Cost Measurement and VBC Webinar Transcript

Managing your organization’s costs is a top priority in the world of healthcare. Learn how to best orchestrate the ins and outs of the Value Based Care model cost requirements with guest Christine Grey from AmeriWound.

well welcome everyone to our webinar and affecting cost and value-based care

our speakers today will be our own molly mynahan our vice president of operations

and innovation and our client guest amer christine gray who’s in her

clinical quality all right and getting into today’s

agenda i’m going to get into a little bit more detail about our two wonderful speakers and then getting into the

webinar itself today we’ll be focusing on the quadruple aim followed by cost under value-based care

models and programs diving into some bbc model cost requirements

and then finishing on how to impact cost and then at the very end we welcome a

question and answer for all of our attendees

and then again yeah anyone that cares to ask any questions please submit that via the chat box as everyone will be muted

and of course just to take care of that housekeeping we do have our disclaimer here at the bottom

as far as our wonderful speakers today as i mentioned we have molly mynahan i’m

our vp of operations and innovation here reporting md molly has been with us for almost 10

years now um while also bringing over 15 years of experience in data research analysis and

reporting and then we also have christine gray from ameriwound who works

as a clinical quality and billing auditor um she’s a veteran in the industry with over 15 years

of experience and she is also a licensed practical nurse with a demonstrated history of working in the hospital and

healthcare industry and then i’m jessica raymond i’m the director of marketing here at reporting

md and then a little bit about our

new organizations um as far as reporting md is concerned we have more than 18 years experience with patient outcome

management for value-based care programs that deliver um we pride ourselves on our dedicated advisors who are here to

answer any and all questions for our clients and potential clients while reducing physician i.t and

administrative burden getting into a maryland they have served patients in long-term care facilities

for close to a decade is currently licensed to provide physician wound care in eight states focusing on skilled

nursing facilities assisted living facilities and independent living facilities and we’ve had the pleasure of

having a marijuana be our client for eight years now

all right i will pass this on to molly to start on the webinar

hi everybody uh so this is the focus is affecting cost value-based care so we’ll

start uh with the quadruple aim so in health care and before 2022 we

focused on what the institute for health care improvement coined the triple aim which is better care for individuals

better care for populations and reduce per capita healthcare costs and more recently and not surprisingly

given the strain on human resources um in the healthcare setting a fourth

aim was added for improving the healthcare team’s well-being so the quadruple aim is is only reached

through the creation of a set of value-based care delivery models

new delivery models which not only use not only cms uses but commercial payers

also use to improve the quality of care and as it relates to the subject matter

of this presentation reduce the cost of care

so whether under the direction of cms or commercial payers the quadruple aim is realized through the value-based

care models and programs being adhered to today the charge for our healthcare

providers and institutions is to refine and perfect workflows processes and

quality care management to not only improve the wellness of individual patients and populations but also slow

the cost of health care and utilization through proper preventive and high quality care

so studies have shown that by improving quality of care for individuals we’ve also seen relative cost of care reduced

as well uh and we know better management of chronic disease and better preventive care management have also been proven to

reduce ed utilization as well as costly and traumatic hospital stays and readmissions

so i want to dive into a couple of value-based care models and more

specifically really how cost impacts and plays a role in those value-based care models so we’ll start out with the mips

program so first this is how cost impacts the mip score and resulting incentives and penalties

on health care providers and practices slash organizations in 2022 cost is worth 30 percent of the

mip score and it continues to be a 12-month reporting window there’s no uh

submission requirement for the cost category under mips as it’s all calculated by cms through

administrative claims there are a couple of different types of measures under the cost category

and i know this is a little bit of a distant distant category because it hasn’t been scored in some time but um just getting

back to the different types of measures the cost uh one is the cost of primary

care which patients receive and that’s known as the total per capita cost the

cost of services provided to medicare patients related to a hospital stay

that’s also known as the medicare spending per beneficiary at the clinician level and then costs for items

and services during 23 different types of episodes of care for medicare patients

we call those the episode-based measures they’ve been adding cms has been adding those on since 2018 when they started to

actually score cost um so in 2022 there are 15 procedural

episode based measures there are six acute inpatient medical condition episode based measures and two chronic

episode based measure chronic condition episode based measures uh the measure type

determines how the cost is attributed to a clinician based on the specifications

so the specification will define that and if practices don’t have enough cases

for any of any or all of the cost measures they would not get scored on the cost category and the points for

that category would then get redistributed to other mips categories so i do have a cost example or scoring

example here this mock practice reached the case minimum on three different cost

measures total per capita cost elective pci procedures and elevated mi with pci

acute inpatient medical condition measure so depending on how the cost for each

measure compared against the benchmark cost for the measure determines the measure

specific score and those scores are then tallied and then re-weighted to or weighted to

the 30 cost category weight under the mips total score and so here you can see

that they achieved you know for the three measures 17 out of 30 points um since the the category is worth 30

percent of the mip score in 2022 they would they would achieve 17 points for cost

so uh the medicare shared savings program or mssp aco is another

value-based care model pushing on the quadruple aim in hopes of moving um away from that

volume and and more toward value and outcomes um it’s obviously it’s an

alternative payment model with the goals of promoting accountability for patient population

coordinating items and services for medicare beneficiaries

encouraging investment in high quality and efficient services

some of the factors that set an aco entity up for success under the model are the minimum savings

rate that’s chosen at the point of contract the level of of risk-based contracts so what the risk is that

you’re taking for that aco contract and then success in achieving the quality requirements under the mssp

in this case for 2022 that really revolves around reaching the quality performance standard

and um the most significant factor however in for for success as an mssp

aco is the management of cost and that is really about creating enough savings

in order to share in the savings that were generated and so in this chart we can see that

aco1 if you see here the gray is the benchmark expenditure so that’s the benchmark the blue is the total

expenditures and the goal as an mssp obviously is to have your blue be much

lower than your gray um and so aco1 these are these are true acos from the

past um and so the first one did not generate enough savings to surpass their selected

minimum savings rate so they would not be able to share in any savings that they generated so this was just this gap

was not enough to share in those savings aco3 here had costs that exceeded their benchmark

cost so the blue was higher than the gray um and that means that this aco had to actually pay back over 2.5 million

dollars in losses to cms um an aco2 in the middle

managed their costs to the extent that their costs were so far below the benchmark um that the entity was

actually able to share in the savings generated in the amount of nearly 4.5 million dollars

so costs is clearly the key piece here so we know

cost matters we know it’s being measured um you know under all of these different value-based care programs um we know it

can result in large penalties or even large incentives in some cases but the big question is how can you

actually impact cost and that seems to be a question that doesn’t get answered um you know we see the facts about cost

but we don’t really get the ideas on how to impact cost or how to move the needle

so next we’re going to take you through six different tactics that can help you manage and improve your costs

and so and then we’ll summarize those those at the end so it doesn’t need to be a black box

first knowledge is key it’s important to know what cost data is available

so what’s out there about your organization that you can analyze and consume under mips for example when cost is

scored cms releases data including the patients and the episodes

scored for each measure so on the cms qpp portal it’s called the quality payment portal

if you log in you can drill into each cost measure score to take a deeper

dive into what contributed to your measure by measure cost scores so if you look here some examples of what’s out

there if you look at the graph you can see your cost scores com how your cost scores compare to the cost benchmarks

for each measure you can also download lists of beneficiaries like you see on the bottom

and their associated costs to understand where your highest costs were

so analyzing these cost data sets can help you understand who in the organization may be contributing the

most to your cost scores who’s driving your cost scores up who’s driving it

down and what are the possible reasons why it also stands to reason that the relative complexity of a provider’s

patient population will contribute to their costs and it may help to understand why the costs of one provider

might be higher or lower than others so for example here you can see on the chart provider

one had the highest total cost on the medicare spending per beneficiary measure

but also had among the highest average patient hcc ranking at 79.16 so it makes sense that their costs

are higher the more complicated their patients are on the other hand provider 2

also has higher costs but the hcc ranking is is lower so why are provider 2’s total cost so much higher but their

patients are less complicated than provider one this is the kind of information

that’s available an analysis that you can you can draw to see if you can start figuring out the trends and the places

that you can look um to figure out where you can start focusing on improving your cost and who who in your organization

maybe you need to start focusing on for for working on cost

so number two the second tactic is uh annual wellness visits ben franklin had

it right when he said an ounce of prevent prevention is worth a pound of cure health care payers are supporting

they’re often even encouraging more preventive care measurement um like the annual wellness visit and that

obviously helps to understand and manage the total quality of care for individuals and patient

populations so annual wellness visits get the full chronic conditions profile

documented for patients they close a long list of quality care gaps

they create additional revenue for all these different types of screenings and preventive measures

and so with so many payers including cms and commercial payers pushing in your

wellness visits it’s just one more pathway to reaching better care and reducing cost

um and speaking one with one of our 200 plus provider organizations recently

when any patient comes in for any visit if they haven’t had their annual wellness visit done so far during the

year they are completing it at that moment they’ve already seen a huge increase in annual wellness visit

adoption and an additional measure in additional revenue as a result of that

so this is a this is a big one number three is risk scores and ensuring

complete and accurate diagnosis coding this is another big one cms utilizes

patient complexity when calculating cost scores for a given year so this is done using hierarchical

condition categories or hcc coding commercial payers also you use risk

scores for payment rates but with the they’re using the office of health and human services calculation model it’s a

little bit different than the cms hcc calculation model since a patient’s complexity score

restarts from xero every single year it’s really it’s critical that accurate

and complete diagnostic coding is utilized to ensure the payers understand the true

complexity of your patient panel physicians should review and report all

chronic conditions at annual visits physicians should not only report diagnoses that describe why the patient

is being seen but also diagnoses associated with chronic conditions that affect treatment choices

we reporting md we’re calculating both the cms and hhs models to understand

risk scores and complexity of patients for all payers for example

the third patient on this patient list has a risk score of 6.31 uh they’re not a medicare patient they

have um at least two nodes so that the point being that they had their risk

score calculated using the hhs model uh they have at least two known open care

gaps they have nine hcc relevant diagnoses that were unsubmitted to payers and no

next appointment scheduled so the payer doesn’t know how complicated the patient is

they have known open care gaps and there’s no appointment scheduled for

this patient but their their risk score is already at six point three uh the patient needs obviously needs further

review and attention before a potential traumatic and costly event occurs

these are the patients that we need to pay attention to so continuing with risk scores

um under value-based care models like the medicare shared savings program aco

changing medicare beneficiary risk scores will not only impact the performance period expenditures but also

the historical benchmarks that costs are compared against accurate diagnostic coding means

accurate risk scoring which leads to improved shared savings potential and reduced loss potential

if an aco if an mssp aco doesn’t exceed their preset minimum savings rate like i

showed before or if their costs are higher than their benchmark like acos one and three that we saw

before they won’t be able to share in savings generated and they could even be liable in cms for losses

so the risk scores impact benchmarks not documenting uh properly will result in lower

benchmarks and um and will reduce possibility of savings

so looking at the impact of risk scores on medicare advantage specifically the

pm pm rates those are the per member per month payments the higher scores translate into higher

payment higher pmpm payment payments um the lower scores translate to lower pmpm

payments so if we take a patient case study the patient has a bmi of 44 the patient

should be coded with a morbid obesity diagnosis code um because they’re they’re

but they’re just coded as just obese and which means that there’s no change to their risk adjustment factor otherwise

known as their wrath score and therefore there’s no change to their medicare advantage payments

so the same patient however being properly diagnosed with the morbid

obesity diagnosis code gets an adjusted raft score which increases their pm pm

payments by nearly three hundred dollars per month and over thirty five hundred dollars per year

medicare advantage uh programs that have inaccurate or incomplete hcc scores will will

definitely suffer financial losses due to underestimated complexity being represented for their patient population

uh number four is ed visits and hospital readmissions so pay attention to ed

visits and hospital readmissions as they equal higher utilization we all know this of course um you know an ounce of

prevention is key so pushing annual physicals annual wellness visits to prevent edu’s is important when it’s not

enough a few ways to target frequent edu use is to offer after hours care

or phone lines reserve times for same day office visits and telehealth visits and offering those

if you’re a mips participant cms releases information on ev utilization as well through the qpp portal so some

practices are measured on administrative claims-based measures like the measure hospital-wide 30-day all-cause hospital

readmission from mips groups the top right hand image shows an example of a

practice that scored quite high with a 0.1416 performance rate the lower the

readmission rate the higher the score so here you can see that the score resulted in 9.24 points for that measure

additionally the items and services information as seen in the the bottom image shows metrics on ed utilization

and i showed you here where you can find that information in the qpp portal under items and services

and that shows metrics on eb utilization from a given reporting year so you can compare this type of information from

year to year it can give you insights on what’s needed to initiate improved ed utilization across your patient panel

so patient care coordination is number five um first get everyone talking care coordinators

keep communication among caregivers open and up to date this includes verbal written digital

forms of communication so that caregivers are up to speed on the agreement and an agreement on

on patient care get everyone sharing ensure that patients patient referrals

are shared amongst caregivers it could include formal agreements or contracts with other providers and

organizations in your area to share that patient information get everyone meaningfully using

certified ehr technology or cert sir offers electronic referral capabilities make sure your team and

your team members and other caregiver partners are taking advantage of those ehr capabilities and that one is a

two-for-one because it also helps the pi category measures under the mips program

when you’re you’re meaningfully using your certified ehr technology

so finally the collection of social determinants of health can be done through assessments and

screening tools and via individual self-reporting

when documented in the diagnosis list social determinants of health can contribute to improved patient

complexity documentation while they don’t currently impact

reimbursement these diagnosis codes can trigger referrals to social services and

other services which can help to reduce health inequities and prevent traumatic ed visits

at the top of the graphic you can see that icd-10 codes z55 through z65 or are

used for social determinants of health and each one is shown in the related graphic below so z 55 you can see is for

education and literacy z 56 is for employment and unemployment

so social determinant of health coding can reduce health inequities and

more value-based care models are focusing on them so for example the cms model

formerly known as direct contracting which is now known as the accountable

care organization realizing equity access and community health also known

as the aco reach model the focus of that model is to improve the health care experience of people

with medicare medicaid and even marketplace coverage and the method is to use this model to identify

underserved communities and then initiate processes to reduce health disparities within those patient

populations so uh sorry social determinants of health

coding can result in those reduced health inequities

continuing on that theme cms is rewarding up to three grants

totaling one million dollars to support research um

sorry three different grants totaling one million dollars to support research being done at

um eligible minority serving institutions msis on how cms can better

meet the healthcare needs of cms beneficiaries this opportunity would support research

on programs policies operations and more that influence

health equity the deadline for applications for those grants is 3 pm on thursday july 28th you can get a little

bit more information it’s really about supporting researchers

that are exploring how cms can better meet the healthcare needs of cms beneficiaries especially those in

underserved communities we have the website here at the bottom as well

so cost does not need to be a black box it’s not a quick

fix but it doesn’t need to be a black box um so first knowledge is key know what data is

out there to understand your baselines and whether or not you’re improving or if you need work on various cost

related measures second strengthen your preventive care with annual wellness visits or in your

preventive care visits that’s also a two for one because it brings in additional revenue for the

visit or for the screenings as well three ensure accurate diagnosis

documentation for improved risk scores making sure you’re communicating the true complexity of your patient

population to payers through accurate diagnostic documentation

offer alternatives to the emergency department after our phone lines 24 7 access to

providers same day office visits telehealth visits these are all pieces and alternatives to ed utilization and

can really cut that down focus on coordinating care

with other providers and surrounding specialists get everyone communicating to improve the complete patient care

continuum and finally social determinants of health may not change payment rates today but accurate

documentation of these can trickles trigger social services and other other referrals and

interventions that can help reduce health inequities

so with that just you want to introduce christine absolutely thank you molly so yes now we

have our guest and client christine gray from amer wound who just will have a few minutes about you know their

correspondence with reporting md hi thanks jess thanks molly um i just

wanted to say that my experience working with reporting md has been phenomenal they have been there every step of the

way for me i’ve been with the mirror wound for a little over going on three years now

and um they have been exceptional in helping me to find my uh

quality measures any questions that i have they’re always available

we service eight states and one of the states we finally submitted

to cms this past year through tom um and being able to use that

aspect of your services as well has been great um we scored 100 on that state that

state was never filed for our company before so greatly appreciative of all your help

with making that dream come true so now i have to find a few more dreams that you guys have to make come true

um but it’s really been an excellent opportunity to be able to work with all

of you thank you christine we appreciate that

thank you all right jess so let’s move

to q a yeah absolutely and again if you know any and all questions are welcome just

submit those via the chat since everyone is muted and you can get that rolling

um as far as what has already been submitted or submitted ahead of time um we’ll start with is there a way for

providers addressing sdoh and a health system to be reimbursed in a value-based care model

so uh as it stands right now sdoh is not does not impact uh reimbursement but

that doesn’t mean that there’s not um it’s not in the future uh we know that it’s critical to help help

reduce those health inequities across patients um coding these getting used to

coding these is probably a good idea now um and again it can bring those

additional referrals um social services and other things to the table that may

not have been available or known about that can that can help reduce you know ed utilization readmissions all

all of that so right now not a lot of um

immediate payment reimbursement for sdoh but it’s it’s on the horizon

next we have how do we know what our budgets are so

um sorry i’m just going to get down to the qa so i think um you know

medicare spending per beneficiary that one’s easy you know what your benchmarks are so

the key with that is making sure that you’re accurately coding for the risk scores uh and keeping those risk scores

up because when you stop or you decline on that or or are not aren’t doing you

know the chronic conditions um uh that means that your benchmark is going

to start getting impacted so your benchmark is key under mssp aco

under mips you know unfortunately cost hasn’t been scored for the last couple

of years due to the covet pandemic um it’s good and bad it’s bad because we don’t really have all the cost

information that’s that cms can can provide to us

so that that one’s a little bit tougher um you know i think generally speaking we’re going

to have more insight more information when we do get scored on cost um and

hopefully hopefully 2022 is going to be a different year so um getting those

benchmarks is key though and and go into the qpp portal take a look at

even 2019 take a look at some of the resources that are out there you can see hospital

information you can see um you know for the different measures medicare spending per beneficiary you can dive in and you

can get the benefit beneficiary list for the measures that were the patients that were used in the scoring of any measure

that you were scored on in 2019

and next for annual wellness do you have recommendations on tracking

on tracking um

so i’m tracking trying to think of specifically um

so i think there are a couple of different ways

there are organizations like reportingmd we actually offer um we offer a measure

where you can actually get we can we will aggregate for the three different annual

wellness visit types that are out there so the the initial um the subsequent um

and the ippe uh we will aggregate for those and give you performance information so you can

actually measure that and you can see your performance on your wellness visits throughout the year

you can i think that you know it really depends on the ehr or the system that you’re using

but some systems do offer annual wellness visit um but

making sure that you’re taking advantage of um sending out letters uh to patients about annual wellness

visits and coming in like we said with that big organization um you know we were just

speaking with them the other day they they mentioned the fact that they have not done well on anyone’s visit that

just has not been a focus in the past and they said this year they were going to do something different if the patient

came in they were seen for any reason and they had did not have an annual wellness visit scheduled or have had

been done that in the year they were doing it at that moment that’s a huge

uh time time requirement it’s a it’s a big initiative but because of that they know that

they’re going to get better coding they’re going to get better documentation they’re going to reduce the possibility of edu visits

and they’re going to bring in additional revenue for all the screenings that’s preventive measure medicine at its best

so i’m really excited to hear about that but utilize the assist the what your your

systems offer uh make sure you know all of what your systems offer um

send up send out mailers to get patients to call up a lot of patients don’t even know what the annual wellness visit is

um uh and and you know talk to reporting md we have resources out there as well they

just have a quick slide deck that takes you through um just an easy to read

annual wellness visit brief um that you can send to to anyone i i sent it to to

my mom and dad so um you know we have resources we’re measuring annual wellness visit uh we’re measuring annual

wellness visit and the gaps from year to year um know what your ehr is capable of

and yeah i think that’s probably the best advice for that

i think the final question will be um how is covet affecting costs

uh so i do have a slide about this it kind of

gives you an idea of what um has happened over the last couple of years from under the mips program for

example um you know for cost in both 20 20

20 20 as well as 2021 the cost category was reweighted uh that means that nobody

was scored on cost in fact we just found out um you know a couple months ago two

months ago after the submission season that cost was not going to get scored for um for 2021.

when that happens that means that the cost category ends up being worth zero percent and the points get redistributed to the

other category so for 2021 quality for large practices becomes actually for all

practices when cost is is the only category that’s reweighted quality became worth 55

the pi category added on an additional 5 um and became worth 30 percent um the

additional thing about cost not getting scored like i said before is just that the resources aren’t out there uh the

qpp portal is one of the best cms resource resources available that i’ve seen

um you know going back to the years of iacs and things like that um you know

the qpp portal is just so welcome there’s so much good information in there and it’s really tough when the

when the the same information is not released when the cost category is not scored um

the extremely uncontrollable circumstances hardship application that is available this year in 2022 as well

so if you are still getting impacted by the covet pandemic you do have the opportunity to get one or um or a couple

or all of the mips categories reweighted um and because we don’t know if cost is

definitely going to get reweighted for 2022 across the board again so if you do want to have that happen

know that um you can apply for a hardship application but also know that if you do that you

are confirming that you will not get scored on the cost category and um and that means that you will also not have

access to any of the information on on how you’re getting scored on the measures or the beneficiaries that are contributing to your cost scores

well again you know thank you molly and christine for your time today thank you for everyone that did attend um as far as

some follow up if you were interested in a one-on-one meeting we are happy to schedule that for you um also i will be

emailing the attendees the slide deck and then the full presentation will be available on our website

um probably by the end of the week as well so again thank you very much everyone thank you

thank you