2nd QCIPN Town Hall Meeting

December 10, 2014

Presenters:

Amita Goyal Garson Lee, MD Donna Mah, MDWhitney Limm, MD Donald Blair, MD Gregg Shimomura, MDAnna Loengard, MD Nadine Salle, MD Alan Suyama, MD

Agenda

TOPIC TIME(minutes)

I. Administrative Updates• QCIPN Membership and Website • Physician Compensation

10

II. Choosing Wisely & QCIPN Clinical Policies 40

III. Initiatives Update 20

IV. Panel Discussion• Questions and Answers

20

3

Participating PhysiciansActive as of November 2014

October 31st was the final date to join QCIPN in the first contract year (Aug 2014 to Jul 2015).

Physician Count Total QCIPN MDs

PHYSICIAN ORGANIZATION PCPs Specialists Total % Queen's Staff % Emails % W-9 Forms

Central Medical 10 3 13 46% 100% 100%

Direct 0 158 158 70% 100% 51%

Filipino 27 18 45 38% 69% 89%

Five Mountain 13 1 14 0% 93% 93%

HIPA 54 59 113 42% 88% 81%

HQPO 35 0 35 26% 100% 97%

KMA 9 4 13 0% 100% 100%

OPG 13 8 21 29% 90% 100%

PMAG 111 388 499 61% 84% 64%

QMG 15 117 132 100% 100% 100%

West HIPA 10 1 11 0% 100% 100%

TOTAL 297 757 1054 60% 89% 73%

QCIPN Website

• Website: http://queenscipn.org– User Name: QCIPNMD– Password: toweavehealth

• Content:– Updates– Policies & Procedures– QCIPN Meeting Recordings and Presentations– Tools and Other Documents

HMSA Physician Compensation Policy

First Year Policy• Sets the terms for how QCIPN will compensate PCPs and Specialists

related to the HMSA contract• Effective August 1, 2014 to July 31, 2015• To be eligible for compensation, QCIPN PCPs and Specialists must:

– Have a W-9 Form submitted to the QCIPN– Comply with the terms and conditions set forth in the physician

participation agreement, and– Comply with the requirements outlined in the QCIPN Membership

Qualification and Technology Requirements Policy

Second Year and/or Additional Payers• Physician compensation policies will be developed specific to each

new payer contract• Goal will be to relate QCIPN payment criteria and methodology

with how physicians are compensated

Physician Compensation ExampleFirst Year

Estimated Physicians Distributions

$ 6,600,000

297 PCPsQuarterly Payment

757 SpecialistAnnual

Payments

PCP Payment Methodology based on:

– Attributed Lives

– PCMH Level

Specialists Payment Methodology based on:

– Meeting Participation

– Specialty Endeavors

– Unique QCIPN Lives

60% of Taxed Revenue will be distributed to Physicians

PCP Payment Examples

Quarter 1 PCP Physician Compensation Pool

7

HMSA Quarter 1 Payment Distribution Amount

PMPM Possible Payments $6.00

Less: General Excise Tax (4.712%) $0.28

Net Revenue for Distribution $5.72

60% Physician Distribution $3.43

50% Specialist Pool Allocation $1.71

50% PCP Pool Allocation $1.71

PCP Payment Allocation – 1st Quarter (Aug – Oct 14)

PCP Pool ($1.71 x 564,503 member months) ~ $965,000

Process Payments ( 70%) Paid Quarterly ~ $675,500

Performance Payments* ( 30%) ~ $289,500

*Final Payment to PCPs for first contract year will include Performance payments if performance metrics are met and compensation is received by HMSA.

PCP Compensation Methodology

8

PCP Payment Projections

Physician QuarterlyDistribution

HMSA Member Months

PCMH Score PCMH Weighted Member Months

Percent of PCMH Weighted

Membership

Distribution to Each Practice or

PCP

Minimum Payment 30 1.0 30.00 0.00006 $38.99

Maximum Payment 6,690 1.0 6,690.00 0.01287 $8,695.63

PCMH LevelLevel achieved by quarter end used for

calculation

Level 3 1.00Level 2 0.85Level 1 0.60

Distribution to PCP’s Q1

70% Process Payment $675,500

*Average PCPs will earn approximately $2,000 per quarter

Specialty Payment Methodology

Participation PoolDistribution for meeting

attendance

• Minimum of 4 QCIPN meetings attended to qualify• Payment of $150 per meeting, and up to $1,000 for attendance at QCIPN 6 meetings• Total maximum payments will be ~ $750,000

Specialty Specific Endeavor Pool

Distribution to all specialists who participate on specific

endeavors developed by the QCIPN Board

• QCIPN Quality Committee to help prioritize specialty endeavors that:

•Encourage and improve PCP and Specialist collaboration•Achieve the triple aim

• QCIPN Board to determine and approve compensation per specialty endeavor, which could include payment for participation in endeavors and completion of deliverables

Activity PoolDistribution based on unique

QCIPN patients

• Remainder of the total Specialty pool will roll over and be paid out based on clinical activity for unique QCIPN patients

Distribution Pools: Total Distributions ~$3.3M :

Q1

Physician Payments Timing

Q1 Q2 Q3 Q4

Aug 14 Sept 14 Oct 14 Nov 14 Dec 14 Jan 15 Feb 15 Mar 15 Apr 15 May15 Jun15 Jul 15 Aug 15 Sept 15 Oct 15

QCIPN Town Hall Meetings – Minimum for 4 required to qualify for payments

1ST PCP Payment

2nd PCP Payment

3rd PCP Payment

Final PCP &

Annual Specialist Payment

SAVE THE DATE: • The 3rd QCIPN Town Hall Meeting will be on February 4, 2015. • To receive credit for the meetings, attestation for 1st and 2nd Town Hall Meetings must be submitted by February 4, 2015.

Choosing Wisely

Dr. Whitney Limm

Queen’s Clinical Integration SVP

QCIPN President

12

Choosing Wisely: Promotes conversations between physicians and patients by helping patients choose care that is:

• Supported by evidence• Not duplicative of other tests or procedures

already received• Free from harm• Truly necessary

Specialty Societies asked to identify “Five Tests or Procedures Physicians and Patients Should Question”to spark discussion about the need—or lack thereof—for many frequently ordered tests or treatments

http://www.choosingwisely.org

Date of download: 11/1/2014Copyright © 2014 American Medical

Association. All rights reserved.

From: The “Top 5” Lists in Primary Care: Meeting the Responsibility of Professionalism

Arch Intern Med. 2011;171(15):1385-1390. doi:10.1001/archinternmed.2011.231

Figure 1. “Top 5” activities in family medicine. AACE indicates American Association of Clinical Endocrinology; ACOG, American College of

Obstetrics and Gynecology; ACPM, American College of Preventive Medicine; AHCPR, Agency for Healthcare Policy and Research; Ann

IM, Annals of Internal Medicine; Cochrane, Cochrane Database of Systematic Reviews; DEXA, dual energy x-ray absorptiometry; ECG,

electrocardiogram; NOF, National Osteoporosis Foundation; Pap, Papanicolaou; and USPSTF, US Preventive Services Task Force.

Figure Legend:

Reaction from

Emergency Room Physicians

• The campaign puts ER physicians at risk for medical liability.

• One of the campaign’s goals is to save money.

• Other specialty societies are telling ER physicians what to do and not do-- creating a culture of “finger pointing”.

• Payers will use these recommendations to deny reimbursement for specific tests and procedures.

1. Avoid computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules.

2. Don’t delay engaging available palliative and hospice care services in the emergency department for patients likely to benefit.

3. Avoid antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissue abscesses after successful incision and drainage and with adequate medical follow-up

4. Avoid CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation.

American College of Emergency Physicians - Choosing Wisely

• American Academy of Ophthalmology– Don’t perform preoperative medical tests for eye surgery

unless there are specific medical indications

• American Academy of Orthopaedic Surgeons– Avoid performing routine post-operative deep vein

thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty

• American College of Cardiology– Don’t perform annual stress cardiac imaging or advanced

non-invasive imaging as part of routine follow-up in asymptomatic patients

Choosing Wisely Initiatives

• American Academy of Pediatrics– Computed tomography (CT) scans are not necessary in the

routine evaluation of abdominal pain

• American College of Radiology– Don’t image for suspected pulmonary embolism (PE) without

moderate or high pre-test probability

• The American College of Obstetricians and Gynecologists– Don’t perform routine annual cervical cytology screening

(Pap tests) in women 30–65 years of age

Choosing Wisely Initiatives

• American College of Physicians– Don’t obtain imaging studies in patients with non-specific

low back pain

• American College of Surgeons– Don’t do computed tomography (CT) for the evaluation of

suspected appendicitis in children until after ultrasound has been considered as an option

• American Psychiatric Association– Don’t routinely prescribe two or more antipsychotic

medications concurrently

Choosing Wisely Initiatives

• Endocrine Society and American Association of Clinical Endocrinologists– Don’t routinely order a thyroid ultrasound in patients with

abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland.

• American Gastroenterological Association– Do not repeat colorectal cancer screening (by any method) for

10 years after a high-quality colonoscopy is negative in average-risk individuals

• American Society of Nephrology– Don’t initiate chronic dialysis without ensuring a shared

decision-making process between patients, their families, and their physicians

Choosing Wisely Initiatives

“Medicine is a science of uncertainty and an art of probability.”

William Osler

“The palest ink is better than the best memory.”

Chinese Proverb

Chest Pain Policy

Dr. Garson Lee

Associate Medical Director, Physician Relations

Hospitalist Program

Purpose: • Reduce unnecessary stress testing on low risk

patients.• Improve quality and safety by limiting

unnecessary exposure to radiation.• Improve cost by reducing unnecessary testing

and reducing emergency department length of stay.

Procedure:• Appropriate Use Criteria will be followed for all

patients with low risk chest pain.

Chest Pain PolicyPolicy #CBPG-001

Institute for Healthcare Improvement. (2013). 28 Oct 2014, from: http://www.mehmc.org/.

• Evidence on Pretest probability and accuracy of exercise stress testing

Chest Pain PolicyPolicy #CBPG-001

Pre-test Probability False Positive False Negative

Low 91 14

Intermediate 13 44

High 4 65

Weiner, CASS, NEJM 1979; 300:1350

• Accuracy of test

Chest Pain PolicyPolicy #CBPG-001

Sensitivity Specificity

Exercise ECG 68 77

Stress echo 76 88

Planar thallium 79 73

0%

20%

40%

60%

80%

100%

120%

Stress ECG (25)

Stress Echo (70)

Dobut Echo (1)

Stress NM (11)

Appropriate

Rarely app

Chest Pain PolicyPolicy #CBPG-001

Our Performance in August 2014 (n=106)

Chest Pain PolicyPolicy #CBPG-001

How are we going to implement this?

• What are we tracking?– Compliance with AUC criteria by using the chest pain order

form

– Rate of stress testing in asymptomatic low risk population

Chest Pain PolicyPolicy #CBPG-001

Pulmonary Embolism Policy

Dr. Donald Blair

Queen’s Medical Director of Imaging

• Revolution in Imaging

• Change in the approach to diagnosis

• ‘Unnecessary’ Imaging Studies

• Evidence based protocol to identify patients that don’t have PE without the use of Imaging– Negative Imaging study is as good as a negative

protocol

Pulmonary Embolism Testing

Overview

• Goals: – Improve patient care

• We reserve Imaging for those patients more likely to have the disease

– Increase % of exams that are positive

– More efficient expenditure of health care dollars

• If the protocol deems a patient to not have PE then they do not. False negative rate comparable to Imaging.

– Improve population Health - Decrease radiation exposure to population

• Decrease the number of exams performed per 1000 lives/ER visits– Improved expenditure of health care dollars

Pulmonary Testing ProtocolGoals

• A clinical prediction rule -Identify the best combination of medical sign, symptoms, and other findings in predicting the probability of a specific disease or outcome

• Wells score:[15]

• Clinical signs and Symptoms of DVT — 3.0 points• PE is #1 diagnosis or equally as likely— 3.0 points• tachycardia (heart rate > 100) — 1.5 points• immobilization (≥ 3d)/surgery in previous four weeks — 1.5 points• history of DVT or PE — 1.5 points• hemoptysis — 1.0 points• malignancy (with treatment within 6 months) or palliative — 1.0 points

Pulmonary Testing ProtocolWells Criteria

• Wells Score > 4 — PE likely. Consider diagnostic imaging. (CTA, V/Q, MRA)

• Wells Score 4 or less — PE unlikely. Consider D-dimer.

– D-dimer elevated Imaging

– D-dimer not elevated No PE

Pulmonary Testing ProtocolAlgorithm

• Increase in Percentage of Positive Yield– 404 ER patients, (+) yield before was 8.4% and 16.7 %

after algorithm

• False Negative Rate– 32% of 3306 patients (82% Outpatients) had Unlikely

Wells Score and Negative D-dimer.

– 0.5% incidence of VTE over next 3 months

– 1.3% incidence of VTE over next 3 months in CT (-) pts

Pulmonary Testing ProtocolLiterature

Drescher F.S. et al. Annals of Emergency Medicine Vol 57 No 6 p613-621Christopher Study Investigators. JAMA Vol 295 No 2 p172-179

• False Negative Rate– 45% of 598 patients had Unlikely Wells Score and

Negative D-dimer.

– 1.5% had PE over next 3 months

• Decrease the number of exams performed per 1000 lives/visits– 6838 ER patients, CTA ordering decreased 20.1%

from 26.4 to 21.1 exams per 1000 patients

Pulmonary Testing ProtocolLiterature

Geersing G-J et al. BMJ 2012;345:e6564Raja A.S. Et al. Radiology Vol 262 Num 2 p 468-474

• Carelink will ask for the Wells score

• IP and ER

• Outpatient

– Draw D-dimer at POB 3

– Patient goes to Imaging and awaits results

Pulmonary Testing ProtocolNuts and Bolts

• Wells, revised Geneva, simplified Wells and simplified revised Geneva were studied on 807 patients

• They excluded PE in 22-24% of patients when combined with D-dimer

• The failure rate were similar (0.5 – 0.6%)

Pulmonary Testing ProtocolComparing CPR

Douma R.A. et al. Annals of Internal Medicine 2011: 154:709-718

• 3346 ER patients, 2898 Not High Likelihood for PE

• 28% D-dimer below 500

• Additional 11.6% D-dimer between 500 and age adjusted D-dimer level

• 3 month False negative rate 0.3%

Pulmonary Testing ProtocolAge Adjusted D-dimer

Righini M. et al. JAMA 2014;311(11):1117-1114

Pediatric Asthma Policy

Dr. Nadine Tenn Salle, FAAP

Dr. Donna Mah, FAAP

QCIPN Board of Directors

Total pediatric inpatient volumes are expected to decrease by 8%, this is in part due to an increased focus on disease management of chronic disorders.

Disease management drives shift of services to outpatient setting.

Pediatric Asthma

Pediatric Asthma

Pediatric asthma services are ripe for care redesign.

–Prevalence: 1 in 10 children

–Emergency Room visits: one of the top 5 diagnoses

–Inpatient: 2nd most common inpatient admissions

Pediatric Asthma

Predicted impact over the next 1-5 years:

–Medical homes with registries for pediatric asthma patients will become standard.

–Compliance with evidence-based care and improved coordination will be a main focus

–Payer scrutiny and penalties for unnecessary care are likely to emerge early in asthma care, targeting potentially avoidable asthma admission and ED visits.

–Mandated quality reporting will increase as metrics evolve and national benchmarks emerge.

Pediatric Asthma

Long term impacts

–Molecular diagnostics and pharmacogenetics will improve disease management and reduce IP and ED but potentially add complexity to the care pathway.

Pediatric Asthma

Program components

–Reference: QCIPN Pediatric Asthma Policy

Pediatric Asthma

Patient Engagement

–Foster self/family management of asthma which has been shown to drive improvements in asthma control

–Utilize emerging patient engagement tools for pediatric patients and their families

Pediatric Asthma

Payment

–Choosing meaningful outcomes and process measures for asthma

Pediatric Asthma

Year One:Community standard for diagnosis of asthma

Primary care (pediatricians) will be asked to create and manage (deleting) their (asthma) registry

Increase CME on targeted asthma interventions and appropriate diagnosis and treatment of bronchiolitis

Pediatric Asthma

Year Two:•Utilizing PCP governed asthma registries to implement:

a.Planned asthma visit

b.Classification of asthma severity

c.>4YO receive spirometry

d.Asthma action plan

Pediatric Asthma

Year Three: Achieve the triple aim

Improve the community standard of diagnosing and managing asthma in pediatric patients

Increase parent/patient understanding of asthma and appropriate management.

Improve cost by improving use of appropriate medical treatment and reducing unnecessary room use

Reduce mortality and morbidity of pediatric asthma

Pediatric Asthma

Preoperative Diagnostic Testing

Dr. Alan T. Suyama

Queen’s Medical Director, Anesthesia Services

The purpose of this policy is to:

•Reduce the number of unnecessary preoperative laboratory tests

•List outcome metrics to measure effectiveness of the policy.

Perioperative Testing

Justification:

• Increased cost of care related to unnecessary testing and potential for false positive results

• Patient inconvenience

• Little benefit to improving the health of surgical patients

Perioperative Testing

• Don’t obtain baseline laboratory studies in patients without significant systemic disease (ASA I or II) undergoing low-risk surgery – specifically complete blood count, basic or comprehensive metabolic panel, coagulation studies when blood loss (or fluid shifts) is/are expected to be minimal.

• Don’t obtain baseline diagnostic cardiac testing (trans-thoracic/ esophageal echocardiography – TTE/TEE) or cardiac stress testing in asymptomatic stable patients with known cardiac disease (e.g., CAD, valvular disease) undergoing low or moderate risk non-cardiac surgery.

Perioperative Testing

Choosing WiselyAmerican Society of Anesthesiologists

• Don’t obtain screening exercise electrocardiogram testing in individuals who are asymptomatic and at low risk for coronary heart disease.

• Don’t obtain preoperative chest radiography in the absence of a clinical suspicion for intrathoracic pathology.

Perioperative Testing

Choosing WiselyAmerican College of Physicians

• Avoid admission or preoperative chest X-rays for ambulatory patients with unremarkable history and physical exam.

Perioperative Testing

Choosing WiselyAmerican College of Surgeons

• Patients who have no cardiac history and good functional status do not require preoperative stress testing prior to non-cardiac thoracic surgery.

• Prior to cardiac surgery, there is no need for pulmonary function testing in the absence of respiratory symptoms.

Perioperative Testing

Choosing WiselyThe Society of Thoracic Surgeons

Quality Initiative Proposal: No routine preoperative diagnostic testing in ASA class 1 and ASA class 2 patients undergoing outpatient or ambulatory surgery.

Population Health and Well-Being

Dr. Gregg Shimomura

QCIPN Board of Director

58

Workgroup 3

Workgroup 3 – Population Health and Well-Being Initiative

HMSA/Healthways Care Model• Predictive model determines 4 cohorts of patients that benefit from

assistance• Assign RN’s, SW’s, Dieticians to work via Care Plans directly with patients• Control costs of care by providing broader patient support foundation

Population Health – Healthways Well-Being Assessment• Self Help• Online interactive survey: health, labs, work, behaviors, emotion• Self Plan with online tools, resources, and services• www.hmsa.com/wbc

59

Care Model

HMSA/Healthways Care Model

4 Cohorts:• Complex Cases• Short-Term Care• Re-Admit Risk• Late-Stage Chronic

Focuses on smaller number of patients. Predictive modeling program identifies who will decrease costs of care with additional support

Enhanced patient engagement with improved communication PCP primary focus; Specialists involved too Healthways Care Model nurses - >100 staffed Collaboration between Program and Physicians Need for phone numbers from PCP’s Hospital post-acute initiatives

60

Well-Being Assessment

Healthways Well-Being Assessment

Preventive Aspects to Disease Development Social Determinants of Health Adjunctive Care Management Support (Science Behind WBA) (Data Collected from WBA)

At the Least: Acknowledgement of the Importance of Health Behaviors Resources for Motivated Patients

Advanced Care Planning

Dr. Anna Loengard

QCIPN CMO

• Provide care consistent with patients’ goals across all sites of care

• Achieve QCIPN/HMSA contracted metrics for year one

Advance Care Planning

ACP Initiative Goals

Advance Care Planning

Goals of Care Known, Documented and Respected

ACP documents

AT HOME

OUTPATIENT SETTING

HOSPITAL

QCIPN-HMSA Year 1 ACP Metrics

Year 1 Advanced Care Planning Metrics

Process Metrics

• Develop and approve Policy for this initiative

• Engage Respecting Choices

• Educational meetings with founding PO’s on policy

Performance Metrics

• Establish a Respecting Choices Program with at least 32 trained facilitators

• QCIPN physicians refer at least 200 non-inpatient commercial and/or Medicare advantage members for Advanced Care Planning discussion

• The ACP policy was out for comment and is under review

• Respecting Choices has been engaged for “Last Steps” program– 32 facilitators will be trained in Feb 2015

• Lori Protzman RN is developing ACP clinic and working with Physician Organizations– Starting on punchbowl and looking for additional

sites

ACP Metrics

Where We Are Now:

• Support physicians in explaining ACP to patients

• Discuss importance of AHCD and help patients to express their general preferences

• Communicate outcome of clinic to provider– AHCD signed/POLST initiated

• Phone follow-up with patient on experience– Track outcome measures

ACP Clinic

Goal of the ACP Clinic:

• Refer any patient you think should have an AHCD

– Both PCPs and Specialists welcome to refer

• Introduce the ACP clinic to patient/families

• Lori will let you know when patient has attended

ACP Clinic

QCIPN Providers:

• Starting January 5, 2015 ACP clinic will be scheduled in the diabetes education center:

– Monday 1-2pm

– Thursday 9-10

– Friday 10-11

• Call Lori at 691-7716 to refer a patient

• We will have ACP referral form on website soon

ACP Clinic

ACP CLINIC SCHEDULE:

“What’s the matter with you?”

AND

“What matters

to You?

Patient Focus

Enhance the Conversation

70

Closing & Questions

Contact Information:

General Inquiries: qcipn@queens.org

Whitney Limm, MD: wlimm@queens.org

Anna Loengard, MD: aloengard@queens.org

Amita Goyal: amgoyal@queens.org