MiPCT Webinar 03/06/2013
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Michigan Primary Care Transformation
Demonstration Project
March 6, 2013 Webinar
Six Month Incentive Disbursements
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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
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Care Managers
Each discipline
• PA/NP/APN
• RN
• PhD/LLPsych
• MSW/LMSW
• Pharmacist
• Dietitian
• Health Educator
• Health Coach
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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
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Care Manager Activity Reporting
Two reporting options available:
• Manual data entry directly into the financial reporting template
• Upload of standardized files
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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
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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
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Care Manager Reporting Activity
PCMH Practice
PCMH Practice ID
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Care Manager Reporting Activity
Care Manager Provides
• Patient Last Name (pre-populated)
• Patient First Name (pre-populated)
• Patient Date of Birth (pre-populated)
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Care Manager Reporting Activity
Face-to-Face Encounters
• Medicaid
• Medicare
• Medicare Advantage
• BCBSM
• BCN
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Care Manager Reporting Activity
Telephonic Encounters
• Medicaid
• Medicare
• Medicare Advantage
• BCBSM
• BCN
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Care Manager Reporting Activity
Unique Patients
• Medicaid
• Medicare
• Medicare Advantage
• BCBSM
• BCN
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Additional Patient Population
Priority
BCBSM Self insured plans
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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
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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
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PCMH-MiPCT Learning Activities
Town Hall dinners
MiPCT Learning Collaboratives
Monthly practice PCMH meetings
Attendance at Annual MiPCT Summit
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PCMH-MiPCT Learning Activities
MNO led activities
PTI led activities with CME and IACET credits
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Education Programs
Certified coder workshops for physicians and
teams
Appropriate use of ICD-9 Codes
Advanced Care Planning
Durable power of attorney
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Webinars
Volunteers for best practices to be presented at
the webinars
Any team member may provide “best practice”
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Medicare Advantage
CMS Risk Adjustment Model
CMS Star Quality Bonus Program
New Medicare Preventive Services & Health Risk
Assessment
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Why Care About Risk Adjustment?
Compliance with CMS diagnostic submission
requirements
Compliance with CMS diagnostic submission
requirements Compliance with CMS diagnostic
submission requirements
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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
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Ten Most Missed Opportunities
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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
Star Quality Bonus Payments
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HEDIS
(Health Effectiveness
Data and Information
Set)
CMS administrative
measures
CAHPS
(Consumer Assessment of
Healthcare Providers and
Systems)
Health Outcomes
Survey
Measures Fall into Four Categories
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Stars Measures
Title Description Data
Source Dates of Service
BCN Advantage
Medicare Plus Blue
PPO
Breast Cancer Screening
Ages 40 to 74, one or more mammograms during the measurement year or the year prior
HEDIS 2011 4 4
Colorectal Cancer Screening
Ages 50 to 75, one or more appropriate screenings for colorectal cancer
HEDIS 2011 5 4
Cholesterol Screening for patients with Heart Disease
Ages 18–75, discharged alive for Acute Myocardial Infarction (AMI), coronary artery bypass graft (CABG) or percutaneous 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
HEDIS 2011 5 5
Cholesterol Screening for patients with Diabetes
Ages 18-75 with diabetes, who had an LDL-C screening test performed
HEDIS 2011 5 4
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Stars Measures
Title Description Data
Source Dates of Service
BCN Advantage
Medicare Plus Blue
PPO
Glaucoma Screening
Ages 65 years and older, without a prior diagnosis of glaucoma or glaucoma suspect, who received a glaucoma eye exam by an eye care professional
HEDIS 2011 3 4
Annual Flu Vaccine
Received an influenza vaccination CAHPS 2012 4 4
Improving or Maintaining Physical Health**
Sampled Medicare enrollees whose physical health status was the same or better than expected
HOS 2009 1st Survey 2011 2nd Survey
5 Plan too new to have data
Improving or Maintaining Mental Health**
Sampled Medicare enrollees whose mental health status was the same or better than expected
HOS 2009 1st Survey 2011 2nd Survey
3 Plan too new to have data
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Stars Measures
Title Description Source of
Data Dates of Service
BCN Advantage
Medicare Plus Blue
PPO
Monitoring Physical Activity
Sampled ages 65 years or older, who had a doctor‘s visit in the past 12 months and who received advice to start, increase or maintain their level exercise or physical activity
HOS 2009 1st Survey 2011 2nd Survey
2 2
Adult BMI Assessment
Ages 18-74 years, who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior
HEDIS 2011 4 3
Osteoporosis Management
Females ages 67 and older, who suffered a 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
HEDIS 2011 1 1
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Stars Measures
Title Description Source of
Data Dates of Service
BCN Advantage
Medicare Plus Blue
PPO
Diabetes Care
Eye Exam Ages 18-75 with diabetes, who had a retinal eye exam
HEDIS 2011 4 4
Kidney Disease Monitoring
Ages 18-75 with diabetes, who had medical attention for nephropathy
HEDIS 2011 5 3
Blood Sugar Controlled**
Ages 18-75 with diabetes, whose most recent HbA1c level is greater than 9%, or who were not tested (This measure is reverse scored so higher scores are better.)
HEDIS 2011 4 2
Cholesterol Controlled**
Ages 18-75 with diabetes, whose most recent LDL-C level was less than 100
HEDIS 2011 5 3
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** Weighting is three times the Star measure.
Stars Measures
Title Description Source of
Data Dates of Service
BCN Advantage
Medicare Plus Blue
PPO
Controlling Blood Pressure**
Ages18–85, who had a diagnosis of hypertension (HTN) and whose BP was adequately controlled (<140/90)
HEDIS 2011 5 2
Rheumatoid Arthritis Management
Diagnosed with rheumatoid arthritis during the measurement year, who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD)
HEDIS 2011 4 4
Improving Bladder Control
Ages 65 or older, who reported having a urine leakage problem in the past six months and who received treatment for their current urine leakage problem
HOS 2009 1st Survey 2011 2nd Survey
3 3
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** Weighting is three times the Star measure.
Stars Measures
Title Description Source of Data
Dates of Service
BCN Advantage
Medicare Plus Blue
PPO
Reducing the Risk of Falling
Ages 65 or older, who had a fall or had problems with balance or walking in the past 12 months, who were seen by a practitioner in the past 12 months and who received fall risk intervention from their current practitioner
HOS 2009 1st Survey 2011 2nd Survey
4 3
Drug Plan Members 65 and Older Who Receive High Risk Meds**
Ages 65 or older, who received two or more prescription fills for a high risk medication
PDE 2011 5 5
Blood Pressure Meds for Diabetes**
Received an ACE/ARB medication among those who were dispensed at least one prescription for an oral hypoglycemic agent or insulin and at least one prescription for an antihypertensive agent
PDE 2011 3 2
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PDE = Prescription drug event records ** Weighting is three times the Star measure.
Stars Measures
Title Description Source of
Data Dates of Service
BCN Advantage
Medicare Plus Blue
PPO
Medication Adherence for Diabetes**
Ages 18 or older, who adhere to their prescribed drug therapy across four classes of oral diabetes medications: biguanides, sulfonylureas, thiazolidinediones, and DiPeptidyl Peptidase (DPP)-IV Inhibitors.
PDE 2011 4 5
Medication Adherence for Hypertension**
Ages 18 or older, who adhere to their prescribed drug therapy for renin angiotensin system (RAS) antagonists (angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or direct renin inhibitor medications).
PDE 2011 5 5
Medication Adherence for Cholesterol**
Ages 18 or older, who adhere to their prescribed drug therapy for statin cholesterol medications.
PDE 2011 5 5
33 ** Weighting is three times the Star measure.
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
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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
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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
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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
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Five Things To Remember
No rule outs
Appropriate signatures
Supportive documentation of diagnosis
Face-to-face visit
Star measurements
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Open Discussion
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