Spring 2019 Newsletter

Effective Jan. 1, SCICN-VC has entered the Anthem Blue Cross Enhanced Personal Healthcare (EPHC) Program, which is a total cost of healthcare ACO. Under this model, a set of physician quality measures function as a “gate” that must be passed for shared savings to be distributed. The program also offers a Per Attributed Member Per Attributed Month (PaPaM) amount for care management, administered by SCICN-VC.

With 57,000 attributed members across all of our California geographies, this is our largest project to date.

The three-year contract is upside-only for the SCICN-VC with a potential to receive 30 percent of the total shared savings. The measures serving as the “gate” are HEDIS measures that we’re already tracking and are claim-based. Those measures include

Participation in EPHC does not impact any existing Anthem contracts or Anthem billing or contracting.

Note: Some providers may already be participating in an EPHC through their medical group. Providers cannot be part of two EPHCs, so if you are already in this program, you will remain in your original contract and will not be included in the attribution for SCICN-VC.

If you have questions, please contact Jocelyn Silerio at [email protected].

SCICN-VC is also is pleased to announce a new value-based agreement with Blue Shield.

SCICN entered into a PPO Accountable Care Organization (ACO) Total Cost of Health Care Model agreement with Blue Shield effective July 1, 2018.  The goal is to improve the quality of care our members receive while reducing the total cost of their health care.

This agreement is “upside-only” — there is no downside financial risk for the network or providers. If we reduce the total cost of care for our attributed patients, there is an opportunity for shared savings.

Quality metrics for this program are listed below and are measured by Blue Shield via claims data. Additionally, if SCICN reaches shared savings targets and makes improvements in quality, Blue Shield will increase the payouts to providers. Improvements in quality are made based on the following quality measures:

We are excited to announce that effective March 1, 2019, Dignity Health Ventura Medical Plans members now have access to Tier 1 benefits for imaging and radiology services at the following locations:

Radiology/Imaging

Dignity Health’s Care Coordination Program was designed to help patients reach their health goals — and to improve patient outcomes — by connecting them with important resources when they need them the most.

Two new videos have been created to highlight the program’s benefits. Through them:

• Patients can learn how Care Coordination works, what they can expect when they participate in the program and how it can help them get back to work, back to life and back to feeling their best faster.
• Clinicians get a quick summary of the program and learn how it helps their patients gain access to the resources and support they need to optimize their health.

We encourage you to watch the videos (each is approximately three minutes long) for more insight into how Care Coordination benefits you as a clinician as well as your patients, and to share the patient video with your patients as appropriate.

Care Coordination Patients

Care Coordination Physicians

As more Medicare and Commercial ACOs appear on the horizon, focusing on strategies that can help us succeed — along with short-term practical metrics for accountability — is critical. Nicholas Stine, MD, Dignity Health Senior Medical Director, Value-Based Care, Population Health Management, offers these four key strategies that can help drive our success for 2019:

1. Proactive engagement of complex and frail elderly patients.

There’s an emerging evidence base  that the majority of potentially preventable Medicare spending is concentrated within the frail elderly. We’ve conducted some initial analyses to better characterize them in our MSSP data. Interestingly, while they have high costs, they are not always the same patients we identify using other risk scoring methods.

2. Increase the use of Transitional Care Management (TCM) coding.

TCM services, which involve close and careful engagement of patients following hospital discharge to transition them back into continuity primary care, are associated with an impressive 11 percent reduction in total costs and 37 percent lower 60-day mortality (see study attached). These services are also heavily underutilized. As our updated TCM toolkit is now complete, we have an opportunity to map out the process — particularly in how Care Coordination and primary care practices work together to scale up TCM utilization across the networks.

3. Focus on post-acute and skilled nursing care.

Post-acute care is the greatest source of Medicare spending variation nationally. Bringing together the different work and programs impacted by post-acute care spending (particularly SNF and inpatient rehab services) to organize a more comprehensive current state assessment, gap analysis and its corresponding strategy are key for success. This is a complex undertaking, but national data and our BPCI experience clearly demonstrate that PAC is a highly modifiable spending area and must be considered a core strategy.

4. Reducing Part B/Specialty Drug costs.

We have an excellent use case in Macular Degeneration and the use of Avastin as a significantly more cost-effective treatment than other anti-VEGF biologics, with no clinically significant differences among them. We must ensure its success while also expanding into a broader strategy for managing Part B/Specialty spending.

Establishing and refining these strategies will be critical for ACO success across our markets.

Transitional care management (TCM) after a discharge from an acute care setting (e.g., inpatient acute care hospital, inpatient rehab facility, SNF) is what patients need. Research shows the use of TCM services is associated with a reduction in mortality and total Medicare costs; however, the use of this service remains low. We also know TCM enhances patient satisfaction, improves care coordination and potentially rewards you for preventing a hospital readmission within 30 days of discharge.

To help your practice more successfully operationalize your TCM services, refer to the new Transitional Care Management Toolkit.

The toolkit:

• Will assist you with the understanding, documentation and the implementation of the TCM services
• Explains TCM, the applicable settings and the advantages it offers
• Provides answers to frequently asked questions
• Gives practices a documentation checklist
• Offers TCM background research and resources

The toolkit is a general guide and is designed to be adapted to each market and practice.

The Practice Transformation Subcommittee, which is distributing the toolkit, will also be identifying key metrics to monitor the impact of our collective improvements in TCM.

Download the TCM Toolkit.

The Medicare Practice Questionnaire is a critical tool that supports preventive care and helps enhance patient outcomes. The questionnaire also satisfies reporting requirements for several MSSP quality measures, including tobacco use, fall risk and depression screenings.

The questionnaire also helps you stay up-to-date on your patients’ health activities — including whether they’ve gotten their flu shots this year or if they are due for a colonoscopy — so you can update their charts accordingly and make recommendations for follow-up appointments or refer them for screenings. We recommend:

• Having patients complete the practice questionnaire during wellness visits.
• For patients who don’t come into the office for their AWV but schedule appointments for acute illnesses or other reasons, the questionnaire can be used to collect the patient-reported data you might otherwise not have the opportunity to capture.
• Saving patients’ answers from the questionnaire electronically in their chart, so that the data can be easily accessed and submitted to CMS.

You can find the Medicare Practice Questionnaire for patients here.

Let’s help our patients get healthier one step at a time. That’s the objective of Walk with a Doc, a national movement founded by an Ohio cardiologist who was frustrated by his inability to inspire change in his patients. He invited them to go walking with him on a Saturday morning, and 100 people showed up. Today, 14 years later, there are 500 Walk with a Doc chapters, including one here in Ventura County.

Dr. Megan Mescher-Cox, DO, Diplomate, ABIM and ABLM, is the Ventura County founding physician of Walk with a Doc. This free program is an opportunity to walk, learn about health and walk with friends.

As a certified Lifestyle Management physician, Dr. Mescher-Cox infuses a focus on physical activity, healthful eating, relationships, sleep improvement and tobacco cessation into her practice using evidenced-based medicine. Lifestyle medicine in the primary care setting often involves a mindset shift.

For more information on lifestyle medicine or if you want to talk about Walk with a Doc, please contact Megan Mescher-Cox, DO, at [email protected].

Welcome to our newest SCICN-VC providers:

• Advanced Dermatology and Skin Cancer Institute
  • Michael Lin, MD, Dermatology
• Advantage Hospitalists
  • Rashita Aggarwal, MD
  • Maneesh Singhal, MD
• California Retina Consultants
  • Nika Bagheri, MD, Ophthalmology
• Coastal Eye Specialist Medical Group
  • Lisha Wan, OD, Optometry
• Dignity Health Medical Group
  • Patricia Lanter, MD, Obstetrics & Gynecology
  • Jennifer Steen, MD, Obstetrics & Gynecology
  • Sunita Sujanani, MD, Family Medicine
  • Ramsey Ulrich, MD, Internal Medicine
• General Surgery Medical Group
  • Karen Chang, MD
• Hera Health Care
  • Mirela Cernaianu, MD, Obstetrics & Gynecology
• inSite Digestive Health Care
  • Vikram Kanagala, MD, Gastroenterology
• Lawrence Lin, MD, Obstetrics & Gynecology
• Matthew Bloom, DO, Physical Medicine & Rehabilitation
• Richard Brand, MD, Diabetes Management
• Rose Avenue Family Medical Group
  • Kristin Anderson, MD, Family Medicine
  • Inga Wilder, MD, Family Medicine
• Scot Roberg, DPM, Podiatry
• Spanish Hills Interventional Pain Specialists
  • Farid Kia, MD, Physical Medicine & Rehabilitation
• Spanish Hills Medical Group
  • Valerie Malinoski, NP
  • Fernando Mendoza, NP
• Surfside Pediatrics
  • Erin Baird, NP
• Ventura Cardiology Consultants Medical Group, Inc.
  • Heidar Arjomand-Fard, MD. Cardiovascular Disease
• West Coast Critical Care Specialists
  • Stephen Eskaros, MD, Critical Care Medicine
  • Darren Maehara, MD, Critical Care Medicine
  • Otto Villa, MD, Critical Care Medicine
• West Coast Pulmonary Physicians
  • Darren Maehara, MD, Pulmonary Disease
  • Gergana Nelson, MD, Pulmonary Disease

Keep Us Updated

Have you recently added a new provider? Have you moved or added a new practice location? Help keep us updated of any important changes to your practice. Please contact your Physician Practice Liaison and let us know what’s new in your practice!

The Chronic Disease Management Task Force developed and rolled out various protocols, care pathways and toolkits last year for a variety of conditions and topics, including diabetes, opioids and annual wellness visits. The most recently released new protocols are for COPD and tobacco cessation.

The Tobacco Cessation guidelines offer a clinical intervention protocol as well as details on helping patients with a quit plan.

The COPD guidelines are divided into two categories:

• Algorithm A: Management of COPD in Primary Care
• Algorithm B: Management of Acute Exacerbations of COPD

Like the previous releases, these guidelines are evidence-based protocols grounded in well-vetted national standards designed to serve as resources for physicians when needed.

To learn more, review the new Tobacco Cessation Protocol and COPD Protocols now.

When the Centers for Medicare and Medicaid Services (CMS) created Meaningful Use in 2010, the focus was on moving to electronic medical records and driving patient engagement with patient portals. The next step was underscoring the importance of sharing data (aka interoperability) among different EMR values to ensure a patient’s data traveled with them.

“Meaningful Use within the ambulatory system became the Merit-based Incentive Payment System, or MIPS,” explains Tom Peppard, MIPS Program Director, Clinical Informatics, Dignity Health. “One of the categories under MIPS is Promoting Interoperability, and CMS also renamed the hospital Meaningful Use program to Promoting Interoperability.”

Last year, a Dignity Health Promoting Interoperability (PI) workgroup was formed with the goal of addressing specific measures within the PI category.

“In 2019 and moving forward, a lot of bonus opportunities are disappearing … and it is going to be much harder to get a really good score in the PI category,” Peppard notes.

The PI workgroup is here to help providers throughout Dignity Health and our clinically integrated networks (CINs) with information and operational guidance to improve processes.

Developing workflows and processes that work for your practice are important. Peppard suggests, for example, taking advantage of points-of-care reminders offered by EMR systems. These reminders help ensure you ask the right questions during an exam based on the patient’s medical records. Plus, he says, there’s value in training for providers and checking monthly compliance reports to monitor your quality scores.

“The PI category is still important — it’s all about performance now on the measures,” Peppard adds. “Developing muscle memory around clinic and EMR workflows is what will get you there.”

The following is a summary of the Group Physician Reporting Option (GPRO) process as well as important new and changed measures and critical dates for 2019.

Process Summary

• GPRO involves quality data collection, measurement and reporting for MSSP, which are conducted at the ACO level.
• The samples for which ACOs will be required to submit clinical quality data will be drawn from all assigned beneficiaries across the entire ACO.
• The ACO will submit via the CMS Web Interface on behalf of the physician groups.
• All data is manually collected from the beneficiary’s medical record; claims cannot be used to verify data.

New and Changed Measures for 2019
Dignity Health’s four MSSP ACOs will now be required to track data for 23 (vs. the previous 31) quality initiatives, with the new breakdowns as follows:

New Measures:

• ACO CAHPS Measures:
  • Courteous and Helpful Office Staff
  • Care Coordination

Changed Measures:

• ACO 11: The number of eligible providers who meet the base score for MIPS Performing Interoperability category.
• 2019: Attestation that 75% of ACO uses 2015 CERHT

Critical Dates:
Following are the critical 2019 GPRO dates for the 2018 performance/reporting period:

• Jan. 1–Dec. 31, 2018: Claims data submitted as claims occur.
• Jan. 22–March 22, 2019: Quality Data submitted via CMS web interface. (This eight-week period is set by CMS each year.)
• April–May 2019: ACOs are selected and provide materials for audits conducted by CMS.
• July–August 2019: CMS releases GPRO results.
• New cycle begins: Cycle repeats for the next performance/reporting period.

The 2018 Value Report for Physician Integration and Population Health Management has been released. Titled From Theory to Action: Executing on the Quadruple Aim, the report highlights how the steps we take to ensure healthier patients — including evolving our clinical workflows, tracking and reporting key quality measures, and developing initiatives that support healthy communities — enhance our ability to care for our patients and our success in value-based programs.

Other highlights include:

• Our success in the Bundled Payment for Care Improvement (BPCI) Program
• The Medicare Shared Savings Program (MSSP) and the work of our five Accountable Care Organizations
• The role of our Clinical Steering Committee and VBA Council in driving our strategy
• How our subcommittees contribute to the work we do
• The value of our digital team, Community Health department, the Foundation and Graduate Medical Education

The 2018 report builds on our inaugural report, which showcased the foundation of the program, and helps educate our internal audiences and leadership on the activities, depth and breadth of Physician Integration and Population Health.

Throughout Dignity Health’s hospitals, medical groups, clinically integrated networks and accountable care organizations, we’ve been focused on collecting actionable data and on setting targets that empower us to achieve the Quadruple Aim. In 2017 and 2018, we saw our strategies take shape as we arrived at key benchmarks. We are optimistic about the opportunities we see on the horizon — and all that we can achieve.

View the digital version of the 2018 Value Report at dignityhealthvaluereport.org.

You can now check the Quality Payment Program (QPP) Participation Status Tool to view your eligibility status for the 2019 performance period under the Merit-based Incentive Payment System (MIPS). Enter your National Provider Identifier (NPI) to find out if you need to participate in MIPS during the 2019 performance year.

CMS determines your 2019 MIPS eligibility status by reviewing both PECOS data and Medicare Part B claims for services provided during two 12-month segments called the MIPS determination period:

• First segment: Oct. 1, 2017–Sept. 30, 2018; includes a 30-day claims run out period.
• Second segment: Oct. 1, 2018–Sept. 30, 2019; does not include a claims run out period.

Preliminary vs. Final Status

The QPP Participation Status Tool update shows your preliminary 2019 eligibility status based on data from Oct. 1, 2017–Sept. 30, 2018. Later this year, we’ll review PECOS and Medicare Part B claims data from Oct. 1, 2018–Sept. 30, 2019, and update the QPP Participation Status Tool to reflect your final 2019 MIPS eligibility status. If you joined a new practice and started billing to a new or different TIN after Sept. 30, 2018, we will evaluate your eligibility under that practice during the second segment of the MIPS determination period.

Changes to the Low-Volume Threshold

We’ve updated the low-volume threshold criteria for the 2019 performance year. Clinicians and groups are excluded from MIPS in 2019 if, during either segment of the MIPS determination period, they:

• Bill $90,000 or less in Medicare Part B-allowed charges for covered professional services payable under the Physician Fee Schedule (PFS), OR
• Furnish covered professional services to 200 or fewer Medicare Part B-enrolled beneficiaries, OR
• Provide 200 or fewer covered professional services to Medicare Part B-enrolled beneficiaries

Clinicians and groups currently identified as eligible (exceeding all three elements of the low-volume threshold) must exceed all three elements of the low-volume threshold in the second segment to remain eligible, unless they opt in to MIPS participation. 

Opting in to MIPS Participation

Clinicians and groups can elect to opt in to MIPS if they meet or exceed one or two, but not all, of the low-volume threshold criteria. Clinicians and groups who do not exceed any of the low-volume threshold criteria (in one or both segments of the MIPS determination period) may voluntarily report, but are not able to opt in.

• Clinicians and groups that opt in will receive a MIPS payment adjustment in 2021.
• Clinicians and groups that voluntarily report will receive a MIPS final score, but no payment adjustment will be applied.

Learn more and get answers:

• Visit the About MIPS Participation page on the Quality Payment Program website
• View the 2019 MIPS Quick Start Guide and the QPP Year 3 Final Rule Overview Fact Sheet
• View the 2019 MIPS Eligibility and Participation Fact Sheet
• Contact the Quality Payment Program at [email protected] or 1-866-288-8292 (TTY: 1-877-715-6222)

In 2017, the U.S. Department of Health and Human Services (HHS) launched the Health Insurance Portability and Accountability Act (HIPAA) Breach Reporting Tool (HBRT), a revised web tool (the original was released in 2009), to help health care entities better identify breaches of health information and learn how they are investigated and resolved.

The revised HBRT features improved navigation and usability that make it easier to search for info on breaches and report incidents. New features include:

• Enhanced functionality that highlights breaches currently under investigation and reported within the last 24 months
• A new archive that includes all past breaches and information about how these breaches were resolved
• Improved navigation to additional breach information

You can access the HBRT here and use it to stay informed about current security threats and in the event that a breach occurs. For additional information on HIPAA breach notification, visit the HIPAA Breach Notification Rule webpage.

St. John’s Regional Medical Center (SJRMC), a Dignity Health hospital, offers a free Diabetes Empowerment Education Program (DEEP) for individuals living with pre-diabetes and diabetes. Link: https://www.dignityhealth.org/central-coast/locations/stjohnsregional/about-us/press-center/diabetes-empowerment-program-offered-at-st-johns-regional

When patients need extra assistance with their health, keep in mind the Good Health classes at St. John’s Regional Medical Center. The classes are great for patients coping with high stress, diabetes, high blood pressure or high cholesterol. Link: https://www.dignityhealth.org/central-coast/locations/stjohnsregional/classes-and-events

Spend less time in your email inbox and never miss important network news by opting in to receive text alerts. With these new alerts, you’ll receive a text when there’s important network news or announcements. (The system is fully HIPAA-compliant, and patient data will never be sent.) So, whether you’re frequently on the go or simply prefer texts, text alerts make it easier to stay up to speed.

If you want to sign up to receive the text alerts, simply use your mobile phone and text “SCICN-VC” to 797979.