The document discusses Michigan's Primary Care Transformation Demonstration Project. It provides information about 6 month and 12 month incentive disbursements, care manager utilization and patient registry status, HEDIS measure attainment, and care manager activity reporting requirements. It also discusses care manager disciplines, activity data collection, reporting options, and required data fields. Additional topics include learning activity requirements, education programs, webinars, Medicare Advantage quality measures and bonuses, risk adjustment importance, and new Medicare preventive services.
February 9, 2012
These slides are designed for Post-Acute Care (PAC) providers seeking additional information about how Model 3 works and a better understanding of the opportunities for PAC providers within the Bundled Payment for Care Improvement (BPCI) initiative to achieve better care, better health and lower costs for their patients through care redesign.
More at: http://innovations.cms.gov/resources/Bundled-Payments-Model-3-Deep-Dive.html
- - -
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
Reporting quality data to the board of directorsCompliatric
This document provides guidance on presenting clinical quality data to health center boards of directors. It summarizes HRSA requirements for clinical quality reporting and the roles of health centers and boards in gathering and discussing this data. Health centers should determine who facilitates quality discussions at board meetings, develop a reporting schedule, and present data in an accessible format. Boards should receive training, review previous quality discussions, and engage in active discussion of quality metrics and their implications for strategic planning. The document also offers strategies for collecting, analyzing, and presenting clinical quality data to support management decision-making.
The document discusses ensuring quality of health care data from a Canadian perspective. It provides an overview of the Canadian Institute for Health Information (CIHI), which collects health data from various partners across Canada. CIHI faces challenges as a secondary data collector, dealing with varying standards and incomplete data reporting. The document outlines CIHI's strategies to ensure data quality, including its data quality framework, quality reports and studies, and techniques for communicating data quality to different audiences.
This webinar will highlight key areas from the document discussing what a strong application to the BPCI initiative should include. We encourage you to review the Models 2-4 application questions and the new Application Guidance document posted on the Bundled Payments for Care Improvement webpage, prior to this webinar.
More at: http://www.innovations.cms.gov/resources/Bundled-Payments-Application-Guidance.html
- - -
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 Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted the first of two webinars on November 19 to describe the final rule and respond to questions about the Comprehensive Care for Joint Replacement Model.
- - -
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
Emerging hscrc methodologies case pohl (final)James Case
The document discusses emerging methodologies being developed by the HSCRC to incentivize population health management under a potential CMS model testing demonstration. It describes how existing methodologies like the Admission-Readmission Revenue program and Total Patient Revenue would need to be modified. New approaches under consideration include Population-Based Reimbursement and requesting authority for bundled payments, ACOs, and gain sharing. Significant effort will be required to translate these approaches to an all-payer environment in Maryland.
The Kidney Care Choices (KCC) Model team hosted a Comprehensive Kidney Care Contracting (CKCC) Model Options introduction webinar on Tuesday, November 12, 2019 from 12:00 p.m. - 1:00 p.m. EST.
- - -
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 Primary Care First Model Options team hosted a payment webinar on Wednesday, July 24, 2019 from 12:00 p.m. - 1:00 p.m. EDT. Topics discussed included how eligible practices can participate in the SIP payment model option of Primary Care First, eligibility requirements, quality measures, and payment.
- - -
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
February 9, 2012
These slides are designed for Post-Acute Care (PAC) providers seeking additional information about how Model 3 works and a better understanding of the opportunities for PAC providers within the Bundled Payment for Care Improvement (BPCI) initiative to achieve better care, better health and lower costs for their patients through care redesign.
More at: http://innovations.cms.gov/resources/Bundled-Payments-Model-3-Deep-Dive.html
- - -
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
Reporting quality data to the board of directorsCompliatric
This document provides guidance on presenting clinical quality data to health center boards of directors. It summarizes HRSA requirements for clinical quality reporting and the roles of health centers and boards in gathering and discussing this data. Health centers should determine who facilitates quality discussions at board meetings, develop a reporting schedule, and present data in an accessible format. Boards should receive training, review previous quality discussions, and engage in active discussion of quality metrics and their implications for strategic planning. The document also offers strategies for collecting, analyzing, and presenting clinical quality data to support management decision-making.
The document discusses ensuring quality of health care data from a Canadian perspective. It provides an overview of the Canadian Institute for Health Information (CIHI), which collects health data from various partners across Canada. CIHI faces challenges as a secondary data collector, dealing with varying standards and incomplete data reporting. The document outlines CIHI's strategies to ensure data quality, including its data quality framework, quality reports and studies, and techniques for communicating data quality to different audiences.
This webinar will highlight key areas from the document discussing what a strong application to the BPCI initiative should include. We encourage you to review the Models 2-4 application questions and the new Application Guidance document posted on the Bundled Payments for Care Improvement webpage, prior to this webinar.
More at: http://www.innovations.cms.gov/resources/Bundled-Payments-Application-Guidance.html
- - -
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 Center for Medicare & Medicaid Innovation (CMS Innovation Center) hosted the first of two webinars on November 19 to describe the final rule and respond to questions about the Comprehensive Care for Joint Replacement Model.
- - -
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
Emerging hscrc methodologies case pohl (final)James Case
The document discusses emerging methodologies being developed by the HSCRC to incentivize population health management under a potential CMS model testing demonstration. It describes how existing methodologies like the Admission-Readmission Revenue program and Total Patient Revenue would need to be modified. New approaches under consideration include Population-Based Reimbursement and requesting authority for bundled payments, ACOs, and gain sharing. Significant effort will be required to translate these approaches to an all-payer environment in Maryland.
The Kidney Care Choices (KCC) Model team hosted a Comprehensive Kidney Care Contracting (CKCC) Model Options introduction webinar on Tuesday, November 12, 2019 from 12:00 p.m. - 1:00 p.m. EST.
- - -
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 Primary Care First Model Options team hosted a payment webinar on Wednesday, July 24, 2019 from 12:00 p.m. - 1:00 p.m. EDT. Topics discussed included how eligible practices can participate in the SIP payment model option of Primary Care First, eligibility requirements, quality measures, and payment.
- - -
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
During this webinar the Direct Contracting Model Options team hosted a webinar on Tuesday, January 7, 2020 from 1:00 p.m.- 2:30 p.m. EST. During this webinar, presenters provided an overview and demonstration of the Direct Contracting application portal and answered questions about the portal from the audience.
- - -
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 Frontier Community Health Integration Project (FCHIP) aims to improve access to care for Medicare beneficiaries in sparsely populated areas through testing interventions like telemedicine, ambulance services, nursing facility care, and home health. The 3-year demonstration will be administered by the CMS Innovation Center and must be budget neutral. Eligible providers must be located in states where at least 65% of counties have 6 or fewer residents per square mile. Applicants must show how their proposed interventions will improve care coordination, decrease transfers, and be cost-neutral through cost savings. They must submit details on staffing, partnerships, and a budget projection to participate.
The Part D Senior Savings Model and Part D Payment Modernization Model teams hosted a webinar on Tuesday, March 23, 2021 from 1:00 to 2:00 PM EDT. During this webinar, presenters provided an overview of the two Models and the Calendar Year (CY) 2022 application process. The session also offered attendees an opportunity to ask follow-up questions.
- - -
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
This document discusses Michigan's Primary Care Transformation Demonstration Project. It outlines the agenda for webinar #10, including discussions on Medicaid and Medicare payments, care managers, project committees and metrics. It then provides details on performance metrics and incentives, care manager roles, clinical quality measures, and expectations for participating medical organizations. The webinar aims to update practices on the project and support development of patient-centered medical home capabilities.
The CMS Innovation Center hosted a webinar on Monday, March 3, 2014 to provide information on how to calculate budget neutrality for the five prongs in the Frontier Community Health Integration Project Demonstration. CMS also provided examples of ways that applicants can respond to the solicitation. Subject matter experts from the CMS Innovation Center and the Health Resources Services Administration (HRSA) provided details and answered questions.
- - -
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
This Medicare-Medicaid ACO Model webinar included information on the structure of the Model, Model details including beneficiary attribution, financial methodology and quality measurement options within the Model, and an explanation of data, learning and evaluation. The state-specific development and application process, including instructions for submitting letters of intent were also discussed. This webinar was open to the general public and targeted towards interested states.
- - -
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 Medicare Care Choices Model aims to expand access to concurrent palliative and curative care for Medicare beneficiaries with serious illnesses. It will test allowing participating hospices to provide supplemental palliative care services to eligible beneficiaries, while receiving curative treatment, in return for a $400 per beneficiary per month fee. Hospices must be Medicare-certified and able to coordinate care. Eligible beneficiaries have advanced cancers, lung disease, heart failure or HIV/AIDS. The model seeks to improve pain and symptom management through 24/7 access to hospice professionals and care coordination over three years. CMS implementation contractors will provide technical support to participating hospices.
The document discusses the transition to value-based care models and accountable care organizations (ACOs). It outlines five core competencies needed for early success in an ACO program like the Medicare Shared Savings Program (MSSP): 1) physician-centered governance, 2) collection and reporting of quality metrics, 3) data analysis and spend identification, 4) developing a post-acute quality provider network, and 5) population management strategies. It provides examples from Methodist Health System's experience in an MSSP ACO.
Conor Burke & Lucy Moore: Learning from an integrated care organisationNuffield Trust
This document discusses integrated care and the role of an integrated care organization called Whipps Cross University Hospital Trust. It notes that Whipps Cross aims to reduce outpatient appointments by 20% and elective procedures by 6% through decommissioning, while shifting 40% of A&E visits, 12% of electives, and 42% of outpatient appointments to prevent chronic conditions and improve acute quality. The document advocates changing systems rather than changing within systems to drive real improvement. It outlines PolySystems' goals of promoting community health, maximizing independence for those with long-term needs, and improving non-critical acute care. PolySystems aims to achieve improved outcomes using strategies like care navigation, improved coordination, and increased access
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
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
MD Revolution offers a digital health services platform called RevUp for chronic care management. RevUp uses algorithms to segment patients by clinical data, goals, and care plans. It then provides personalized coaching through secure messaging from care teams. In clinical trials, RevUp users experienced reductions in body fat, weight, blood pressure, and improvements in cardiorespiratory fitness after 90 days. MD Revolution provides an end-to-end chronic care management solution with tools for patient enrollment, care plan creation, clinically relevant messaging through multiple modalities, and billing automation.
MAFP Quality Reporting for Cash-CMS Incentives and Your Bottom Linelearfieldinteraction
This document discusses quality reporting incentives from CMS and their impact on physician practices. It outlines the requirements and incentives for three separate CMS programs - Meaningful Use, PQRS, and e-Prescribing. Participation in these programs can provide incentives, but failure to participate may result in payment penalties beginning in 2015. The document provides an overview of each program's objectives, measures, and reporting options to help physicians incorporate quality reporting into their practices.
The involvement of the Board of Directors is a critical component of a successful Quality Management Program. This webinar is for Health Center Grantees and their Board of Directors, and will provide strategies for presenting and discussing clinical quality data.
Areas of focus will include the following:
(1) The role of the Board of Directors in receiving clinical quality data.
(2) The role of the Health Center role in presenting quality data
(3) What factors to consider when gathering and presenting clinical quality data.
(4) The manner in which clinical quality data should be presented.
The alphabet soup of clinical quality measures reporting and reimbursement 2...Bill Presley
CMS is transitioning to what the they call "a new and more responsive regulatory framework" for quality reporting and reimbursement. CMS goals are "…electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people". Over the next couple years, we will see a transformation of fee for service into value-based care models driven by the VBP, Quality Payment Program, MACRA, Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM). Healthcare organizations will no longer be motivated by implementing and meeting Meaningful Use, but instead will be driven by value-based care and risk-based payment models that focus on quality outcomes for reimbursements.
In this Education Session we will review:
• How CMS is aligning clinical quality measures (CQMs) to reduce the reporting burden for healthcare organizations and providers. We will cover the vision and goals for achieving quality alignment for CMS.
• We will dive into the following CMS reporting programs and how they interact with each other: Value-Based Purchasing (VBP), Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payments (MIPS), Hospital Inpatient Quality Reporting (IQR), The Joint Commission (ORYX), Outpatient Quality Reporting (OQR), and Alternative Payment Models (APM).
• How the Eligible Hospital and Eligible Professional reimbursement models will change in 2017 and going forward.
• Compare and contrast the requirements for quality measure reporting and identify strategies to ensure compliance.
• The potential impact to hospital reimbursement of current and proposed programs that will affect quality reporting for hospitals and providers.
• How to improve efficiency and quality by aligning measures across initiatives.
• Where to find current information (and breaking news) on each of these Quality Initiatives.
In the past, organizations participating in quality reporting initiatives involved abstractors sifting through a small sample set of unstructured data in paper charts to then manually convert their findings to discrete reportable data. This approach is time consuming and requires extensive amount of resources from both IT and Quality staff. Aligning quality initiatives can improve efficiencies and processes, and contribute to population health management efforts, both locally and nationally.
At the conclusion of this presentation, attendees will be able to apply what they’ve learned about aligning Clinical Quality Measures across initiatives specific to their organization to improve reimbursements, reduce their reporting burden, increase efficiencies, and realize the benefits of Population Health Management.
If you are responsible for hospital quality, IT, clinical quality measure initiatives or have a vested interest in making sure your organization is aligning quality measures reporting, this informational session is a must.
MOC is a lifelong learning process designed to document that physician specialists, certified by one of the 24 Member Boards of the American Board of Medical Specialties, maintain the necessary competencies to provide quality patient care.
This document provides information about the 2007 Physician Quality Reporting Initiative (PQRI) including coding for quality measures. It discusses the PQRI tools available to help providers implement reporting like the measure list, coding handbook, and code master spreadsheet. It explains key principles for understanding the quality measures such as their scope, construct using codes to report clinical actions, and use of quality data codes and performance modifiers to relay reporting information. The document is intended to help providers successfully participate in the PQRI program.
Prepping for CCJR: Lessons Learned in Physician Alignment and Bundled PaymentsWellbe
With CMS’ recent announcement of its Comprehensive Care for Joint Replacement (CCJR) payment model and its plan to implement in seventy-five geographic areas, hospitals must be prepared to manage the entire episode of care from the time of surgery through ninety days after discharge. CCJR presents both opportunities and challenges for hospitals. In order to achieve success, organizations must manage their system of care delivery, ensure they are aligned with their physicians and post acute providers, and master the analytics necessary for driving high quality, low cost care.
MedAssets has worked with numerous providers to implement alignment models that bring hospitals and their physicians together, evaluate, identify, and implement changes to the care delivery system to improve quality and decrease cost across the continuum, and employ meaningful analytics for managing an episode of care.
Kevin Lieb, Senior Director for MedAssets’ Physician Alignment Solutions division, will share examples demonstrating how organizations have successfully implemented Episodes of Care. Mr. Lieb will also share examples from both hospital led and specialist led programs and provide lessons learned from these experiences.
This webinar will enable attendees to do the following:
• Identify alignment models within bundled payments and understand their applicability to your organization
• Understand the analytic capabilities necessary for success in a bundled payment environment
• Identify opportunities and strategies for cost reduction and quality improvement
About the Speaker:
Mr. Lieb has more than 20 years of healthcare-related experience focusing on quality improvement, market development and cost reduction initiatives for the hospital provider market. Mr. Lieb has worked for a number of well-known healthcare companies including GE Medical Systems, HCIA and LBA in Denver, Colorado. His responsibilities included healthcare consulting with a focus on process improvement and quality initiatives.
The document discusses clinical quality measures (CQMs) and reporting CQMs through Practice Fusion to meet requirements for programs like Meaningful Use and PQRS. It explains that providers are increasingly evaluated on quality and outcomes, describes key quality programs and their CQM reporting requirements, and provides guidance on selecting applicable CQMs and the reporting process through Practice Fusion.
During this webinar the Direct Contracting Model Options team hosted a webinar on Tuesday, January 7, 2020 from 1:00 p.m.- 2:30 p.m. EST. During this webinar, presenters provided an overview and demonstration of the Direct Contracting application portal and answered questions about the portal from the audience.
- - -
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 Frontier Community Health Integration Project (FCHIP) aims to improve access to care for Medicare beneficiaries in sparsely populated areas through testing interventions like telemedicine, ambulance services, nursing facility care, and home health. The 3-year demonstration will be administered by the CMS Innovation Center and must be budget neutral. Eligible providers must be located in states where at least 65% of counties have 6 or fewer residents per square mile. Applicants must show how their proposed interventions will improve care coordination, decrease transfers, and be cost-neutral through cost savings. They must submit details on staffing, partnerships, and a budget projection to participate.
The Part D Senior Savings Model and Part D Payment Modernization Model teams hosted a webinar on Tuesday, March 23, 2021 from 1:00 to 2:00 PM EDT. During this webinar, presenters provided an overview of the two Models and the Calendar Year (CY) 2022 application process. The session also offered attendees an opportunity to ask follow-up questions.
- - -
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
This document discusses Michigan's Primary Care Transformation Demonstration Project. It outlines the agenda for webinar #10, including discussions on Medicaid and Medicare payments, care managers, project committees and metrics. It then provides details on performance metrics and incentives, care manager roles, clinical quality measures, and expectations for participating medical organizations. The webinar aims to update practices on the project and support development of patient-centered medical home capabilities.
The CMS Innovation Center hosted a webinar on Monday, March 3, 2014 to provide information on how to calculate budget neutrality for the five prongs in the Frontier Community Health Integration Project Demonstration. CMS also provided examples of ways that applicants can respond to the solicitation. Subject matter experts from the CMS Innovation Center and the Health Resources Services Administration (HRSA) provided details and answered questions.
- - -
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
This Medicare-Medicaid ACO Model webinar included information on the structure of the Model, Model details including beneficiary attribution, financial methodology and quality measurement options within the Model, and an explanation of data, learning and evaluation. The state-specific development and application process, including instructions for submitting letters of intent were also discussed. This webinar was open to the general public and targeted towards interested states.
- - -
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 Medicare Care Choices Model aims to expand access to concurrent palliative and curative care for Medicare beneficiaries with serious illnesses. It will test allowing participating hospices to provide supplemental palliative care services to eligible beneficiaries, while receiving curative treatment, in return for a $400 per beneficiary per month fee. Hospices must be Medicare-certified and able to coordinate care. Eligible beneficiaries have advanced cancers, lung disease, heart failure or HIV/AIDS. The model seeks to improve pain and symptom management through 24/7 access to hospice professionals and care coordination over three years. CMS implementation contractors will provide technical support to participating hospices.
The document discusses the transition to value-based care models and accountable care organizations (ACOs). It outlines five core competencies needed for early success in an ACO program like the Medicare Shared Savings Program (MSSP): 1) physician-centered governance, 2) collection and reporting of quality metrics, 3) data analysis and spend identification, 4) developing a post-acute quality provider network, and 5) population management strategies. It provides examples from Methodist Health System's experience in an MSSP ACO.
Conor Burke & Lucy Moore: Learning from an integrated care organisationNuffield Trust
This document discusses integrated care and the role of an integrated care organization called Whipps Cross University Hospital Trust. It notes that Whipps Cross aims to reduce outpatient appointments by 20% and elective procedures by 6% through decommissioning, while shifting 40% of A&E visits, 12% of electives, and 42% of outpatient appointments to prevent chronic conditions and improve acute quality. The document advocates changing systems rather than changing within systems to drive real improvement. It outlines PolySystems' goals of promoting community health, maximizing independence for those with long-term needs, and improving non-critical acute care. PolySystems aims to achieve improved outcomes using strategies like care navigation, improved coordination, and increased access
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
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
MD Revolution offers a digital health services platform called RevUp for chronic care management. RevUp uses algorithms to segment patients by clinical data, goals, and care plans. It then provides personalized coaching through secure messaging from care teams. In clinical trials, RevUp users experienced reductions in body fat, weight, blood pressure, and improvements in cardiorespiratory fitness after 90 days. MD Revolution provides an end-to-end chronic care management solution with tools for patient enrollment, care plan creation, clinically relevant messaging through multiple modalities, and billing automation.
MAFP Quality Reporting for Cash-CMS Incentives and Your Bottom Linelearfieldinteraction
This document discusses quality reporting incentives from CMS and their impact on physician practices. It outlines the requirements and incentives for three separate CMS programs - Meaningful Use, PQRS, and e-Prescribing. Participation in these programs can provide incentives, but failure to participate may result in payment penalties beginning in 2015. The document provides an overview of each program's objectives, measures, and reporting options to help physicians incorporate quality reporting into their practices.
The involvement of the Board of Directors is a critical component of a successful Quality Management Program. This webinar is for Health Center Grantees and their Board of Directors, and will provide strategies for presenting and discussing clinical quality data.
Areas of focus will include the following:
(1) The role of the Board of Directors in receiving clinical quality data.
(2) The role of the Health Center role in presenting quality data
(3) What factors to consider when gathering and presenting clinical quality data.
(4) The manner in which clinical quality data should be presented.
The alphabet soup of clinical quality measures reporting and reimbursement 2...Bill Presley
CMS is transitioning to what the they call "a new and more responsive regulatory framework" for quality reporting and reimbursement. CMS goals are "…electronic health records helping physicians, clinicians, and hospitals to deliver better care, smarter spending, and healthier people". Over the next couple years, we will see a transformation of fee for service into value-based care models driven by the VBP, Quality Payment Program, MACRA, Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APM). Healthcare organizations will no longer be motivated by implementing and meeting Meaningful Use, but instead will be driven by value-based care and risk-based payment models that focus on quality outcomes for reimbursements.
In this Education Session we will review:
• How CMS is aligning clinical quality measures (CQMs) to reduce the reporting burden for healthcare organizations and providers. We will cover the vision and goals for achieving quality alignment for CMS.
• We will dive into the following CMS reporting programs and how they interact with each other: Value-Based Purchasing (VBP), Medicare Access and CHIP Reauthorization Act (MACRA), Merit-based Incentive Payments (MIPS), Hospital Inpatient Quality Reporting (IQR), The Joint Commission (ORYX), Outpatient Quality Reporting (OQR), and Alternative Payment Models (APM).
• How the Eligible Hospital and Eligible Professional reimbursement models will change in 2017 and going forward.
• Compare and contrast the requirements for quality measure reporting and identify strategies to ensure compliance.
• The potential impact to hospital reimbursement of current and proposed programs that will affect quality reporting for hospitals and providers.
• How to improve efficiency and quality by aligning measures across initiatives.
• Where to find current information (and breaking news) on each of these Quality Initiatives.
In the past, organizations participating in quality reporting initiatives involved abstractors sifting through a small sample set of unstructured data in paper charts to then manually convert their findings to discrete reportable data. This approach is time consuming and requires extensive amount of resources from both IT and Quality staff. Aligning quality initiatives can improve efficiencies and processes, and contribute to population health management efforts, both locally and nationally.
At the conclusion of this presentation, attendees will be able to apply what they’ve learned about aligning Clinical Quality Measures across initiatives specific to their organization to improve reimbursements, reduce their reporting burden, increase efficiencies, and realize the benefits of Population Health Management.
If you are responsible for hospital quality, IT, clinical quality measure initiatives or have a vested interest in making sure your organization is aligning quality measures reporting, this informational session is a must.
MOC is a lifelong learning process designed to document that physician specialists, certified by one of the 24 Member Boards of the American Board of Medical Specialties, maintain the necessary competencies to provide quality patient care.
This document provides information about the 2007 Physician Quality Reporting Initiative (PQRI) including coding for quality measures. It discusses the PQRI tools available to help providers implement reporting like the measure list, coding handbook, and code master spreadsheet. It explains key principles for understanding the quality measures such as their scope, construct using codes to report clinical actions, and use of quality data codes and performance modifiers to relay reporting information. The document is intended to help providers successfully participate in the PQRI program.
Prepping for CCJR: Lessons Learned in Physician Alignment and Bundled PaymentsWellbe
With CMS’ recent announcement of its Comprehensive Care for Joint Replacement (CCJR) payment model and its plan to implement in seventy-five geographic areas, hospitals must be prepared to manage the entire episode of care from the time of surgery through ninety days after discharge. CCJR presents both opportunities and challenges for hospitals. In order to achieve success, organizations must manage their system of care delivery, ensure they are aligned with their physicians and post acute providers, and master the analytics necessary for driving high quality, low cost care.
MedAssets has worked with numerous providers to implement alignment models that bring hospitals and their physicians together, evaluate, identify, and implement changes to the care delivery system to improve quality and decrease cost across the continuum, and employ meaningful analytics for managing an episode of care.
Kevin Lieb, Senior Director for MedAssets’ Physician Alignment Solutions division, will share examples demonstrating how organizations have successfully implemented Episodes of Care. Mr. Lieb will also share examples from both hospital led and specialist led programs and provide lessons learned from these experiences.
This webinar will enable attendees to do the following:
• Identify alignment models within bundled payments and understand their applicability to your organization
• Understand the analytic capabilities necessary for success in a bundled payment environment
• Identify opportunities and strategies for cost reduction and quality improvement
About the Speaker:
Mr. Lieb has more than 20 years of healthcare-related experience focusing on quality improvement, market development and cost reduction initiatives for the hospital provider market. Mr. Lieb has worked for a number of well-known healthcare companies including GE Medical Systems, HCIA and LBA in Denver, Colorado. His responsibilities included healthcare consulting with a focus on process improvement and quality initiatives.
The document discusses clinical quality measures (CQMs) and reporting CQMs through Practice Fusion to meet requirements for programs like Meaningful Use and PQRS. It explains that providers are increasingly evaluated on quality and outcomes, describes key quality programs and their CQM reporting requirements, and provides guidance on selecting applicable CQMs and the reporting process through Practice Fusion.
This document provides an overview and summary of quality in healthcare initiatives. It discusses the industry background and shift towards quality and value-based care. It outlines key federal quality programs like CMS Star Ratings and accrediting entities like NCQA. It also summarizes Puerto Rico's quality retention fund and examples of clinical quality measures like breast cancer screening and diabetes management. Finally, it reviews risk adjustment programs in Medicare Advantage, Commercial ACA, and Managed Medicaid.
During this webinar, a high-level overview of the ACO REACH Model was provided including information on the participation and eligibility requirements, Accountable Care Organization (ACO) types, payment mechanisms, and beneficiary alignment methodology.
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Clinical Integration: The Foundation for Accountable Care - Presentation delivered by Keynote Speaker Marvin O’Quinn, Senior Executive Vice President and Chief Operating Officer, Dignity Health at the National Healthcare CXO Summit held in Las Vegas Oct 19-21, 2014.
This document provides an overview and agenda for a presentation on succeeding under MACRA and MIPS. It discusses what MACRA is and why providers should care about it. MACRA replaces previous payment systems with two new tracks: MIPS and Advanced APMs. MIPS has four performance categories that will determine reimbursements starting in 2017. It also provides a checklist for MIPS participation eligibility and requirements. The presentation reviews the specific criteria and measures under each MIPS performance category. It outlines the MIPS reporting timeline for 2017 and options to pick the best pace. The document concludes by explaining how the Elation software can support practices in meeting MIPS requirements through built-in quality tracking, clinical decision support, and other tools.
An actionable summary of the MIPS Merit-Incentive Based Payment System, MACRA (or the Quality Payment Program), and how to approach value-based healthcare.
This document advertises a study seeking 20 adults aged 35 or older who are at risk of or living with diabetes, have not had formal diabetes education in the past year, regularly use the internet, and can read and speak English, to complete two 20-minute online surveys for $40 total to help improve a diabetes website, with recruitment occurring through November 15, 2014.
This document contains guidelines for the Patient-Centered Medical Home (PCMH) and PCMH-Neighbor programs run by Blue Cross Blue Shield of Michigan (BCBSM). It outlines 14 domains of function that practices must meet capabilities for, such as patient registries, performance reporting, care management, and coordination of care. The document provides details on the required capabilities within each domain, interpretive guidelines, and requirements for verification site visits. It also addresses how specialists can partner with primary care practices through the PCMH-Neighbor program to better coordinate care for shared patients.
This document provides updates on quarterly reports that must be submitted to Christine and ensure accuracy. It discusses that MiPCT requested MNO attestation of using the registry, having a quality improvement process, and reviewing data. Finally, it addresses education requirements of three 4-hour sessions on CPT and ICD-9 use, and notes that care management numbers have decreased but the care team remains. An extension of MiPCT is unknown and status quo for now.
This document provides information on various programs and services available for breast and cervical cancer screening, family planning, pregnancy and new mother support, pediatric care, and dental care in Macomb and Oakland counties in Michigan. It lists contact information, eligibility requirements, and services offered for programs like BCCCP, WIC, Medicaid family planning services, food pantries, counseling services, and low-cost dental clinics.
The document describes strategies for developing effective healthcare teams. It discusses establishing care teams with interdisciplinary members and providing training. Key elements of team-based care include protocol-driven processes, care management services, managing care transitions, and engaging patients and families. The document also outlines metrics for measuring utilization, clinical quality, and care processes and explains that implementing a bundle of improvement changes through an interdisciplinary team approach leads to better outcomes.
This document outlines the agenda for a MiPCT Demonstration Project meeting, including: introducing new practice team members, comparing G code billing results between practices, discussing care managers and metrics for 2014. It reviews utilization, clinical quality, and process measures that will be assessed. Learning requirements are outlined for care managers and practice teams, including ICD-10 workshops and a learning collaborative. Participating practice teams are listed and an open discussion is invited.
This document summarizes a focus meeting for PCPs that covered several topics: Medicare risk adjustment, risk scoring, and quality star ratings; the Choosing Wisely campaign; advance care planning; and patient-centered medical homes. It provided details on CMS risk adjustment models, proper medical record documentation for risk adjustment, and ways accurate coding can improve reimbursement and lower member premiums. It also reviewed the STAR bonus program metrics and preventive services. Finally, it discussed introducing advance care planning conversations, documenting patient preferences, and applying advance directives when needed.
This document summarizes a PCP focus meeting that covered several topics: Medicare correct coding initiative, Choosing Wisely campaign, advance care planning, patient-centered medical home designations, organized systems of care, optimizing risk adjustment and stars ratings, and advance directives. It provides details on CMS risk adjustment models, required medical record documentation, acceptable provider types and signatures, case studies, and steps for successful advance care planning.
Behavioral Health Specialist Meeting: Keeping You in the Loopmednetone
The document summarizes key points from a meeting between Medical Network One and behavioral health specialists. It introduced Medical Network One and described its history of collaborating with BCBSM on initiatives like the Physician Group Incentive Program (PGIP), Patient-Centered Medical Home (PCMH), and Organized Systems of Care (OSC). It discussed how collaboration between Medical Network One and behavioral health specialists might work, including developing shared goals and responsibilities. The document also provided an overview of the PCMH, PCMH-Neighborhood, and OSC models, and explained how performance is measured using standards like HEDIS.
This document summarizes a new Medicare Advantage Gain Sharing program offered by Blue Cross Blue Shield of Michigan and Blue Care Network. It provides incentives for providers to improve performance in documentation and coding, utilization, costs, and quality measures. Providers can earn a share of financial gains if they meet education and performance criteria, such as attending training, closing diagnosis code gaps, and improving quality scores and readmission rates. The program compares potential earnings to an alternative diagnosis closure incentive program, paying providers the higher of the two amounts. It includes examples of how earnings are calculated based on members' risk scores and expenses.
The document summarizes key points from a PCP cluster meeting held on November 13, 2013 in Monroe, Michigan. The meeting focused on several topics: Medicare correct coding initiative, Choosing Wisely campaign, advance care planning, patient-centered medical home designations, organized systems of care, and risk adjustment. The risk adjustment portion provided details on CMS risk scoring, hierarchical condition categories, documentation requirements, and a case study example. It also discussed the Medicare Advantage STAR bonus program and its quality measures. Finally, the document covered advance care planning and POLST (Physician Orders for Life-Sustaining Treatment) forms.
This document outlines guidelines for collaboration between primary care and specialty care providers to improve patient care. It defines key terms like patient-centered medical home and discusses different types of care transitions including pre-consultation, formal consultation, complete transfer of care, and co-management. The guidelines establish mutual agreements around maintaining accurate records, safe transfers of care, and adopting a referral system. It provides templates for primary care and specialty care expectations in areas like maintaining records, ordering tests, informing patients, and timely communication. The overall goal is to enhance communication and collaboration between providers through coordinated, patient-centered care.
This document outlines a webinar for the Michigan Primary Care Transformation Demonstration Project. It lists the practices in attendance at the webinar and their scheduled dates for best practice showcases. It also details the learning requirements for care managers and practice units in 2014, including required hours and acceptable training activities. Finally, it lists the practices that participated in a learning event in 2013 and those that were absent.
This document outlines details from a webinar on the Michigan Primary Care Transformation Demonstration Project that took place on October 23, 2013. It lists the practices in attendance and their scheduled dates to present their best practices. It also discusses funding, learning requirements, practice visits, the Choosing Wisely campaign, and the State Innovation Model initiative. The webinar covered key details about the project for the participating primary care practices.
This document outlines a webinar for the Michigan Primary Care Transformation Demonstration Project. It lists the practices in attendance at the webinar and their scheduled dates for best practice visits. It also details the learning requirements for care managers and practice units in 2014. Finally, it notes which practices attended a learning event in 2013 and which were absent.
The document advertises the R-Team healthy lifestyle program for kids and teens. The 10-session program teaches healthy eating, exercise, self-esteem and goal setting. Each child receives an individual assessment before starting group sessions. Parents must attend all sessions with their child. Contact and registration information is provided for programs in Madison Heights, Woodhaven and Rochester, Michigan between March 2015 and November 2015.
This document provides information about the Michigan Primary Care Transformation Demonstration Project webinar that took place on September 25, 2013. It lists the practices that attended the webinar and announces an upcoming learning event on September 28th to provide updates to practice teams on new billing codes, advance care planning, and quality improvement processes. It then outlines the schedule for best practice showcases at different practices between September 2013 and April 2014. The document concludes by defining key terms related to the Multi-payer Advanced Primary Care Practice Demonstration, including the purpose and goals of evaluating the demonstration and defining care management.
This document summarizes a webinar for the Michigan Primary Care Transformation Demonstration Project. It lists the attendees of the webinar and recognizes practices that have achieved URAC accreditation or provided appreciation. It outlines quality metrics and goals for care managers, such as engaging patients in care management. It also announces upcoming training events for care managers and practices in July and a challenge to enroll new patients. Time is allotted at the end for open discussion.
The document describes several healthcare organizations' Performance Recognition Programs (PRP) for 2013. It outlines changes made to the programs, including increasing budgets, eliminating pay-as-you-go components, and scoring providers individually on quality measures. Providers can earn payments by meeting quality goals or improving scores by a certain percentage. The programs include measures related to preventative screenings, disease management, and controlling conditions like diabetes and cardiovascular disease. Bonus payments are available for measures like adult BMI tracking and annual medication monitoring.
This referral form provides patient and physician information for referral to Medical Nutrition Therapy and Diabetes Self Management Education. It includes the patient's name, date of birth, contact information, insurance information, and health details like blood pressure, height, and weight. The form indicates a need for either initial or follow-up Medical Nutrition Therapy, and lists possible reasons for referral to Diabetes Self Management Training. Relevant medical details and lab results are requested to better assess the patient's needs. The referring physician's signature and contact information is included.
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. Care Managers
Each discipline
• PA/NP/APN
• RN
• PhD/LLPsych
• MSW/LMSW
• Pharmacist
• Dietitian
• Health Educator
• Health Coach
4
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. Care Manager Activity Reporting
Two reporting options available:
• Manual data entry directly into the financial
reporting template
• Upload of standardized files
6
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. 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
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
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. 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. PCMH-MiPCT Learning Activities
Town Hall dinners
MiPCT Learning Collaboratives
Monthly practice PCMH meetings
Attendance at Annual MiPCT Summit
17
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. Webinars
Volunteers for best practices to be presented at
the webinars
Any team member may provide “best practice”
20
21. Medicare Advantage
CMS Risk Adjustment Model
CMS Star Quality Bonus Program
New Medicare Preventive Services & Health Risk
Assessment
21
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. 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. 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 427.81
105 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 557.9
108 COPD: 491.xx, 492.x, 493.2x, 496, 518.1, and 518.2
131 Renal Failure: 403.x1, 404.x2, 404.x3, 584.x, 585.x (excludes 585), 586, and 753.14
132 Nephritis: 078.6, 580.xx, 581.xx – 583.xx
This information can be accessed at CMS.gov
24
26. Measures Fall into
Four Categories
HEDIS
(Health CMS
Effectiveness administrative
Data and measures
Information
Set)
CAHPS
(Consumer Health
Assessment of Outcomes
Healthcare Survey
Providers and
Systems)
26
27. Stars Measures
Medicare
Data Dates of BCN
Title Description Plus Blue
Source Service Advantage
PPO
Breast Cancer Ages 40 to 74, one or more mammograms HEDIS 2011 4 4
Screening during the measurement year or the year
prior
Colorectal Cancer Ages 50 to 75, one or more appropriate HEDIS 2011 5 4
Screening screenings for colorectal cancer
Cholesterol Ages 18–75, discharged alive for Acute HEDIS 2011 5 5
Screening for Myocardial Infarction (AMI), coronary
patients with artery bypass graft (CABG) or percutaneous
Heart 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 performed
Cholesterol Ages 18-75 with diabetes, who had an LDL- HEDIS 2011 5 4
Screening for C screening test performed
patients with
Diabetes
27
28. Stars Measures
Medicare
Data Dates of BCN
Title Description Plus Blue
Source Service Advantage
PPO
Glaucoma Ages 65 years and older, without a HEDIS 2011 3 4
Screening prior diagnosis of glaucoma or
glaucoma suspect, who received a
glaucoma eye exam by an eye care
professional
Annual Flu Received an influenza vaccination CAHPS 2012 4 4
Vaccine
Improving or Sampled Medicare enrollees whose HOS 2009 5 Plan too
Maintaining physical health status was the same 1st new to
Physical or better than expected Survey have
Health** 2011 data
2nd
Survey
Improving or Sampled Medicare enrollees whose HOS 2009 3 Plan too
Maintaining mental health status was the same 1st new to
Mental or better than expected Survey have
Health** 2011 data
2nd
Survey
28
29. Stars Measures
Medicare
Source of Dates of BCN
Title Description Plus Blue
Data Service Advantage
PPO
Monitoring Sampled ages 65 years or older, who had a HOS 2009 1st 2 2
Physical doctor‘s visit in the past 12 months and who Survey
Activity received advice to start, increase or maintain 2011 2nd
their level exercise or physical activity Survey
Adult BMI Ages 18-74 years, who had an outpatient visit HEDIS 2011 4 3
Assessment and who had their body mass index (BMI)
documented during the measurement year or
the year prior
Osteoporosis Females ages 67 and older, who suffered a HEDIS 2011 1 1
Management 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. Stars Measures
Medicare
Source of Dates of BCN
Title Description Plus Blue
Data Service Advantage
PPO
Diabetes Care
Eye Exam Ages 18-75 with diabetes, who had a retinal eye HEDIS 2011 4 4
exam
Kidney Ages 18-75 with diabetes, who had medical HEDIS 2011 5 3
Disease attention for nephropathy
Monitoring
Blood Sugar Ages 18-75 with diabetes, whose most recent HEDIS 2011 4 2
Controlled** 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 3
Controlled** LDL-C level was less than 100
** Weighting is three times the Star measure.
30
31. Stars Measures
Medicare
Source of Dates of BCN
Title Description Plus Blue
Data Service Advantage
PPO
Controlling Ages18–85, who had a diagnosis of HEDIS 2011 5 2
Blood hypertension (HTN) and whose BP was
Pressure** adequately controlled (<140/90)
Rheumatoid Diagnosed with rheumatoid arthritis during the HEDIS 2011 4 4
Arthritis measurement year, who were dispensed at least
Management one ambulatory prescription for a disease
modifying anti-rheumatic drug (DMARD)
Improving Ages 65 or older, who reported having a urine HOS 2009 3 3
Bladder leakage problem in the past six months and who 1st
Control received treatment for their current urine Survey
leakage problem 2011
2nd
Survey
** Weighting is three times the Star measure.
31
32. Stars Measures
Medicare
Source Dates of BCN
Title Description Plus Blue
of Data Service Advantage
PPO
Reducing the Ages 65 or older, who had a fall or had problems HOS 2009 4 3
Risk of with balance or walking in the past 12 months, 1st
Falling who were seen by a practitioner in the past 12 Survey
months and who received fall risk intervention 2011
from their current practitioner 2nd
Survey
Drug Plan Ages 65 or older, who received two or more PDE 2011 5 5
Members 65 prescription fills for a high risk medication
and Older
Who Receive
High Risk
Meds**
Blood Received an ACE/ARB medication among those PDE 2011 3 2
Pressure who were dispensed at least one prescription for
Meds for an oral hypoglycemic agent or insulin and at least
Diabetes** one prescription for an antihypertensive agent
PDE = Prescription drug event records ** Weighting is three times the Star measure.
32
33. Stars Measures
Medicare
Source of Dates of BCN
Title Description Plus Blue
Data Service Advantage
PPO
Medication Ages 18 or older, who adhere to their prescribed PDE 2011 4 5
Adherence for drug therapy across four classes of oral diabetes
Diabetes** medications: biguanides, sulfonylureas,
thiazolidinediones, and DiPeptidyl Peptidase
(DPP)-IV Inhibitors.
Medication Ages 18 or older, who adhere to their prescribed PDE 2011 5 5
Adherence 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 5
Adherence for drug therapy for statin cholesterol medications.
Cholesterol**
** Weighting is three times the Star measure.
33
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. 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. 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. 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. Five Things To Remember
No rule outs
Appropriate signatures
Supportive documentation of diagnosis
Face-to-face visit
Star measurements
38