of the bullet points)
For instance NCQA which blah, blah, blah, blah
And URAC, which blah, blah, blah
Obtaining accreditation and maintaining certifications leads to increased enrollment, improved quality of care for their members, and ultimately better financial performance.
URAC Client contracting with Inovalon (01/11/2016 – 02/29/2016)
Inovalon Project Kick off and Implementation with URAC Clients
(03/15/2016 – 05/13/2016)
Test Data Load and processing - Data from URAC Client to Inovalon (optional step for those that have test/mock data prepared; 05/16/2016 – 06/15/2016)
Initial data load and processing - Data from URAC Client to Inovalon
(07/01/2016 – 07/15/2016)
Preliminary rate production - Rates from Inovalon to URAC Client
(07/15/2016 – 07/29/2016)
URAC Clients work with Inovalon to perform data updates and corrections
(08/01/2016 - 09/30/2016)
URAC Clients complete all audit related remedial actions
Final Data Due by URAC Clients to Inovalon (post data refresh, if required)
Final Rate Production by Inovalon (09/30/2016 – 10/15/2016)
Final rate submission from Inovalon to URAC Client and URAC
Highlight:
Budget neutrality
Supplemental data limitations
Highlight:
Budget neutrality
Supplemental data limitations
CMS developed and manages the Hierarchical Condition Category (HCC) methodology to evaluate the risk adjusted disease burden for Medicare ACOs, Medicare Advantage and Commercial ACA health plans. State Medicaid authorities use a variety use a variety of similar risk adjustment methodologies for their managed Medicaid plans, including CDPS, CRG and others.
These logical groupings of diagnoses designate a reimbursement for accurate patient disease burden.
Doctors are typically not experts in coding accurate disease burden for risk adjustment….after all, they didn’t go to medical school to become expert coders, rather they focus on providing great care to their patients. Therefore, incomplete and erroneous coding is common and can affect the accuracy of the patient risk score.