Transcript Unraveling Evaluation and Management Coding

A Step by Step Approach to Building
a Patient-Centered Medical Home
What Does That Mean for One Patient?
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Ms. Jones, a 55 year old diabetic, is a patient of Dr. Smith’s practice
Dr. Smith’s practice in 2010
In 2010, Ms. Jones:
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Showed poor understanding of her
diabetes and link between diet and
blood sugar readings
Rarely checked her blood sugar at
home
Did not consistently take her
medications for diabetes or high
blood pressure
Hgb A1-C >10; BP 170/110; Wt. 165
Went to ER 5 times with complaints of
headache and blurred vision; an
infected foot ulcer; pain and tingling
in her feet
Dr. Smith’s practice in 2011 as a PCMH
In 2011, Ms. Jones:
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Met 1:1 with the Diabetes Educator
and attended group diabetes classes
with her husband
Learned how to check and record
her blood sugar results daily
The Care Manager helped her obtain
low cost medications from a
pharmaceutical company
Hgb A1-C down to 8.3; BP 140/80;
Wt. 143
Went to ER once for chest pain and
shortness of breath
Case Manager coordinated her
referral to cardiologist
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Key Points from the Patient - Centered Primary Care
Collaborative February 2016 Annual Update Report
• PCMH studies continue to demonstrate impressive
improvements across a broad range of categories including: cost
of medical care, utilization of services, population health,
prevention, access to care, and patient satisfaction.
• Advanced primary care is foundational to delivery system
transformation. The PCMH model continues to play an important
role in strengthening the larger health care system, particularly
Accountable Care Organizations and other integrated healthcare
delivery systems.
• Payment reform is necessary to sustain delivery system changes.
Multiple payment innovation models are currently being tested,
such as pay-for-performance; per member per month (PMPM)
payments, often adjusted for PCMH Recognition level, in addition
to FFS billing; and/or shared savings arrangements.
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PCMH Success: Examples of PCMH results
Initiative
Health Cost & Utilization Outcomes
Health Outcomes
Years of Data
Review
PA Chronic Care Initiative
• All- cause hospitalization reduced
1.7%
• All - cause ED visits reduced 4.7%
• Specialty visits reduced 17.3%
• Higher performance 4
Diabetes measures
including HbA1c testing
and eye exams; and
breast cancer screening
10/20079/2012
North Carolina:
Community Care of North
Carolina (Medicaid)
Colorado Multi-Payer
PCMH Pilot
Patient
Satisfaction
2003 - 2012
• Decreased spending almost all
categories
• Reductions in readmissions,
inpatient admissions for diabetes,
ED visits for asthma
• Approx. 10.7% decline in
prescription drug use
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9.3 % fewer ED visits
Reduction in ED costs of $3.50
PMPM
10.3% reduction in ACSC
inpatient admissions
• Increased cervical
cancer screening rates
2009-2012
Source: The Patient-Centered Medical Home’s Impact on Cost and Quality: Annual Review of Evidence 2014-2015; February 2016
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What Is a Patient-Centered Medical Home?
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Defined as “a team-based model of care led by a personal physician who
provides continuous, coordinated care throughout a patient’s lifetime, to
maximize health outcomes.” (American College of Physicians)
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The PCMH provides or arranges for all of the patient’s healthcare needs,
including:
• Preventive care
• Treatment of acute and chronic illnesses
• Assistance with end-of-life/palliative care
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Key building blocks: teamwork, leadership, communication, willingness
to change
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Core Components of a Patient - Centered
Medical Home
Transformation of care delivery to become a model of primary care,
delivering care that is:
Patient
centered
Comprehensive
Coordinated
Accessible
Continuously focused on improvement through systems-based approach to quality and safety
These core components track closely with NCQA’s PCMH Recognition
Standards.
Source: Agency for Healthcare Research and Quality- An agency within the Department of Health & Human Services
committed to improving care safety and quality
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Key Attributes of a PCMH
Physician
Leadership/
Engagement
Use of Health
Information
Technology
Identify and
Measure key
Quality Indicators
Team-based
approach to care
delivery
Use of Evidencebased Medicine
and Clinical
Decision Support
Tools
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Characteristics of a PCMH
Ensure
continuity of
care
Identify and
manage high
risk patients
Develop and
document
patient selfmanagement
care plans
Involve patients
and caregivers
in shared
decision
making
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Implementing a PCMH Model of Care:
Factors to Consider
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Ensure that you will get a return on your investment
• Assess the state of your system, when applicable
• Assess the state of your practices
• Determine any gaps in care & service delivery in relation
to the PCMH Standards
• Calculate the cost of PCMH implementation
• Calculate the potential benefits, including opportunity for
higher reimbursement based on PCMH Recognition
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Creating a Profile of Your Patients
Focus
Priorities
Estimated percentage of
Patient Panel
Complex care patients
Intensive, multi-disciplinary care
coordination in a community-based model
5%
High risk chronic care
Need for aggressive, ongoing monitoring of
symptoms, focus on compliance
15%
Lower risk chronic care patients
Longitudinal monitoring of symptoms with
focus on managing risk factors
25%
Healthy / chronic disease risk
Longitudinal monitoring and management of
risk factors
20%
Healthy / primary prevention
Focus on prevention
20%
0-5 children / compromised or
at risk
Aggressive, early, multi-disciplinary
intervention emphasizing parent
engagement
5%
0-5 healthy children / primary
prevention
Protocol driven primary prevention
10%
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Building an Interconnected, Patient-Centric Care System
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Becoming a PCMH
Evaluate current
work processes
GAP
ANALYSIS
Improvement
plan &
implementation
NCQA
Accreditation
Getting paid for
value
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Process for NCQA Recognition
Participate in
NCQA PCMH
Learning
Initiatives
Follow
required NCQA
registration
Purchase
survey tools
Obtain approval
to apply for
multi-site PCMH
Internal review
Documentation
for Standards &
Elements
Selfassessment
Submit
application
Complete online tool
Upload appropriate
documentation
Recognition decision within 60 days of site Survey Tool submission.
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NCQA Recognition Program
The National Committee for Quality Assurance (NCQA)’s Patient-Centered Medical
Home Recognition Program provides a roadmap to physician practices working to
improve care delivery and the experience of care for both patients and clinicians.
Six PCMH Recognition Standards
Patient Centered
Access
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Team-Based
Care
Population
Health
Management
Care
Management
& Support
Care
Performance
Coordination Measurement
& Care
& Quality
Transitions
Improvement
The six Standards align with the core components of primary care
Three possible Recognition Levels: Level I-III
• Based on total points scored on the Recognition application
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NCQA Must-Pass Elements
Six Must - Pass Elements considered essential to a successful PCMH and
required to achieve recognition at any level:
1A: PatientCentered
Appointment
Access
2D: The
Practice Team
3D: Use Data
for Population
Management
4B: Care
Planning &
Self-Care
Support
5B: Referral
Tracking and
Follow-up
6D: Implement
Continuous
Quality
Improvement
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Enhance Access and Continuity
*Must earn a score of 50% or higher to pass this element
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Provide Team-Based Care Continuity
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The Practice Team
*Must earn a score of 50% or higher to pass this element
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Plan and Manage Care
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Use Data for Population Management
*Must earn a score of 50% or higher to pass this element
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Provide Self-Care Support and Community
Resources
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Provide Self-Care Support and Community
Resources
*Must earn a score of 50% or higher to pass this element
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Track and Coordinate Care
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Track and Coordinate Care
*Must earn a score of 50% or higher to pass this element
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Measure and Improve Performance
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Measure and Improve Performance
*Must earn a score of 50% or higher to pass this element
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Appendix 1 – Scoring Sheet
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Getting Started: Evaluate Current Work
Processes
Fundamentals
Revenue Cycle
Efficient patient
Ability to
flow
manage
documentation,
Is it patient billing, and
centric?
collections
Information
Technology
Do you have a
robust platform
that all staff
members can
use effectively?
Data Reporting
Are you sending
information to
your providers on
a regular basis?
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Evaluate Current Work Processes
Next level of requirements
Governance
- Do you engage
your physicians
in decisionmaking?
Provider
compensation
- Can your
compensation
structure
accommodate
quality metrics?
Human
Resources
Cost of Service
- Do you have
the right mix of - How much does
it cost the practice
staff members
to offer a given
and are they in
service?
the right
positions?
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Evaluate Current Work Processes
Gap analysis
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Revenue cycle
Efficient patient flow
IT platform
Data reporting
Governance
Provider compensation
Human Resources
Cost of Service
• Evaluate current care and service
delivery
• Pay particular attention to the
NCQA Must - Pass Elements
• Determine priorities and identify
“low-hanging fruit” to begin
transforming care delivery
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Implementing the PCMH Model of Care
Implementation
Plan
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Develop & implement standardized
treatment orders/evidenced-based
clinical guidelines
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Utilize Disease Registries for population
health management
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Track and coordinate care across
healthcare continuum
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Exchange clinical information
electronically with referral providersbuild a strong “Medical Neighborhood”
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Integrate comprehensive medication
management program
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NCQA Patient-Centered Medical Home (PCMH 2014)
Recognition Program - Standard Survey Pricing
Number of Clinicians in
the Practice
Initial Fee for Practice to Obtain a
Survey Tool License
Application Fees for NCQA
Review and Recognition
Total License and Application
Fees
1
$80
$550
$630
2
$80
$1100
$1180
3
$80
$1650
$1730
4
$80
$2200
$2280
5
$80
$2750
$2830
6
$80
$3300
$3380
7
$80
$3850
$3930
8
$80
$4400
$4480
9
$80
$4950
$5030
10
$80
$5500
$5580
11
$80
$6050
$6130
12
$80
$6600
$6680
13
$80
$6600 + $55 for each
clinician
$6800 + $55 for each
clinician
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PCMH Implementation: Potential Challenges
& Obstacles
• Potential increased physician practice costs upfront: additional staff,
expanded office hours, acquisition/implementation of Health
Information Technology
• Limited or no reimbursement by payors for PCMH infrastructure and
care management/care coordination functions
• Inconsistent availability/use of Health Information Technology
• Must have functional EHR to achieve NCQA Level 3 Recognition
• Lack of Electronic Health Record system interoperability between
hospitals and physician practices
• Physician collaboration and communication
• Patient buy-in and participation in self-care management
• Engagement and collaboration with community-based organizations
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Questions
Resources
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Patient Centered Primary Care Collaborative: http://www.pcpcc.net/
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National Committee for Quality Assurance : www.ncqa.org
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American Academy of Family Physicians:
http://www.aafp.org/online/en/home/membership/initiatives/pcmh.html
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Thank You
Contact for more information:
Louise Bryde
Principal, Stroudwater Associates
404.790.8251 mobile
[email protected]
770.206.9160
Mike Fleischman
Principal, Stroudwater Associates
770.913.9094
[email protected]
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