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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