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MiPCT Webinar 03/06/2013
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.
MiPCT Webinar 03/06/2013
- 1. Michigan Primary Care Transformation Demonstration Project March 6, 2013 Webinar
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- 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 ActivityReporting 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 ActivityReporting Two reporting options available: • Manual data entry directly into the financial reporting template • Upload of standardized files 6
- 7. Care Manager ReportingActivity 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 ReportingActivity Option Two • PO generates a file that conforms to specific file requirements (e.g., tab-delimited text file) and contains practice unit and care manager IDs • MNO submitted appropriate file for testing • MNO generates file electronically, making it much easier and more accurate than typing the information into the web application 8
- 9. Care Manager ReportingActivity PCMH Practice PCMH Practice ID 9
- 10. Care Manager ReportingActivity Care Manager Provides • Patient Last Name (pre-populated) • Patient First Name (pre-populated) • Patient Date of Birth (pre-populated) 10
- 11. Care Manager ReportingActivity Face-to-Face Encounters • Medicaid • Medicare • Medicare Advantage • BCBSM • BCN 11
- 12. Care Manager ReportingActivity Telephonic Encounters • Medicaid • Medicare • Medicare Advantage • BCBSM • BCN 12
- 13. Care Manager ReportingActivity Unique Patients • Medicaid • Medicare • Medicare Advantage • BCBSM • BCN 13
- 14. Additional Patient Population Priority BCBSM Self insured plans 14
- 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
- 18. PCMH-MiPCT Learning Activities MNO led activities PTI led activities with CME and IACET credits 18
- 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 AboutRisk Adjustment? Compliance with CMS diagnostic submission requirements Compliance with CMS diagnostic submission requirements Compliance with CMS diagnostic submission requirements 22
- 23. Why Care AboutRisk 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 MissedOpportunities 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
- 25. Star Quality BonusPayments 25
- 26. Measures Fall into FourCategories 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 ToRemember No rule outs Appropriate signatures Supportive documentation of diagnosis Face-to-face visit Star measurements 38
- 39.