2020 ar medicaid pcmh - afmc · 2020 ar medicaid pcmh performance based, moving forward. agenda •...
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2020 AR Medicaid PCMH
Performance Based, Moving Forward
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Agenda• Status of Current Medicaid PCMH Program• Activities and Validation Process for 2020• Antibiotic Stewardship• Metrics for 2020
o Quality o Core (Low Performance Metrics)o PBIP Measures
• Reconsideration for 2019 PBIP• 2020 Reporting • SHARE Update
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Current Medicaid PCMH Program Status
Interesting Year! New Tools ProvidedThankfulMoving Forward
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2018 Performance Period compared to 2017
2019 PBIP MeasuresHospitalization was down by 12.3% Emergency room visits down by 3% Adolescent Wellness up by 5.9%
2019 Core MeasureInfant Wellness up by 7.2%BMI still struggled
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2020 PCMH Activities and
Validation Processes
Shelley Ruth PCMH QA Manager
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2020 Practice Support Activities
Activity3 Month
3/31/20206 Month
6/30/202012 Month
12/31/2020
A Identify top 10% of high-priority patients (including BH clients) •
B Provide 24/7 access to care •
C Document approach to expanding access to same-day appointments •
D Capacity to receive direct e-messaging from patients: Describe method of e-messaging used •
E Childhood/Adult Vaccination Practice Strategy •
F Join SHARE or participate in a network that delivers hospital discharge information to practice within 48 hours
•
G Medication Management: Describe the practices EHR reconciliation process. Document updates to active medication list in EHR for HPB
•
H Care Plans for High Priority Patients: create care plans •
I Patient Literacy Assessment Tool: Choose any health literacy tool and administer the screening to at least 75 patients (enrolled in the PCMH program) or their care givers
•
J Ability to receive Patient Feedback: Indicate method used to receive patient feedback and describe how feedback is used to make improvements
•
K Care Instructions for HPB: Create and share with the patient an after-visit summary of the patient’s visit. Include diagnosis, medication list, tests and results (if available), referrals (if applicable), and follow up instructions
•
L 10-day follow up after an acute inpatient hospital stay •
M Developmental/Behavior Health Assessment for Children and Adolescents •
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Fast Track Care Plan Audit Details
§ Fast Track Audit vs. Regular Audit• Only required to submit five care plans for Fast Track• 20% of the attested to care plans are selected for regular audit
§ Qualifications for the Fast Track Care Plan Audit• Must pass at least two consecutive years of care plans audits • Must not have been placed in remediation for care plans
§ Fast Track Disqualifications• Not meeting the 80% target• Placed in remediation
§ Scoring method• Two points for each required element• Care Plan validation spreadsheet
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Virtual Validation of Activities
§ Virtual Validation vs Onsite Validation• Submits supporting documentation electronically• Email is the preferred method of submission
§ Qualifications for Virtual Validation• Must pass at least two consecutive years of activity validation• Must not have been placed in remediation for activities
§ Virtual Validation Disqualifications• Not meeting activity requirements• Placed in remediation
§ Process• Complete attestations by deadlines• Submit supporting documentation
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OUTPATIENT ANTIBIOTIC STEWARDSHIP WILLIAM GOLDEN MD MACP
MEDICAL DIRECTOR, OFFICE OF HEALTH INFORMATION TECHNOLOGY
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Antibiotic Resistance
CDC. Antibiotic resistance threats in the United States, 2013. www.cdc.gov/drugresistance/threat-report-2013/
$20 billion in excess direct healthcare costs annually
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Stewardship across the spectrum of healthcare
http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html
http://www.cdc.gov/longtermcare/pdfs/core-elements-antibiotic-stewardship.pdf
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Fleming-Dutra. JAMA 2016;315(17): 1864-1873. The Pew Charitable Trusts. May 2016.
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Provider variability: Habit of prescribing antibiotics§ In a large study of 1 million VA outpatient visits for acute respiratory infections (ARIs, many of which
did not require antibiotics)
– Highest 10% of providers prescribed antibiotics in ≥95% of ARI visits
– Lowest 10% prescribed antibiotics in ≤40% of ARI visits
§ In a pediatric network, antibiotic prescribing variability among 25 practices
– 18 to 36% of acute visits resulted in antibiotic prescriptions by practice
– 15 to 57% of antibiotics were broad-spectrum by practice
Child with same complaint in high use practice: 2x as likely to get antibiotics and 4x as likely to get broad-spectrum antibiotics
Jones. Ann Int Med 2015;163(2):73-80.
Gerber. JPIDS 2015;4(4): 297-304.
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Meeting the CARB goal
§ Reduction of inappropriate outpatient antibiotic use by 50% by 2020
§ 30% of outpatient antibiotic use is inappropriate
§ Goal: Reduction of overall outpatient antibiotic use by 15% by 2020
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Diagnoses leading to antibiotics — United States, 2010–11
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OUTPATIENT ISSUES
• Respiratory Conditions
• Unsatisfactory Literature
• Variable Patient Presentations
• Prescribing 2-4x Higher Than Recommended for Select Conditions
• Mixed Track Record For Improvement
• Viral URI i, Sinusitis n, Ears n, Pharyngitis n
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WHY COMPARE BROAD VS. NARROW?
Conflicting guidelines
• AOM
• AAP recommends amoxicillin; RCTs used amoxicillin-clavulanate for AOM
• Sinusitis:
• AAP recommends amoxicillin; IDSA recommends amoxicillin-clavulanate
• GAS pharyngitis:
• cephalosporins?
50% of antibiotic use for children is broad-spectrum
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Target rate for outpatient antibiotic prescriptions
30%
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GLOBAL VALUES
• CDC 6/18 Project
• All Payer Presciption Rates
• USA – 880/1000 Patients
• AR – 1070/1000 Patients
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PCMH VARIATION
• Panels of Patients Attributed for > 6 Months
• Scripts Originated from All Sources
• 3-4 Fold Practice Variation
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total >=18 <18
Antibiotics/100 patientsPopulation 107.5 103.5 108.5PCMH Median 114 104 118Highest PCMH 220 179 231Lowest PCMH 46 21 25
% Receiving 1 PrescriptionPopulation 50% 49% 50%PCMH Median 54% 49% 55%Highest PCMH 75% 66% 78%Lowest PCMH 28% 14% 18%
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PHYSICIAN PERCEPTION OF PATIENT EXPECTATIONS§ Overt requests for antibiotics are rare
§ When physicians think patients/parents want antibiotics, they are more likely to prescribe
• 62% when they thought parent wanted antibiotics
• 7% when they thought parent did not want antibiotics
Knapf Family Practice 2004;21(5):500-6. Mangione-Smith Pediatrics 1999;103(4):711-8
§ Physicians are terrible at predicting which patients want antibiotics
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STEWARDSHIP PLAN
• Biannual PCMH Report Card
• Informational Reports 2020
• Accountability 2021
• Quality Metric and Core Metric
• Goal: 15% Reduction by Start of 2022
• 920/1000 Patients
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2020 PCMH Quality MetricsCore MeasuresPBIP Measures and 2019 PBIP
Reconsideration
Larry “David” BallardPCMH Program Manager
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2020 Quality Metrics and Targets 7 Claim Based Metric 2020 Target 2019 ComparePCP Visits ≥83% 1% ↑Infant Wellness ≥68% 6% ↑Child Wellness ≥72% 1% ↑ Adolescent Wellness ≥53% 3% ↑URI ≤45% 2% ↓ COB ≤30% 5% ↓Tamiflu ≤18% 2% ↓
3 EHR Based (eCQM) Controlling BP ≥62% 4% ↑Tobacco Use ≥80% 5% ↑HbA1c Poor Control ≤28% 5% ↓
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2020 Core Metrics (Low Performance) and Targets
• Infant Wellness- If you have 15% or more of your beneficiaries who turn15 months old during the performance period who have 0-1 wellness visits and you do not Pass the Infant Wellness Quality Metric.
• Body Mass Index- if less than 60% of your patient panel (3-17 years of age) have a BMI Measurement. (Self Reporting)
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2020 Core Metrics (Low Performance) and Targets
• PCP Visits- If you have ≤60% of your High Priority Beneficiaries with as least 2 visits in the past 12 months. 2020 Target for PCP Visit is 83%
• HbA1c if ≤50% of your diabetes beneficiaries (18-75 years of age) who complete a annual HbA1c. 2019 Target was 75%
o Removed from Quality Metrics but will still be monitored.
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Reconsideration for 2019 PBIP Measures
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2019 Performance Based Incentive Payment (PBIP) Measure Reconsiderations.
#1 Be Proactive! • Don’t wait until Reconsideration period.
# 2 Special PBIP report ran during Q2 of 2020 for 2019 PBIP measures.
#3 PCMH’s will be given 30 days to submit Reconsideration on these measures! (This will provide DMS adequate time to make determinations before Payment determinations are made)
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2019 Performance Based Incentive Payment (PBIP) Measure Reconsiderations.
Again this will be only for PBIP measures. If you see anything questionable then I suggest submitting it. We will not except Reconsideration on these 3 measures after payments are made.
Quality Metric Reconsideration will be like normal. Once Payments are made and if you missed payment because of not passing 2/3 of Quality Metrics.
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gdit.com
PCMH 2020 UPDATE
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PHMR Overview
The PHMR is a monthly report that allows medical providers to better manage their Medicaid beneficiary population with:
• Being produced monthly with latest processed data • Easy filtering to identify “Gaps in care” and utilization of services to better manage and educate the
populationPHMR reports (individual worksheets)
• Information • Summary• All quality metrics• Point in Time (PIT) attributed beneficiaries report including HPB indicator • Performance Based Incentive Payment (PBIP)
o Acute Hospital Utilization (AHU)o Emergency Department (EDU)
• Emergency room monitoringGDIT Proprietary39 | gdit.com
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PHMR new additions
New features for the second half of 2019• All of the additional features are on the PIT attribution report
o Last PCP visit date and where it occurred (within or outside the PCMH)o If the beneficiary is 6 month attributedo For the October 2019 release, beneficiary attribution status (continuous, new or break (last date on
attribution list))
• Always listening to providers and GDIT continuous analysis drives additional features
GDIT Proprietary40 | gdit.com
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PERFORMANCE BASED INCENTIVE PAYMENTS (PBIP)
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PBIP
For 2019• Continue to see results in quarterly report
For 2020• Same approach for incentive as 2019
o Must pass 2/3 of CORE metrics
o Must meet minimum performance metrics
o Be in the top 10% or 11 – 35 percentile rankings of incentive metrics
• Incentive Metricso AHU: Hospital Utilization
o EDU: Emergency Department Utilization
o Focus Metric: Adolescent Metric
GDIT Proprietary42 | gdit.com
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ARTIFICIAL INTELLIGENCE/MACHINE LEARNING
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Artificial intelligence/Machine Learning
New tool for 2020• Initial concentration of PBIP metrics
o Testing different modelingo Currently analyzing the identification preventable ER visitso Currently analyzing identifying avoidable hospitalizations
• Identifying the most effective way of delivery to PCMHs
GDIT Proprietary44 | gdit.com
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2020 SCHEDULE REPORTS
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Schedule reports
New tool for 2020• Quarterly reports
o 2018 Final Reporto Two full reports (current reports)o Two reduced (contain information that PCMH are tracking)
• Monthly PHMR beginning in February• 2019 PHMR Reconciliation Report• Supplemental reports
o Bi annual chronic opioid usageo Bi Annual antibiotic stewardship (new for 2020)
• AI/ML (new for 2020)
GDIT Proprietary46 | gdit.com
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SHARE Connecting Providers and Organizations to Improve Quality Care
Anne Santifer, Director [email protected]
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48
ConnectionsHospitals 72Provider Practices/Other 660CPC + Practices 160PCMHs 187
WHO SHAREs?
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SHARE and PCDH
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DAILY ADT REPORT
Daily ADT report
PATIENT FLYER
View our patient consent flyer here.
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DAILY ADT REPORT
ü Sent Nightly ü Assists with Follow
up Visitsü Can include all
patients regardless of payer
ü Proven Results
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HOW TO GET CONTACT SHARE
Visit our Website: SHAREarkansas.com
ORCall: 501.410.1999
OREmail:
HOW TO GET IN TOUCH