“2014 ACO GPRO Audit-What this
means for your practice”
Sheree M Arnold
ACO Clinical Transformation Specialist
Agenda
• Catholic Medical Partners ACO overview
• Attribution and sampling of patients
• ACO quality measures
©2011 Proprietary and Confidential
Catholic Medical Partners ACO
Overview
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3-year contract with Medicare for Medicare Shared Savings Program
Made up of providers who voluntarily agree to work together to coordinate
care for patients while meeting certain quality standards to share in any
savings they achieve for the Medicare program.
•
– 273 participating practices
– 860 primary and specialty providers (188 primary care physicians &
672 specialty care physicians)
– The ACO has the following institutional providers: Catholic Health
Hospitals, Mt. St. Mary’s Hospital and Health Centers, Bertrand
Chaffee Hospital, Bry- Lin Behavioral Health System
Take care of a defined population of patients
– Medicare FFS beneficiaries only
– ~25,400
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ACO GPRO Attribution
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CMS assigns a Medicare beneficiary to Shared Savings Program ACO based on current program rules
– Beneficiaries are assigned to the Shared Savings Program ACO if they: Have at least one month of
Part A and Part B enrollment
– Do not have any months of Medicare group (private) health plan enrollment (i.e., Medicare
Advantage)
– Reside in the United States or U.S. territories and possessions
– Have a primary care service with a provider at the ACO
• Have the largest share of their primary care services (by Medicare allowed charges) provided
by the participating ACO , defined as: Step (1): having more primary care services furnished
by primary care physicians at the participating ACO than furnished by primary care physicians
at any other entity; or
• Step (2): (for those beneficiaries who have not received any primary care services from a
primary care physician) having at least one primary care service furnished by specific types of
physicians and had more primary care services furnished by professionals at the participating
ACO than at any other entity (Participating Specialist)
Timing of attribution: Shared Savings Program ACO attribution: Use beneficiaries attributed for the 2014
3rd quarter report
A patient attributed in one year of Shared Savings Program ACO may or may not be attributed to the
ACO in the following reporting years
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ACO GPRO Sampling
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CMS analyzes Medicare claims submitted and captured in the Integrated Data Repository (IDR)
from January 1, 2014 through October 31, 2014 (i.e., sampling period)
Patients are sampled using a methodology that increases the likelihood of patients being sampled
into multiple modules
Assigned/Aligned beneficiaries who meet additional quality eligibility criteria may be sampled into
GPRO Web Interface modules through a three-step process described in the following slides
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Attribution and Sampling
Overview
• The GPRO Reporting requires ACOs to report data on a pre-determined
population of patients
• Beneficiaries are attributed to the ACO
• Attributed beneficiaries are assessed for quality measurement eligibility
and then randomly sampled based on measurement and disease criteria.
• Sample is used for quality reporting
©2011 Proprietary and Confidential
ACO QUALITY MEASURES
ACO Quality Measures
• Goal = 90th percentile
Domain
Measure
Description
Patient/Caregiver Experience
Patient/Caregiver Experience
Patient/Caregiver Experience
Patient/Caregiver Experience
Patient/Caregiver Experience
Patient/Caregiver Experience
Patient/Caregiver Experience
Care Coordination/Patient Safety
Care Coordination/Patient Safety
Care Coordination/Patient Safety
Care Coordination/Patient Safety
Care Coordination/Patient Safety
Care Coordination/Patient Safety
ACO #1
ACO #2
ACO #3
ACO #4
ACO #5
ACO #6
ACO #7
ACO #8
ACO #9
ACO #10
ACO #11
ACO #12
ACO #13
Getting Timely Care, Appointments, and
How Well Your Doctors Communicate
Patients’ Rating of Doctor
Access to Specialists
Health Promotion and Education
Shared Decision Making
Health Status/Functional Status
Risk Standardized, All Condition Readmissions
ASC Admissions: COPD or Asthma in Older Adults
ASC Admission: Heart Failure
Percent of PCPs who Qualified for EHR Incentive
Medication Reconciliation
Falls: Screening for Fall Risk
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90th perc.
90
90
90
90
60.71
76.71
N/A
15.45
0
0.18
90.91
90
73.38
ACO Quality Measures cont.
• .
Domain
Preventive
Preventive
Preventive
Preventive
Preventive
Preventive
Preventive
Measure
Health
Health
Health
Health
Health
Health
Health
Preventive Health
At-Risk Population Diabetes
At-Risk Population Diabetes
At-Risk Population Hypertension
At-Risk Population IVD
At-Risk Population IVD
At-Risk Population HF
At-Risk Population CAD
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ACO #14
ACO #15
ACO #16
ACO #17
ACO #18
ACO #19
ACO #20
Description
Influenza Immunization
Pneumococcal Vaccination
Adult Weight Screening and Follow-up
Tobacco Use Assessment and Cessation
Depression Screening
Colorectal Cancer Screening
Mammography Screening
Proportion of Adults who had blood pressure
ACO #21
screened in past 2 years
ACO #22. Hemoglobin A1c Control (HbA1c) (<8
Diabetes
percent) ACO #23. Low Density Lipoprotein (LDL)
Composite ACO (<100 mg/dL) ACO #24. Blood Pressure (BP) <
#22 – 26
140/90 ACO #25. Tobacco Non Use ACO #26.
Percent of beneficiaries with diabetes whose
ACO #27
HbA1c in poor control (>9 percent)
ACO #28
Percent of beneficiaries with hypertension
Percent of beneficiaries with IVD with complete
ACO #29
lipid profile and LDL control < 100mg/dl
Percent of beneficiaries with IVD who use
ACO #30
Aspirin or other antithrombotic
ACO #31
Beta-Blocker Therapy for LVSD
ACO #32. Drug Therapy for Lowering LDL
CAD Composite Cholesterol ACO #33. ACE Inhibitor or ARB
ACO #32 – 33
Therapy for Patients with CAD and Diabetes
90th perc.
100
100
100
90
51.81
100
99.56
90
36.5
10
79.65
78.81
97.91
90
79.84
CARE-1: Medication Reconciliation
Measure Description
• Percentage of patients aged 65 years and older discharged from any inpatient facility
(e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days
following discharge in the office by the physician providing on-going care who had a
reconciliation of the discharge medications with the current medication list in the
outpatient medical record documented
Guidance
• This measure is reported for each discharge found for the patient
•
The practice may verify the discharge date if evidence of hospitalization or discharge
is found in the record within 1-2 days of the pre-populated discharge date
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CARE-2: Falls: Screening for Future
Fall Risk
Measure Description
• Percentage of patients aged 65 years and older who were screened for
future fall risk at least once during the measurement period
Guidance
• Screening for future fall risk must include: Documentation of no falls in the
past year or only one fall without injury in the past year or documentation of
two or more falls in the past year or any fall with injury in the past year
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Diabetes Mellitus (DM) Module
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The Diabetes Mellitus (DM) Module contains one measure and one composite
measure made up of five component measures: DM-2: Percentage of patients aged
18 through 75 years with diabetes who had most recent hemoglobin A1c greater than
9.0%
– Optimal Diabetes Care (All or Nothing Scoring) DM-13: Diabetes Mellitus: High
Blood Pressure Control
– DM-14: Diabetes Mellitus: Low Density Lipoprotein (LDL-C) Control
– DM-15: Diabetes Mellitus: Hemoglobin A1c Control (< 8%)
– DM-16: Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for
Patients with Diabetes and Ischemic Vascular Disease
– DM-17: Diabetes Mellitus: Tobacco Non-Use
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HF-6: Heart Failure: Beta-Blocker Therapy for
Left Ventricular Systolic Dysfunction (LVSD)
Measure Description
• Percentage of patients aged 18 years and older with a diagnosis of heart
failure (HF) with a current or prior left ventricular ejection fraction (LVEF) <
40% who were prescribed beta-blocker therapy either within a 12 month
period when seen in the outpatient setting OR at each hospital discharge
Guidance
• If the patient has ever had an LVEF < 40% or a documented LVEF as
moderate or severe answer “Yes” to the presence of LVSD
• Bisoprolol, carvedilol, or sustained release metoprolol succinate are the
ONLY beta-blockers allowed for this measure
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PREV-5: Breast Cancer Screening
Measure Description
• Percentage of women 50 through 74 years of age who had a
mammogram to screen for breast cancer within 27 months
Guidance
• Screening includes breast imaging, breast x-ray, diagnostic
mammography, digital mammography, mammogram, screening
mammography
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PREV-6: Colorectal Cancer
Screening
Measure Description
• Percentage of patients aged 50 through 75 years who received the
appropriate colorectal cancer screening
Guidance
• FOBT includes ColoCARE, Coloscreen, EZ Detect, Fecal occult blood test,
flushable reagent pads, flushable reagent stool blood test, guaiac smear
test, Hemoccult, Seracult, stool occult blood test, FIT
• Colorectal screening does not include: virtual colonoscopy, Barium enema,
or Colovantage
• Patient refusal is not a reason to exclude
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PREV-9: Preventive Care and Screening:
Body Mass Index (BMI) Screening and
Follow-Up
Measure Description
• Percentage of patients aged 18 years and older with a documented BMI during the
encounter or during the previous six months AND when the BMI is outside of normal
parameters, a follow-up plan is documented during the encounter or during the
previous six months of the encounter
• Normal Parameters: Age 65 years and older BMI ≥ 23 and < 30
• Age 18 – 64 years BMI ≥ 18.5 and < 25
Guidance
• Follow-up may include, but is not limited to: documentation of education, referral
(such as, a registered dietician, nutritionist, occupational therapist, physical therapist,
primary care provider, exercise physiologist, mental health professional, or surgeon),
pharmacological interventions or dietary supplements, exercise counseling or
nutrition counseling
• Follow-up plan is not required for normal BMI
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PREV-11: Screening for High Blood
Pressure and Follow-Up
Documented
Measure Description
• Percentage of patients aged 18 years and older seen during the measurement period who
were screened for high blood pressure AND a recommended follow-up plan is documented
based on the current blood pressure reading as indicated
Guidance
• Patients with a Medicare claim indicating a history of hypertension prior to the first day of
the measurement period (1/1/2014) will not be included in your sample for this measure
• A normal blood pressure reading (<120 systolic and < 80 diastolic) requires no
documentation of follow-up
• Recommended follow-up based on BP classification includes: recommending screening
interval follow-up, lifestyle modifications, referrals to alternative/primary care provider, antihypertensive pharmacological therapy, laboratory tests, or an electrocardiogram
• Need to link the recommended follow-up to the elevated blood pressure using guidance
provided
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PREV-12: Preventive Care and Screening:
Screening for Clinical Depression and
Follow-Up Plan
Measure Description
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Percentage of patients aged 12 years and older screened for clinical depression on the date of the
encounter using an age appropriate standardized depression screening tool AND if positive, a
follow-up plan is documented on the date of the positive screen
Guidance
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Screening includes completion of a clinical or diagnostic tool used to identify people at risk of
developing or having a certain disease or condition even in the absence of symptoms
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This measure requires the screening to be completed in the office of the provider filing the code
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Follow-up plan may include a proposed outline of treatment to be conducted as a result of positive
clinical depression screening
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Use a normalized and validated depression screening tool developed for the patient population
where it is being utilized. Examples of depression screening tools include but are not limited to:
Adolescent Screening Tools (12-17 years)
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Patient Health Questionnaire for Adolescents (PHQ-A), Beck Depression Inventory-Primary Care
Version (BDI-PC), Mood Feeling Questionnaire, Center for Epidemiologic Studies Depression
Scale (CES-D) and PRIME MD-PHQ-2
©2011 Proprietary and Confidential
What’s next…
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GPRO starting! January-March 2015
Keep eye out for charts reviews
Weekly Q&A Conference line-March2015
Questions? Please contact Sheree Arnold (716)862-2453 or David
Nielsen (716)862-2161
©2011 Proprietary and Confidential