for joining today's workshop. Welcome, everyone. Thanks for joining today's workshop, Demystifying Value-Based Care. My name is Margaret Cordes, and I am the Director of Education at HCCI. Before we get started, just a couple of housekeeping items. Today's workshop is going to be recorded, and we will be uploading the recording to the HCCI Learning Hub within 24 hours of the workshop. So you can expect to find it there. If you have any questions during the workshop, feel free to submit them in the Q&A box. That will go directly to the moderator and presenters. But you can also use the chat box if you want to share any comments or communicate with any of the other workshop attendees. So next slide. And the next slide. So this is a disclosure slide just to state that none of the planners or faculty of today's workshop have at present nor have had within the last 24 months any financial relationships with ineligible companies. And as a reminder, that today's workshop is designated for four AMA PRA Category 1 credits. You can claim credit after the workshop in the Learning Hub. Next slide. And today, we'd just like to acknowledge the John A. Hartford Foundation, which today's workshop is supported in part by. And as I mentioned, you can access the workshop materials in the Learning Hub. That's the same link that you would There you can find the slides for today's workshops, the recording after it's completed, a handout, and also our learning plan. So if we go to the next slide, you can see a picture of what that looks like. This is just a helpful handout that you can use today and to help you with your learning plan. And I'm going to go ahead and share with you a few of the slides that we're going to be using. This is just a helpful handout that you can use today and over the next two upcoming workshops. There are questions like, which concepts do you want to learn more about, if there's things you want to remember. We would love if you jotted down some of your ideas throughout the workshop. We ask that if you do complete it, you can return it to us. It's really helpful to HCCI to get an understanding of what learners are looking to achieve from our education activities. So I encourage you to access that in the Learning Hub and complete it and submit it to us. And if you, at any point, need any help, you can reach us at education at hcciinstitute.org. Next slide. So there's the email address. In the next slide, we'll review the workshop objectives. So today, we're going to be discussing the shift towards home-based primary care and exploring the socioeconomic drivers for its business case. You'll learn how to assess the strengths and weaknesses and readiness of your clinical model to perform well under a risk contract, describe the steps in building relationships with payers and other potential partners in demonstrating your practice's value, and leveraging key quality metrics data. We will also be discussing how to discern when specialty care is appropriate in coordinating with specialists and evaluating a framework for success for home-based care in value-based payment arrangements. So the next slide is a review of today's agenda. We're going to be starting with the future of value-based health care as home-based primary care. We'll move on to quantifying the value of home-based primary care. And then before our first break of the day, we'll talk about how to leverage HCC coding and risk adjustment. Around 155, we'll aim to have a brief bio break for you to run to the washroom, grab a drink of water. And then the rest of the afternoon, we'll be talking about current Medicare advancement payment models, working with specialists, and demonstrating the value of home-based primary care. So for today's workshop, we have a great panel of experts that are going to be speaking with us today, starting with Dr. Paul Chang. He's a senior medical advisor and practice advisor for Home-Centered Care Institute. He's also the Medicare director for Northwestern Medicine home care positions. And he has impressively recently made his 36,000th house call. We also have Amanda Tufano. She's the chief executive officer at Genevieve. She's also a board member of the Minnesota American College of Health Care Executives and the Minnesota Association of Geriatric-Inspired Clinicians. And lastly, we have Michael Helly, director of clinical programs in the Office of Population Health at University of California, San Francisco. So thank you all so much for being here. And without further ado, I am going to pass it over to Amanda. Hi, y'all. Welcome. Well, I'm so excited that we're going to talk about this all afternoon, but we're really going to kick off just our first morning session, or afternoon session, I guess, with a video. So if you go to the next slide, a couple of things we'll talk about in the video is the value of home-based primary care. And give it just a second to load here, but it also includes our founder, Dr. Tom Cornwell. So, you know, think about some things as you're going through and ask questions, again, in that Q&A section for us. Thanks. In the U.S., it is estimated that more than 7 million older adults are homebound or home limited. And the overwhelming majority of these chronically ill, medically complex patients do not have access to primary health care and therefore often must rely on calls to 911 and visits to the emergency room to receive even basic care. And this group is growing exponentially, with 10,000 baby boomers turning 50 this year. 10,000 baby boomers turning 65 every day. And those aged 85 and over projected to quadruple by 2050. This group is also part of the 5% of high utilizers who consume 50% of Medicare's $800 billion budget. The good news is there is a solution. It's called home-based primary care, as the modern-day house call. With this type of care, physicians, nurse practitioners, and physician assistants provide ongoing health care to patients in their homes. These visits can include lab tests, EKGs, x-rays, ultrasounds, and more. House calls not only improve outcomes and the quality of life for patients and their caregivers, but also reduce the overall cost of care. Currently, however, only about 15% of those who need this type of care can get it. That is because there simply are not enough providers and practices offering longitudinal home-based primary care. Experts agree that due to the increased prevalence of value-based contracts and Medicare Advantage, not to mention the impact of the current global pandemic, demand for home-based primary care is predicted to grow at a rate of 10% annually for the next 10 to 20 years. The Home-Centered Care Institute is a national nonprofit organization focused on scaling home-based primary care and bringing it into the health care mainstream through four main focus areas, education, consulting, research, and advocacy. HCCI is an authoritative source for clinical and operational best practices. Clients can count on HCCI to answer questions and conduct market analysis to inform their business decisions and help them assess opportunities for starting or expanding practices that offer home-based primary care. Dr. Thomas Cornwell, founder and executive chairman of HCCI, explains the impact home-based primary care has on patients, their families and caregivers, clinicians, and payers. So what is home-based primary care? Home-based primary care brings providers as well as modern technology into the homes of mostly homebound patients in order to improve their quality of life, the lives of their caregivers, while reducing healthcare costs by enabling them to stay at home and avoid hospitals and nursing homes. A perfect storm of forces is fanning the sails of the modern house call movement. Just some of these include the aging population, advancing technology, increased home and community-based services being funded by the government, the value of house calls, and payment reform. The first force is the aging of society and the cost of increased chronic disease burden. The extremes on this graph are surprising in that the least expensive 50% of the population consumes only 3% of total cost, but conversely, the top 5% consumes 50%, and the top 1% consume an astounding 21% of all the cost at an average cost of over $100,000 per patient. These high costs are caused by our fragmented healthcare system that is not set up to care for the sickest patients who are often homebound. Bringing home-based primary care to these patients has been shown to dramatically improve their quality of life and, again, the lives of their caregivers while reducing these healthcare costs. Advancing technology is another force. I like to say that house calls are principally high-touch primary care in the home, but we also have the high-tech capability to provide quality care in the home. Just some examples are smartphones that can do rhythm strips in seconds. They have numerous apps now that I can do vision testing, drug databases, decision support, and much more. Portable x-rays and ultrasounds can be done in the home. Labs can be done in the home, including point-of-care testing, as well as we can draw blood in the home and spit it down in the car in a centrifuge that's plugged into the lighter. Modern technology has enabled me to do more in the home than most primary care practices can do in their offices. The third force is increased funding of home and community-based services. Government funding of long-term support and services are made up of institutional care, nursing home care, and home and community-based services. This graph shows that back in 1983, 99% of all funding went to nursing home care, so your only option if you needed help was to go to a nursing home. Over the past two decades, there has been a remarkable shift in funding, where now over half of all the dollars goes to home and community-based services, and this enables nursing home-eligible individuals to remain in the community. These individuals create an increased demand for home-based primary care. Recently, there was a study in the Journal of the American Geriatric Society showing how integrating home-based primary care and home and community-based services delayed nursing home placement by 13 months. A major force has been the data that has come out showing the value of house calls, but before getting to the data, I wanted to share a couple stories illustrating just how valuable this care is. Our first story is about Amanda, who when I met her in June of 2017 was 34 years old, suffering from type 1 diabetes that she had had since she was a child. She had kidney failure and was on renal dialysis. She also had coronary artery disease and already had had four stents. She also suffered from chronic pain. In the four months before we saw her, she had been in the hospital 30% of the days. We were able to dramatically reduce that over the following seven months of 2017. In 2018, she was so much better that she did not spend one day in the hospital and sent me this wonderful picture of her at an art festival in the fall. In 2019, she did go back to the hospital because she'd gotten so much better that she now qualified for a kidney transplant and she had a kidney and pancreas transplant which cured her of her diabetes and removed her need for dialysis. What a joy to be able to give someone their life back like this. Elsa was born in Germany in 1921 and came to the United States after World War II. I was called out to see her to fill out nursing home paperwork. When I met her, I learned she was no longer able to get out to see her doctor because of her right foot being amputated and her left leg being amputated and had been in the hospital six times over the previous four months because of multiple chronic problems including heart failure and diabetes and pressure sores. The patient shared with me that part of the reason she lost her legs was from frostbite caused by cold winters in a concentration camp. Through quality home-based primary care, we were able to quickly get her heart failure and diabetes under control. We ordered home health that she was previously not able to get because there was no doctor to sign orders. We got her a hospital bed and enabled her pressure sores to heal. She got so much better that we were able to arrange and pay for transportation to an outpatient rehabilitation center where she got new prosthesis so she could actually walk again. Over the next eight years, she only went back to the hospital twice. Besides powerful stories, we also have compelling data such as from the VA's Home-Based Primary Care Program which is the largest home-based primary care program in the country. The program's director, Dr. Tom Eades, about 2005, was told to cut the program because they were spending $11,000 more per veteran sending doctors and nurse practitioners and physician assistants, mental health workers and others into the home than usual care such as home health. Dr. Eades asked to have all the cost data reviewed and they went back to 2002 and what they found, I think, even surprised Dr. Eades. They found an 87% reduction in nursing home use, 87%. They found a 63% reduction in hospital use and overall savings of $9,000 per veteran and when you multiply that by the 11,000 veterans in the program, it came out to $103 million savings by giving them $11,000 more care in the home, by giving them what they wanted. As a result of this data, the VA program has grown to over 30,000 veterans and would serve even more were it not for the shortage of providers. This data also led to significant support for home-based primary care on Capitol Hill and at CMS. The last part of home-based primary care's value equation I would like to discuss is cost-effective quality end-of-life care. The last year of life is the most medically expensive, consuming 25% of all Medicare dollars. 70% of Americans say they would like to be at home at the end of life. Only 33% died at home. Hospice use markedly increased over the past decade from 22 to 42% and is now up to 50% but also over the last decade, ICU stays in the last month of life increased to 29% and hospitalizations in the last three months of life went up to 69%. End-of-life care at the house call program I founded, Northwestern Medicine's Home Care Physicians, is much different. A quarter of our patients die yearly and over the past five years, 76% have died at home. 77% were on hospice and the median house call length of stay that they were on our program was 1.3 years and so we covered them during that costly last year of life and dramatically reduced hospitalizations. One side benefit to this is because we have so many patients pass away at home and less go to the hospital, we actually were able to help reduce our hospital's mortality rate which is another selling point to health systems. The last force we will discuss which is helping to expand home-based primary care is payment reform. Medicare has increased fee-for-service payments to better support house call providers. This includes payments for advanced care planning discussions and chronic care management where practices can be reimbursed monthly for the non-face-to-face care management time that occurs for patients with multiple chronic conditions. Medicare has also increased the amount it reimburses for transitional care management which provides services during the handoff period between the inpatient and community settings. Research has shown programs with a formal transitional care program reduce hospital readmissions by up to 30%. Additional fee-for-service revenue opportunities include prolonged services before or after visits for reviewing extensive medical records and discussions with family caregivers. While increased fee-for-service payments help, new value-based payments are creating the economic engine stimulating the national expansion of home-based primary care. Value-based payments reward quality outcomes instead of the volume of services. Value-based organizations take on different levels of risk including full risk and then are rewarded when they improve care and drive down costs. Home-based primary care dramatically improves the care of the sickest and costliest patients and this includes quality end-of-life care. And under value-based payments, these providers are financially rewarded for the reduced acute care utilization. A great example of value-based payment reform is the highly successful Independence at Home Medicare House Call Demonstration that began in 2012. There is an ongoing effort to expand it into a new Medicare program. Its greatest benefit has been to inform Capitol Hill and CMS of the value of home-based primary care. This has led to the creation of other models that benefit or incorporate home-based primary care like Primary Care First and High Needs Direct Contracting which requires only 250 patients to start. Direct contracting entities are required to have 5,000 patients, a number not attainable for house call practices. Several DCEs have incorporated home-based primary care into their model to improve care and reduce costs. The direct contracting name will end in 2022 and be replaced in 2023 by ACO REACH, which stands for Realizing Equity, Access, and Community Health. The programs will be very similar, with ACO REACH having an increased emphasis on social determinants of health and health equity. There are opportunities for smaller, independent programs to partner with these and earlier ACO models to become preferred providers. To drive home how beneficial the new value-based models are for home-based primary care, I will give an example. If a direct contracting entity has 10,000 Medicare lives, you would expect the sickest 5% or 500 to benefit from home-based primary care. If we do a great job billing under fee-for-service, such as 10 visits a year and billing for chronic care management, advanced care planning, time spent before and after visits, and some procedures, we would expect about $1 million in revenue. Under full risk direct contracting, we would get around $16.3 million for these 500 patients. Out of these dollars, the DCE must have the infrastructure to pay all their medical bills, including those to hospitals, specialists, home health, hospice, and DME. The flexible reallocation of dollars gives DCEs the ability to transform health care by using money to provide great care in the home that is paid for mainly through reduced hospitalizations. This is the reason value-based and venture capital organizations have become interested in home-based primary care. CMS continues to expand value-based care models with a goal of all fee-for-service Medicare beneficiaries being in a care relationship with accountability for quality and total cost by 2030. With these forces creating a huge demand for home-based primary care, now we need the workforce. Over 7 million homebound and home-limited patients could benefit from home-based primary care, yet less than 15% are being served. In the United States, 3,000 full-time providers make at least 1,000 home visits per year, but we need 12,000 to meet the growing need. Three states—Alaska, South Dakota, and Vermont—do not have even one high-volume house call provider. It's critical we expand the workforce to enable all in need to have access to this wonderful care. Contact the Home-Centered Care Institute for industry-leading experience, products, and services that can help you succeed. HCCI exists to help ensure that those patients who need house calls get them, because the future of healthcare is in the home. Fantastic video, fantastic video. I know it's a little bit on the long side, but it really outlines, you know, what are the impetuses to do this work, and who's doing this work, and how can we really think about it? So, Dr. Cornwell references what he calls compelling stories of Amanda and Elsa, but really, that is our why. That is our North Star here. All the other things we're going to kind of continue to talk through around, you know, how do you think about success in value-based care, both today and in two weeks for another half-day session. But six components, patient identification, gaps in care and quality, managing the cost, data and financial considerations. There's certainly, when you're paid under value-based care, different things to think about, different things to track, and how to think about your financials. Revenue capture, we're going to cover some of that today, and payer negotiations. And so, we'll have a pretty robust conversation between this session, or this day and the next day, but there are a lot of incredible content inside of this. But again, you know, there is nothing that hits home harder than those patient stories. That is really the why. And a lot of times, all being in healthcare, we think we've heard them, and someone knows that, and they really don't. So, next slide. So, you saw today, again, these industry forces, how there's incredible value while reducing the cost of healthcare, and how there are some new models. And Michael and I are going to talk through some new models in a couple of slides. Slide. Please put any questions for the chat in me. I'm going to go to the next module, but if you have any questions about kind of our opening session, let me know. Slide. So, I really want to talk about quantifying your value. Let's think about how we think about expenses against this reimbursement to talk about different types of funding and capitated payments. Let's talk about the readiness of your clinical model and how you build key relationships with your payers and other partners. Slide. So, first, you should have a case study Minerva. Minerva is a pretty typical patient. Slide. I'm not a clinical person. So, when I look at Minerva, I see community dwelling, long list of diagnoses, medication, hospitalizations, treatment. Ultimately, she's a high utilizer of healthcare. She is in and out of healthcare. She is touching healthcare, especially with medications, at least monthly. Let's say in our example that she's dual eligible. So, Medicare is going to pick up the 80%. They're going to pick up the medical spend, hospitalization, pharmacy visits, you know, the Part B visits, and any skilled nursing stays right under Part A. Medicaid is going to come in and pick up wavered services. So, PCA, durable medical equipment, potential meals, and then they'll pick up the remaining 20% that Medicare didn't pick up. So, let's just hypothetically, we have Minerva, who is a high utilizer of healthcare, and her insurance is a dual eligible product. Slide. You're not going to do anything different clinically versus someone who's feed for service versus, or excuse me, versus someone who is not dual eligible. You're really going to talk about her care clinically, and the ways that you're going to actually impact her trajectory are to discuss the goals of care, right? Discuss her advanced care planning. Discuss her main point of contact. Make sure you understand if they're, you know, one child, you know, one relative that's making a decision, or if there's six of them and they're all spread out all over the country, how do you get on the same page? You're going to look at that medication list. I was at AMDA this last month, and the stat came out that if you're on 10 or more medications, you have 100% chance of a med error. So, you're going to look to reduce polypharmacy, and what are the meds that she's on today, and are we doing drug cascading? You're going to provide the correct home care support. You're going to talk about is she living in the right living situation, and does she have the right support to continue to live in that location? And you're going to address any medical or psychosocial concerns. Regardless of her insurance or product, the way you'll change her trajectory is address these lists, and you'll likely get paid for your fee for service visit. You'll try to, you know, keep it in a set period of time. Maybe you may not be able to do that. You might get a couple other things, right? She might be a patient with you where you get some chronic care management. So, I call it kind of fee for service plus additional dollars for caring for her, kind of wraparound services, but you're not making a ton of money necessarily to go out to see her and address that long list. Now, as you think about a value-based contract, they're all set up differently, but, you know, there are opportunities to set them up in different ways, and Dr. Cornwell kind of talked about some of those as a direct contracting example. But how do you get paid under a value-based contract? You can get a monthly payment for care coordination, just a flat payment for doing kind of prescribed care coordination, and that can mean very different things based on your contract. You possibly could get the fee for service for her billable visits. You possibly could have a risk or shared savings model for the pool of patients, like in a savings ACL model. So, I really describe there are two types of patients. There are patients where you can lower their costs and improve their quality, right, and there are other patients where you're improving their quality, but you're not lowering their costs to become profitable. You're just lowering a very expensive patient, right? So, you're taking a $200,000 patient, you make them $100,000. So, as you think about your value-based contracts, you know, you're not going to take risk on all groups of patients. You may have a shared savings model where we're just spending less, or you could have a model where you say we have a quality structure in place and we have quality bonuses and incentives with payer or health system. Like, we're taking these top 5% and we're making them less sick and we're spending less money, and we're going to hit these quality measures, and those still exist. Those were not just for 10-plus years ago when kind of pay-for-performance was around, including quality bonuses on top of other structures you have in value-based care contracts. Very common. Well, you know, if it sounds too good to be true that you could be, you know, $500, $600 per member per month for Minerva, you know, make sure you're really ready for it. And so, as we, I have another talk when we talk about kind of thinking about payers and negotiation, but this one is really quantifying your value and are you ready at readiness assessment. So, as I lay this foundation, the first thing to think about is your clinical model. Is your clinical model ready? What are the strengths and weaknesses of your group? What do you need and who do you need on board before you're ready? And think through some things like, you know, are your providers, have you been paying them? They've been there forever. They've been there for 20 years. You've been paying them on fee-for-service, work RVUs, and you've been, well, are you really ready? And then finally, kind of do some work on your clinical team to say, hey, you're going to get paid in a different way. Let's talk about how this looks. You know, do you have an infrastructure that's set up for a fee-for-service, get as many people in the door and through the system as possible? And if you're not quite ready with the clinical infrastructure and you feel like your teams and your clinical processes and people technology are really ready, you're really going to be signing a risk contract and expecting a different outcome. So you've got to kind of think through that base clinical model first. And I think what we see often is someone says, hey, I'm doing all the right things. I'm set up and posed in the right positions. I'm seeing the right patients. But just adding a value-based care contract on top of your current work does not necessarily guarantee success. Because the devil's really in the details here. You know, start asking more about your clinical model and more about your business model. What's your value proposition? What can you prove that you're doing well? What are the things you actually have data about that you can prove you're really good at? What are those strengths and what are those weaknesses? And be truly honest with yourself and say, you know, we, I can tell you for our organization, we have been tech laggards historically. And our strengths have been clinical education, clinical ethics, clinical, you know, evidence-based work. And we've invested a lot of energy and time and money and years of time into that strength. But we have not been strong on the tech side. And so say, hey, here's something we've not been great at. Well, do we need that for this new proposition? And think about how you fit within the larger health care system in your area. Right. Are there five large health care systems that are all competing for market share? Where do you fit inside of that? You know, are you partnered with someone today? Could you be partnered with someone? Who would you partner with? Are you in a rural area? Are you in a place where one is the dominant player? What is what if one payer is the dominant payer? What if you're in a spot where there are five pairs and they all have 20 percent of the market share? So start thinking about your the food chain and who's in the food chain and that larger health care system. So when you kind of get those those big picture things, you say, here's what my value is. Here's my strengths and weaknesses here. So I fit in the larger ecosystem in my area. And then how do you leverage that? Who is willing to partner with you? What are you trying to focus on? What are your shared goals? How do you get to that piece and what data will you get from your partner? So what do you how do you formalize that relationship and what information do you need? Slide. So as you kind of think about that, you start building these relationships and you're building relationships with entities that have people in them. But at the end, it's the people leave and the entity relationships stay. Think about payers and other partners, other ACOs, other health systems as long term relationships. And make sure you have a persuasive champion on your team to lead those discussions. Oftentimes that could that's a clinical person. That's a CMO. That's your medical director that can really open with that story and said, this is really what we're seeing out there. This is really what we need. And understand when you're sitting across the table from someone, what the other potential partner values, what are their goals? Are they quality focused? Are they community based? Are they market growth focused? You know, is it fewer days in hospital beds prepared to, you know, come prepared to talk about that metric? One of the organizations that we work with is is very focused on community. And that is in every market. You watch commercial. You receive their paper in the mail. You go to their website and you can see that first and foremost, they're putting the patient first. And they have 10 different ways this year that they've been able to outline that. Well, don't come with a financial proposal that doesn't open with something that ties to community. And they're they're leaning into community and patients. And that's an easy one to pick on in some ways, because it's like, well, every all health care is focused on patients. It really isn't. Everybody has different ways they market and brand themselves and different focuses. And so look at that mission. Look at those values. Look at their long term leaders. How long have they been there? So be able to speak to those gaps that maybe they have or things that they do well that you can even strengthen even more that you're going to fill in for them. And so, again, utilize those stories and the right person to get in touch or to get your message across. And this can take years. And once you build that foundation, you get this long relationship side. So as you maintain the relationship, make sure you get into is create ongoing ways to demonstrate performance and outcomes to your partner. I recommend a scorecard or dashboard for your practice based on the population that you're working with. Capture those key metrics, capture those key quality metrics, financial metrics, enrollment metrics. Think about tracking sickest patients, you know, days at home, days in hospital. Those are financial savings. Use the information in that video of Dr. Cornwell and say, you know, here's the annual savings for a VA patient. I was able to do these things. I just I just extrapolated that and put that in. What's great about HTCI is you don't have to recreate the wheel. You can go to them for some of those financial general financial data pieces to put into your quality data that you already have. So that's that's really nice. And if you have the direct data, great use it. Slide. Finally, I'll talk about a couple types of value based contracts that exist. Certainly, there are alternative payment models that come up as an alternative route from MIPS or APMs. There's augmented fee for service or fee for service plus. I call these things where you still have to generate a fifteen hundred part B bill. You still have to put in a code to your billing server to your to your NPS, but that you don't have to do a direct visit. It could be care management. It could be transitional management. It could be record review. So those are things you can build on top of. Sometimes they have per member per month or per enrollee per month. And those are abbreviated here. And you might see those come up. Those are the same kinds of ideas as augmented fee for service where you're getting paid for doing a lump sum or a lump sum of type of work. But it doesn't go through fifteen hundred. So it's a it's an arrangement to be responsible for the total cost of care of a patient. But but not through fifteen hundred. And you don't necessarily have to prove a certain number of minutes or time or type of billing. You just say, hey, I am responsible for this patient. I will accomplish the agreed upon goals that we each have. You get fee for service plus care coordination. You can get just care coordination. You get, again, just fee for service plus some augmented stuff. You can also look at the shared savings tracks, Medicare shared savings, ACO. Now we have reach ACO. There are quality bonuses still. And these can be layered on top for paying for performance that we talked earlier about that. And then there's gain share of, hey, at the end of the day, I'm responsible for the total cost of care. The the managed care organization has revenue and then we have total expense. And at the end of the day, if that is profitable, maybe we split that 50 50. There is also fuller significant risk and you can have floors and ceilings inside of this. So maybe you say, OK, now there's that P&L and at the bottom there is a loss or there is a gain. And we're going to share in that risk. And so we might say, OK, well, we have 100 percent of that risk. So you take an admin fee. I take my care coordination. Anything that's left over, you get 100 percent of delegated provider group. Or you could say maybe it's significant risk. I get 80 percent. You get 20 percent if there's money left over. And you can, again, put put floors and ceilings on that so you could say, well, I can't afford to lose more than a million dollars. So it's a it's a floor. Well, then you probably can't get more than a payer might or a partner might put a million dollars ceiling. So you can't get more than a million dollars either. And so there are a lot of ways to set up kind of a capitated structure. And then still, though not as common, there are episodes of care payments and bundled payments. And there are organizations that certainly, you know, within HCCI or within the larger health care that that still collect this. It's a little more popular when it's not someone responsible for the total cost of care or primary care. But let's say you have under your umbrella a specialist. You might say, I'm responsible for this episode of care. I'm an orthopaedic cardiologist and now I'm starting to do some business. Now I'm responsible for more of a bundled picture for a set of diagnoses or a condition. Slide. So as you think about, you know, your key components to successful value based organization, start with that clinical model. I just cannot emphasize that enough. If the clinical model is readiness or is is really good and really solid, look at that organizational change readiness. What's it going to take from an organization standpoint to get us there? Can we do it? How long will that take? And then start looking for those partners. Who are the right partners? Who is who is there to share dollars with me? And as we think about value based care, that's really what we're focusing on is there is money in the system. If you improve quality, you often lower costs for the entire system. You often lower costs for that patient experience. So if you're lowering costs, you're doing it for someone. How can you share in that financial gain and build meaningful relationships? And then when you have those relationships, you're in, you're out, deliver on those results. And you'll find that you kind of stay in that top bucket when you're really ready is I just I deliver my results. I keep working on my financial contracting. I keep building these deep relationships as a successful value based care organizations. Slide. So I'll take any questions if anybody has any for me about how to think about readiness and as for your next steps. Okay, thank you. All righty, so we are going to transition into talking a little bit about how to leverage ATC coding and risk adjustment in your home-based care program. And for, you know, later on, we're going to talk about some programs that are value-based programs or a variety of programs that Medicare has. And you're going to find that ATC coding is really important when it comes to the payment model that you're going to or what you're going to get paid by Medicare. So during this, we're going to talk a little bit about risk score calculations and how you're going to use your HCC codes and the impact it has on your home-based primary care practice, how you can develop some workflows that ensure your HCC codes are assigned accurately, and then really how we apply strategies that support quality documentation for your HCC codes. Next slide. So as we know, we have many, many ICD-10 codes that are out there for providers to pick from. And from those about 71,000 codes, what has happened is Medicare has mapped out about 11,000 that are directly related to HCC coding. And from there, they've put them into bucket categories. Next slide. So why is this important? Next slide. So why is this important? Well, the reason it's very important is because what's going to happen is Medicare created what's known as this HCC risk adjustment, which is a predictive modeling to basically look at your beneficiaries and decide how much they cost your program. And that then leads into your payment model. So it's really important that you assure that you are correctly coding the severity of your patients when you start working with your providers on how they do this during these visits. Next slide. So basically then what happens with this score is they take a bunch of factors, they put them together, and this is what is known as your RAF score or your total adjusted factor. And in this, there's many components. The first one is just your demographics, which really goes through your age, your gender, but most importantly, where that patient is actually housed. And it is very important because you do need to make sure that you code your patients appropriately, whether they live in the community versus if they're institutionalized. And when we say institutionalized, we mean do they live in a facility for an extended period of time. And it's important, especially with your annual visits, when you recode your patients, which we have to do this on an annual basis, that if that changes throughout the year, that that does get updated in your patient's chart to make sure that it's documented appropriately. Then you have your diagnosis. And then you have your interactions, which we'll talk about here in a second. And then you have your multiple HCC conditions, which make up your RAF score. And essentially then what happens is every year, Medicare publishes their denominator or how much the risk scores convert into dollars. And from there, then they take your RAF score times that denominator and that gives you your estimated annual expenditures for your patients. And again, when you look at this, and we'll talk a little bit down the road here, this is all determined from prior year coding. So what you coded your patients out last year is going to determine your payments this year and then so moving forward. Next slide. So we talked about in those factors, what are these interactions? And these interactions basically are when you look at a variety of different combinations of items that you're going to put together that can help you actually bump up your RAF score. So for instance, you may have, you know, one disease that leads into another. So you may have a diabetic who also has congestive heart failure, or you may have somebody that actually has heart failure. And let's say they're under the age of 65. So they've opted into Medicare at an earlier, younger age, because they're under a disability status. So they're disabled, plus they have something. So you want to make sure again, as you are working with your providers, that these very specific things are added into either a template for them to do their documentation on while they're doing their visit so that we don't miss any of these important things. All right, next slide. And these are just some examples of the different types of interactions. So we have our disease interactions, and then you have your disability with your disease interactions. And again, it's really important to give your providers cheat sheets. And HCCI does have a really nice HCC guide that you can give your providers that allows them to kind of have some cheat sheets to go through. If you're in an EPIC system, a lot of this stuff has been built into your EPIC system so that you're able to, as providers do their documentation, they add things into their problem lists within EPIC, you are able to, you know, identify these. Sometimes, though, these interactions are not always easily identifiable in your medical records system. So again, having some type of reference guides that your providers can look at, especially for a lot of these, you know, chronic patients is really important. Next slide. So every year, Medicare does look at the different HCC codes and determines if things should be added or excluded. So in 2020, there were a few things that actually got added in that were good, and that was our dementia codes, because a lot of our patients in our home-based primary care practices do have dementia. So they did add that, and then they also went in and added the pressure ulcers, which, you know, is really important when you start looking at staging of your pressure ulcers, because starting at stage two and up is when your HCC coding kicks in. But more importantly, when you look at your stage two, which is your partial thickness skin loss with exposed dermis versus your stage three, which is full thickness, there is quite a significant in the weighing between those. So you want to make sure that when you are doing your pressure ulcers that you're staging them appropriately, because there is a pretty big bump up between stage two and stage three. But it is important just to make sure that you continue to watch every year, because Medicare may include other codes that maybe were not in from the prior year. And then more importantly, if you don't have a large medical record system, like an Epic or a Cerner or McKesson, or you're using a homegrown system, that whoever does your upgrades every year, make sure that if this is an automated thing in your problem list that you guys make sure that that gets updated also throughout it to help your providers out. Next slide. All right. And again, as we talked about, you know, it's really important that we want to make sure that we are picking HCCs that have payments attached to them. For the most part, you have to have four or more HCs for things to start getting weighed out. So it is important just as you guys are looking through and putting your programs together and educating your providers, making sure that you understand the weighting factors on how this works with your payment structure. Next slide. And this slide just is going to show a really good example of why it is important and when it comes to dollars, you know, how much payment significantly go up. So if you can look in the first section, you know, we coded out a demographic of a 78-year-old male patient. They're dual eligible, so there are many, many patients. They're type 2 diabetes, so that's not coded out. CHF, not coded out. Alzheimer's, not coded out. So it gives you a risk score of a .692, so you can see what your anticipated annual payment or cost for that patient is, okay? But then when you start looking at adding in your and in connecting your diagnoses, now I have a type 2 diabetic patient that has no complications, but on top of it, they also have congestive heart failure, okay? That actually bumps up your coding there because then you have that disease interaction between the congestive heart failure and the diabetes, which then brings up that risk score. So you can see just by adding that interaction in there, it brings up your risk factor and you can see your payment almost doubles on what your anticipated annual payment is. But then if you start to look in here and you have other factors such as the Alzheimer's, which is late onset, now they're saying the patient has a respiratory failure, you know, they've had a right great toe amputation, major depression with remission, colostomy status, you know, and then they still have the CHF plus the diabetes. Now you start to add up these HCC codes and now you have, you know, multiple codes that are actually eligible for payment, which then bumps up your risk factor. So you can see how much your annual anticipated cost for this patient can go or allocation for this patient can go up. And again, if there's any questions, please make sure you throw them in the Q&A or in the chat section for us so that we can definitely try to answer some of this throughout the presentation. Hi, Michael. Yeah. Oh, I'm sorry. It looks like there is a question. When you're when you have a chance there about that. All right. So I think what I'm reading in this question is we have some insurance companies out there that are paying third party vendors to do their HCC coding. And yes, that is starting to become very common. I actually we have a MA contract with UnitedHealthcare and we just unfortunately have encountered about five of our patients now that have actually had one of these third party companies actually go out and do coding, which number one, it does get really confusing for our patients because they don't know who these people are that are calling. But you know, the thing about it is, is when these companies go out and they do their coding and they code it in the insurance company gets that code or does the risk adjust or the risk HCC coding for us. It's important that our providers get those risk adjustments back and make sure that those match with our problem list. And we're running into some issues currently right now having to reconcile with UnitedHealthcare specifically because they're going through an audit right now. And we have some of our patient records that our providers are not agreeing with the third party vendor and how they coded some of these out. So it is important. And I think that's where this question is going the way I read it in here. But Paul, I don't know if you have any other thoughts on this. Um, Michael, I do not have any thoughts about that. We are not at Northwestern, we are not using a third party vendor to help us with HCC coding. It is important. Let me back up. It's an ongoing education. We are actually having a HCC coder coming to talk to our practice and our clinicians next week. And this individual was here last year. So I think I'll summarize by saying stay up to date, HCC coding and what diseases are covered varies from year to year. What is what is covered in 2023 may not be covered in 2024. Actually, there's already some talk about some significant changes in 2024. So stay tuned regarding that. Again, just summarizing by saying is an ongoing education for myself and also for my staff. So I want to refer you guys back to the Minerva case that Amanda went through for this next slide. And essentially, what I want everybody to do is to look through this slide. And in the chat, or in the queue, maybe in the chat would be easiest. Why don't you type in the can we go to the next slide? There you go. Go ahead and type in based off of the information you know on Minerva, which of her codes that come up here are HCC specific codes. I'm going to monitor the chat here. I'm going to look to see which of these codes you guys are thinking are HCC. So somebody said the depression. There's one here that we just talked about in just the previous slide that was one of the newer codes that was added. Not so many, buddy. Let's jump to the next slide and we'll go through the ones that that are appropriate HCC codes. All right, so the ones in purple here, you can see. So we have our, oh, sorry, one slide back. So, yes, so we have our Alzheimer's, other Alzheimer's disease that qualifies. We have our dementia that qualifies, which again was one of the newer codes. We have the heart failure code that's in here. We have the pressure ulcer, which we said is a stage four. And then we have the major depressive disorder. So again, putting all these codes together onto the next slide is really what gives us then our risk score. And so in this case, if we were to complete coding on here and assume that Minerva's risk score is 3.163, you can see that then she falls into that group four where you have that per month payment that you can get through this. And we're going to talk a little bit later about this leakage adjustment, but in some of our risk models, specifically the primary care first model, Medicare does penalize us if we have patients that are seeking primary care outside of where they're assigned beneficiary primary care is supposed to be. And I'll talk a little bit about that here when Amanda and I present the different models to you. Okay, next slide. So it's really important that we make sure that, especially if you are programming your HCC codes in your medical record, that you have the right HCC codes and you know, we've done a lot of work in the last three years within our practice and just within our whole primary care here at UCSF and trying to, you know, look at, because when we were in a Medicare shared savings model pre-pandemic, you know, we were getting really hit hard. We were getting hit really hard with our providers not doing a great job with HCC coding, which really meant it looked like at our academic center that we were taking care of really healthy Medicare patients when the reality of it is, is most of our business is tertiary, quaternary level care business and we knew the patients that were attributed to us were very, very sick patients. So it is really important to make sure that your providers understand the difference between these unspecified codes versus having a very specific code. And I'll just use this depression code, you know, this depression unspecified, somebody comes into our clinic, they do a PHQ-9 on the patient, the patient scores greater than 10, the provider diagnoses them with this depression unspecified. That code is not a code that's going to be recognized. So it will not weigh out all the work that you're going to do by putting that patient on medication, you know, monitoring those patients, getting them into cognitive disability, brain waste therapy, and all of the work that you would do around the major depressive disorders. And, you know, the feedback we got from our providers is, you know, they're not psychiatrists, they're not psychologists, you know, it's hard for them sometimes to know which type of depression they want to code out. So really what we've done is we've now limited in our medical record, you know, what providers can pick and then we give them an explanation for each one of these so it's easier for them to code a lot of this. But these are just some really good examples of, you know, codes like, you know, hypertension alone is very little value, but if you have hypertension where you have a heart failure or chronic kidney disease or so forth, you know, then it does bump your values up. Same with your diabetic codes and so forth. All right, next slide. It is important to remember that acute codes are not codes that can be applied. So if they can be applied to an inpatient visit, then they cannot be used, a lot of them can't be used for certain periods outside of the hospital visit. So it is really important to remember that some of these acute codes are not acceptable. So for example, if you have a patient who's had an active stroke, it's only reportable when they're in the acute phase, which is typically in the inpatient setting. Upon discharge, then, you know, they have a history of stroke or they may have some long lasting effects that possibly can be diagnosed and reported instead, but the actual CVA itself cannot be reported because that's usually done on your inpatient. And just remember that inaccurate coding inappropriately, you know, just to inflate your risk scores really does put you at risk during your audit. So, you know, we really work hard to tell our providers that it's important that we code everything appropriately. But as we all talked about here in a couple more slides, you have to have all the documentation to support it. So there has to be good supporting documentation because when you get into an audit, sometimes you can get into trouble if numbers don't match up with the documentation. Next slide. All right. So again, you know, we hear a lot of times that, you know, this is just a coding game for Medicare, and it's just a way for insurance companies to make more money, and it is a big burden on our providers. But really, you know, when you are in a value based program and you are looking at, you know, the work that you do with these patients, we want to be able to prove through our documentation that we really are caring for the sickest patients and we want to make sure that we get credit based on that. So, you know, Medicare wants us to measure the severity so that they can pay us based on the great quality that we're providing. And if we're doing good quality of care, then we should be reducing a lot of the costs for that patient as time goes on. So the cost of, you know, them going to the ED three or four times a month or them getting admitted to the hospital once or twice a year or three or four times a year, you know, if we're working with these patients, treating them through good care management, then we should be, you know, getting some of the benefits back from Medicare. So we really want to show that these patients, you know, show the true acuity of our patients. So we again want to make sure that the HCC scoring increases if the patient's risk stratification goes up. And, you know, for a lot of different organizations, you know, a lot of, you know, hospitals have built risk stratification. So you can tell when your scores are going up, you know, whether you're using the Charlton score or, you know, your LACE score or other things that usually you have indicators to say, hey, there's a change in our patient or they got admitted to the hospital. Their risk stratification scores have went up, you know, let's review that at the next primary care visit and see if there's been other things that have been added in that should get added to that patient's problem list. Or on the opposite, you could see patients going down in their risk stratification and, you know, because things may be resolving or improving. So again, we just want to make sure that, you know, this is going to provide additional resources, you know, to the health plans to help us then make our shared savings in our, you know, back to the practices for a score patient. Next slide. We talked a little bit about the documentation. And again, this is really, really important is making sure that this face to face progress note that happens, you know, at least on a once a time basis supports all the conditions that were evaluated and considered during the specific encounter. And, you know, what is needed in your assessment plan is going to we're going to talk about the meat here in a second. But again, remember that this is an annual thing. So on those annual wellness visits, you should be recoding your patient, make sure you're doing your HCC coding. And again, this burden doesn't always have to lie on just the providers. I mean, we have, you know, where we have nurses that do the first line assessment for all patients that are going to get their annual wellness visit. They answer tons of the questions. They do about a 40 minute assessment with our patients and make sure that everything's up to date. So when our providers get to the visit, the providers can go through the problem list, you know, update, you know, things appropriately in the medical record so that when we finish off that visit, we have appropriate documentation to support the HCC. So again, remember, if you get an audit, the audits going to come through, they're going to pull your documentation. We'll talk a little bit about when they pull your documentation. They usually pull a fair number of high coded out HCCs, moderate and then some lows and they validate a percentage of those when they pull the progress notes and the procedural notes to validate that. Anything else, Paul? No. Thank you. Thank you. So the MEET MEET mnemonics just really stands for, next slide please, is just for monitoring. So just really looking at your signs, your symptoms, your disease progression or regression, evaluate. So you're going to, you know, do testing, make sure that when those test results come back in and that's where it gets really hard because sometimes people will order things during that annual wellness visit. And then what will happen is those test results get back, but then nobody loops back to close the loop on it to then put in the results of those tests. So it is really important to do that. Again, during this evaluation really talking about the effectiveness of medications, specifically if you're titrating patients during a period of time and then really what is their response to the treatment. Your A is just your assessment and addressing. Are they stable? Are they unstable? Is it suboptimal? With that, and then really your treatment is the last one, which is, you know, your continuation of your medications. Again, being very specific when you prescribe meds, what they're being prescribed for, you know, specifically what you're looking for outcome objective, you know, outcomes to be with these patients. Any other therapies or referrals, education and counseling, monitoring. This is just all really important stuff. And again, sometimes it has to happen outside of that one visit where you get a lot of this information that you would have to update it after it is completed. Next slide. Alright, so the next one is just some sample language that, you know, we wanted to give you all some examples about. So just some terms that support your evaluation or, you know, what is the status of your chronic conditions. So, you know, in that assessment section, you know, talking about is something stable or is it well controlled? Is it worsening? Improving? You know, are they tolerating the medications? Do they remain asymptomatic? You know, there's a failure to change as expected, you know, increasing pain and so forth. Under your plan, obviously monitoring, you know, monitor and calling with results. If you're going to order further testing, making referrals to other specialists, you know, continuing current meds or your titrating, you may be prescribing diabetes or diet and exercise, you know, improved compliance, etc. But really start avoiding the terms such as unchanged, you know, or resolved. Again, improving, worsening, stable, you know, inadequate control, and so forth. They really pick at this stuff when they really look at these audits and I've been through a couple of them now, so it is interesting when these auditors start to sit down and look at provider charts that, you know, how they interpret some of this. Next slide. We talked a little bit about this when we talked about the interaction between conditions, but, you know, using the words with or in, you know, could be, should be interpreted to mean associated with or due to, you know, when it appears. So, you know, when you're trying to link two things together, like we talked about the diabetes with hypertension or diabetes with heart failure or hypertension, or hypertension with chronic kidney disease or hypertension with end stage renal disease, it's just important that a lot of times we can try to connect these together, because it does then allow us to, you know, get higher risk scores when we use terminology like that that links the two. Next slide. Over to you, Paul. Thank you, Michael. Michael did a great job giving all of us some context regarding why HCC is important and the documentation and the relevance of that. I think I'll just add by saying it's an opportunity using HCC to tell the story of our patients. Dr. Cornwall, in the video, talked about, you know, our patients are really sick, and those of us that are doing this, we know these patients are really sick. And through HCC, you know, under fee-for-service, you can just bill for anything, like COPD unspecified or whatever. But with the HCC, and especially if you have MEET documentation to support that, it gives you an opportunity to tell the insurers about how sick our patients are. So I want to frame it as telling a story through numbers, if you will, through the HCC numbers. And the other is sometimes learners will say, oh, there's just so much more documentation I have to do with the MEET and so on. Again, I don't know your EHR or its capabilities. If you are able to create macros or smart phrases and whatnot, that kind of highlights the MEET criteria, if you will, in your note about a particular condition. And then you can just click through the required wording, if you will, so that if you do get an audit, that your documentation is there to support the case and the HCC score for your patients. Next couple slides, I just want to highlight a couple of HCC codes that, as house call providers, oh, can we just go back to that slide, please, to the previous slide. Not to overlook, we deal with pressure ulcers quite frequently. Patients have artificial openings, whether that's tracheostomy tube, gastrostomy tube, or colostomy that patients have. Many of our patients have peripheral vascular disease. They have amputations. And I won't read through the rest, but maybe just highlighting one that's a secondary hypercoagulable state due to atrial fibrillation. Many of our patients have AFib. So not only do you code for the AFib part, but you can also code HCC related to AFib, and that's being hypercoagulable. Next slide, please. Again, looking on the left side, taking a quick glance as to, you know, do you recognize some of these diagnoses? And these diagnoses, I suspect, more often than not, will apply to the kind of patients that you see at home. One to highlight in the middle of this box here is the rheumatoid arthritis, and some of them are immunosuppressive agents, and you can build an HCC code related to that immunosuppression due to, say, chronic steroid therapy or other immunosuppressive agents. Next slide, please. Again, be specific with your diagnoses. Rather than COPD specified, again, in that middle section here, chronic respiratory failure with hypoxemia and or hypercarbia, I know you see these patients at home. We take care of them. Again, using the HCC code to tell the story of just how sick our patients are. I'll just go down to the last two sections here about the hemiplegia or the hemiparesis. Michael told us that you can't use, you know, stroke as an HCC score because that tends to, oh, that implies that a patient is having an acute event that you're seeing. Now, if you are, then go ahead and bill for that, but many of our patients that we see at home have hemiplegia or some kind of impairment after the stroke. So go ahead and use the hemiplegia or hemiparesis or functional quadriplegia to document the appropriate HCC coding for the condition that your patient has. And finally, about the with, you know, the hypertensive with kidney disease or with heart failure and so on, don't forget linking those diagnoses together. Next slide, please. Thank you. Michael, yeah, I'll let you take it from here. All right. So again, we talked about the data validation and what you need. So again, you know, the MA plans are audited every year and they usually review the unedited encounter data. So really what that means is if your documentation doesn't really support the diagnosis codes that were reported, then what's going to happen is it's going to result in an error rate penalty to the actual plan. And this is really important because it does then involve any of your risk sharing arrangements that could affect that. Like I had said earlier, typically they'll take a third of the high risk patients that are scored out, a third of the moderate, a third of the low, and then from there they will pick additional charts just at random. And if they suspect any errors in any of those different categories, then they may require or ask for additional charts. And just to throw some figures out there, between 2010 and 2013, they recovered about $650 million from a variety of different MA plans just through these audits. And if that does get founded, it does become active on the OIG website and part of their work plan. So it is really important that we just make sure that we're putting in the facts and every fact that we put in, we have supporting documentation for it. Next slide. So again, when you're implementing your HCC in your practices, it's really, really important that we have really good discussions and education for the entire team on the importance of why this is, especially when you're in these contractual arrangements. And it stems from social workers, nurses that might be in your practice to the providers that are actually going to be doing these visits. We even have healthcare navigators that do a lot of data collection on behalf of our providers prior to those visits. So you want to make sure that everybody understands what it is and the importance of what it means to your team, what it means to your practice, what it means for your patients, and what it means for your overall revenue into your practice. Again, try to utilize your electronic health record as much as possible to make sure that it picks HCC codes for you appropriately or tells you if codes are not appropriate. So going back to that depression or that hypertension unspecified, so that you kind of have some stop gaps there. If you have the opportunity to have coders in your practice that are familiar with these codes, a lot of times what we do here at UCSF is we have our CDI nurses. They review all cases before the patient comes in even for their annual wellness visits. They review the cases from the year before. They wait for the chart to come in from the provider. They review it afterwards, and then they get any clarifications for the providers for anything that doesn't look right or if a provider forgot to mention something. A very common one is leaving obesity on a patient's record, and now they've had significant weight loss, and now that obesity, you know, their BMI has fallen, and now they're not classified as obesity, but nobody takes it off the list. So make sure that you implement a good process to code every chronic condition and diagnosis that your patients have at least once a year. So if you can do that during your annual wellness visit. Again, you want to make sure you capture complications, severity, and staging with your ICD-10 codes, and that should be an ongoing thing, not just once a year, but if things come up throughout the year. Again, make sure you report each condition or diagnosis that coexists at the time of treatment or affects the patient's management or treatment. Make sure you have documentation to support each of your diagnoses. Again, having that internal auditing and monitoring. A lot of times, you know, you can kind of figure out what your risk scores are if you're trending in the right direction or down, or a lot of people sometimes they will, you know, have consultants come in and assist with some of that. Make sure that you give your providers good, timely feedback. So if you have people monitoring and reviewing these charts after the visits, if there's specific things, make sure that you put them together and give a summary back to your providers. A lot of times, you know, especially when you implement this stuff, you'll start to see that there's trends with providers doing the exact same thing. So a lot of times, you know, you can come up with either newsletters or best practice alerts or things like that within your system that you can notify them and make sure that they're aware of. And again, making sure that somebody's maintaining accurate and up-to-date problem lists. This is really, really important. Don't code a condition if it doesn't relate to the services being rendered during each encounter. And then again, make sure you're cross-training other team members who might be available to help prep the chart. Because I can tell you having that 40-minute assessment on the phone with the patient before they come in with their annual wellness visit really has led to increased provider satisfaction, you know, within our practice. And, you know, and specifically, it's actually led to better compliance because we're identifying things ahead of time before that patient comes in or right after the visit that we can identify it fairly quickly. Yeah, just two quick comments. One is about the importance of maintaining a up-to-date problem list. As you know, I don't know about your EHR, but my EHR, when the patient goes to the hospital and comes home, the problem list is just bloated by maybe a third with like AKI and sepsis and hypotension and relative care encounter or whatnot. Some of you document based on problem lists, and that could be a problem, right? If you have a bloated problem list with conditions that no longer apply, then that could be a point of confusion for you. So clean it up when you can, not only for documentation sake, but also for the ER doc, when they look at the list and they want to find out, you know, what's going on with your patient. And the second quick comment is that this needs to be done every year. I think Michael mentioned that it should be the ACC score every 12 months. January 1st, the amputated toe, according to CMS, will grow back unless you document that that patient has provovascular disease and has had an amputation. Great. So Paul is going to go through just some examples of just some very specific disease conditions with us, and we'll talk a little bit about these codes as we get ready to wrap up here. Yep. Again, we talked about trying to avoid vague language and trying to be specific as possible. Remember, remember going back to telling the story through the numbers, and this is your chance. Our patients don't just have diabetes. They have diabetes plus multiple other things, right? Whether they're uncontrolled with hyperglycemia, or they have retinopathy, or nephropathy, diabetes with CKD, and so on, or neuropathy, and they're pregabalin or gabapentin. Pull those diagnoses in because it's, again, telling the story, but it's also clinically relevant. You are addressing your neuropathy. Is the neuropathic pain controlled? Are you changing the dose of the medication? If you do so, document that, right? Getting credit for the work that you are already doing. Next slide, please. Again, a different heart failure. I think next week I'm going to talk about management of heart failure and so forth, whether this is an acute condition or a chronic condition that you're managing, refilling the medications, or if it's an acute issue that you are intervening, that you're changing their furosemide dose, or you're adding maybe metolazone, or the new recommendation is using SGLT2 for various heart failure. Again, document what you're addressing today, whether it's management of a chronic condition or if there's an acute decompensation that you need to address. Next slide, please. Again, I won't belabor the point about COPD and being specific about the condition. Many of us go in there with acute exacerbation where we have to treat with a corticosteroid or antibiotic or talk about end-of-life issues and so on. One point to highlight here, it doesn't apply to ACC per se. You're going to hear more about social determinants of health and some of the Z codes that are coming in. Now, they don't carry ACC weight as of yet, but they can help you identify some social determinants that your team, through maybe retrospective look with your coding and so on, identify some of the needs your patients may have from a social aspect that your team may be able to intervene and reduce the overall cost of care, whether it's through Meals on Wheels or getting some social worker to support your work or talk about tobacco cessation and so forth. Just something to keep in mind for the future. Next slide. Paul, one thing I'll just add into that is when Amanda and I talked here after the break on some of the ACO Medicare models out there, some of the models actually require you to have a social determinants of health screening program and show that you are doing it. Again, the only way you can show it is by adding those Z codes in because unlike a commercial payer who may accept a flat file from you for each patient on the codes, that doesn't usually work with Medicare. It is something if you're going to consider going into one of these value-based models that you are going to have to get providers comfortable dropping those codes as they identify the social determinants. We talked about that Medicare adds things into their mapping and this is where, again, somebody that does compliance within your practice, it's really, really important that they stay up to date with the CMS guidelines and that you know changes that are happening. Usually there's an announcement ahead of time. Usually if you apply to the risk coding or risk adjustment listserv on Medicare's website, you'll get notice of some of this stuff coming out, but it is really important that people go through and look at this. Again, next slide. I did mention that HCCI does have a quick reference guide. It is a really good guide and it's a tool for us to use, but again, just making sure that even if you're using, whether it's HCCI's tool or a tool that somebody in your practice has put together, if that changes or if those codes change, please make sure that somebody is doing that auditing and then you get those tools rescinded and get the new ones out there because that's always the trouble sometimes with paper copies is people tend to hold on to them and they may not get the updates. So talking a little bit about some of the exclusion criteria, specifically if you're reporting HEDIS measures back is they do allow exclusions for patients who are in hospice, palliative care, who are advanced illnesses, frailty, if they're a long-term nursing home resident, and again, these services sometimes aren't really acceptable for the patient's goals of care. So for instance, patients who are over 66 and older can be excluded if they have both advanced illness and frailty around breast cancer screenings, colorectal screenings, controlling your blood pressure, your osteoporosis screenings, and a variety of different things. So it is really important to make sure that if you're in an organization that relies on your HEDIS funding that you know which of these can and cannot be excluded. And then the other category is 81 and older can be excluded for these measures just with frailty, and that's your controlling blood pressure, your osteoporosis, and your anti-hepatitic drugs. Next slide. All right. So just some key takeaways here is, again, as we talked about, we want to be specific and remember conditions, status, and plan at all times. As Paul indicated, we have to keep the problem list up to date. So don't rely on the problem list only. We have to review that problem list with our patients every year to make sure that things are still pertinent when they're on there. If they're not pertinent, we get them off of there and that we're not coding based off of an old problem list. If you do have a Medicare Advantage population, you know, make sure that your patients are seen every year and you get that annual wellness visits. I mean, that's a plus. There's a payment for it. The other thing, though, just to throw out there is depending if you're with other payers, such as, you know, I'm in a Cigna and an Anthem commercial PPO network for our ACO, they are now looking at coding for our patients also. Because what's happening, you have to remember is, you know, you have people that are working longer than age of 65. You know, it's not uncommon, especially here in California through the UC system, where we may have a spouse that's, you know, 55 years old and their spouse is 65 years old and their spouse at 65 doesn't go on Medicare. They stay on their commercial plan, but that spouse is sick and has a lot of chronic conditions. So even a lot of our commercial payers right now are starting to move towards some risk coding. Make sure you have good internal monitoring. Somebody's doing compliance monitoring. You know, be prepared for audits whenever possible. And then make sure, again, that we're reporting on every chronic condition a patient has every year and consider a rotation strategy for those patients when they're seen in the office. All right. So if there are any other questions, please feel free to put them in the Q&A and we can answer them throughout the session. If they're related to this session or any of the sessions that Amanda did prior, we'll keep an eye on that and try to answer questions appropriately for you. Thank you, Michael. Thank you, Paul, Amanda. Before we take a break, I just wanted to, well, invite our attendees to enter into the chat box where you're from, what the goals of you attending this workshop are. I know Amanda, Michael, and Paul are more than happy to help and answer questions. So we really welcome you to use that. Oh, it looks like we do have one question. Can you tell me if any of the EHR systems provide HCC coding automatically? Sorry about that. To my knowledge, you pay to get that HCC code automatically. You pay to get that update. I know, and Paul, I know you're on EPIC too, but even though Medicare publishes it and EPIC updates their HCC section, we still have internal people within our informatics team that goes through. Compliance requires us to go through and revalidate everything before we actually go live with that upgrade on EPIC. But also remember that it doesn't matter which medical record system you are on. It doesn't mean that we're all on the most current version of their system. I mean, people sometimes are a year, two years, three years, four years lagging in what they purchase from the vendor. So just make sure that you do have somebody that can go through and revalidate that to make sure your codes are appropriate. Yeah, EPIC, we use like Michael here at Northwestern, when you type in a particular diagnosis code or diagnoses, for example, chronic respiratory failure or whatnot, it will give you choices. And behind the choices, you will have a CMS-ACC associated with some of the diagnoses, not all of them. So you get to choose within our EHR capability. Now, the question specifically asked, I think, does it tell you the weight of each diagnosis? No, we're not that sophisticated yet in terms of is one point one higher than the other that we don't have the capability. Right now, EPIC just encourages me to pick from one of those that has ACC weight associated with it, but not the specific weight per diagnosis. And thank you, New Haven, Connecticut, yay. Yes, we're trying to swim away from the fee-for-service model, but it is difficult to have feet in both canoes, let's be honest, right? Rowing and fee-for-service is one direction and value-based is a little different direction. But I think Michael and Amanda, I know they will help guide all of us as we kind of transition from one payment model to the other. There are some similarities, there's some quality metrics that are important in both, but then obviously there are points of digression between the two payment models. Yes, welcome Jennifer, yes. Yes, all right, well thanks for sharing. If anyone else wants to add, you know, where they're from and some information they're looking for, you know, this is, I think everyone here registered for the entire three-part series, so we'll be seeing you over the next two following weeks as well, and we would love to help you in any way you can, so just make sure to ask any questions, and our faculty are here to help. With that, I think we'll be taking a brief break, and when we return in about, let's say about 5-10 minutes, we can pick up at what you need to know about current Medicare Advanced Payment Models. Okay, all right, we'll see you back here, let's say 2-20. Thanks, Margaret. Bye-bye. Okay everyone, it's been about 10 minutes. It's 2 20. So I think we can pick up where we left last left off. You might notice we are running a little bit ahead of schedule. We do our best to kind of estimate how how long these presentations will last. But we're about 20 minutes ahead of time, but there's some variance. So we'll see where the rest of the afternoon takes us. But yeah, I will pass it over to Amanda. You're muted. Oh, sorry, excuse me. It's all right. All right. Well, so yeah, so we're going to jump in and Amanda and I are going to talk a little bit now about what you need to know just about the current Medicare advance payment models. And, you know, there are a variety out there. And I think that the good part about it is is Medicare has started to realize that they need to be able to focus on small practices along with the large practices. And I think for a while there, you know, if you weren't a large system that could bring in 5000, you know, Medicare beneficiaries into your program, it was really hard to be part of some of these models. So we're going to talk a little bit about those. So today we're going to identify, you know, what are value based payment model opportunities that exist out there today? Discuss just some of the main attributes for for the model requirements. You know, what it takes to be in the program, what their payment structures are like, they fall risk or they partial risk and so forth, and then share insights on how home based practices can prepare, you know, themselves for a value based care transformation. The next slide. So, you know, Medicare, as we know, is run by the federal government. It's funded by our by the trust funds and administered by the Social Security Administration. But these value based care programs have a couple different ways that they can get created. And number one is, is they could be brought in by legislation, where they make a decision that we want to move forward with these models, or the Center for Medicare and Medicaid Innovation Center, they can do demonstration projects, which they get funded, usually on, you know, certain time periods, to pilot programs, and they, you know, allow people to, you know, submit their interest in being part of these pilots and many of the different programs that have happened in the past and in future programs are done through these demonstration projects. And as most of us all know, Medicare is running out. And, you know, the, the, you know, Medicare has already announced that by 2023, all Medicare beneficiaries are going to be associated with some type of an accountable care relationship. So, you know, we're, we're in 2023. Right now, that's not too many years down the road. So it will be interesting to see, you know, where we are, you know, closer to that date. Next slide. So there are just a variety of different models out there today, and we're going to just go through and talk a little bit about some of these programs and, and how they might relate to you and, you know, just a little bit of, of some of, you know, of some of the details around them. So the first one we're going to jump into, next slide, is we're going to talk about what was the Global and Professional Direct Contracting model, which is a model that was really under, created under the Trump administration, and essentially has now stopped as of January 2023, and has basically moved into the new model, which is the ACO REACH program. And REACH stands for Realizing Equity, Access, and Community Health REACH. And really, if you look at the programs, what it's doing is it's, it's just kind of enhancing some of the things that we knew we needed to do, specifically around really promoting health equity and addressing healthcare disparities for underserved communities. And I think, as many of us know, when the pandemic hit, we started to realize that there were many, many programs out there that did not cover our underserved communities. And I think for many of us in healthcare, we've known that for years, we've always known there's been a gap there. But, you know, unfortunately, it took our pandemic to make us really realize that there were people in our communities that really were not getting the appropriate level of care. So their, their, their whole focus is really about improving, you know, the quality of care for these Medicare beneficiaries, just, you know, through a variety of connecting, you know, the beneficiaries closer to the healthcare providers, and making sure that we're including everybody across the board and not those that just can afford it. Really starting to look at transforming this, this, you know, risk sharing agreement in a Medicare fee-for-service world into more of this risk-based model where you're getting the incentives to care for these patients, but if you don't do a good job, then, you know, you may have to pay some money back, you may not meet your shared savings. And, you know, again, it's, you know, depending on what your, where your practice is at, whether you're embedded within a big health system, or you're an independent practice, sometimes this is really hard when you have to pick some of these different value-based programs, right? Because in my instance, you know, we are still a very, very much a fee-for-service world, so when you start throwing value-based programs into this fee-for-service world, and now you have these patients getting admitted to the hospital, what I'm saying, no, no, no, I don't want them in the hospital, I don't want them coming to the ED, but the four walls of your hospital depend on some of that fee-for-service revenue every year, it does get to be a little bit harder. And then, you know, we really want to make sure that we're protecting our beneficiaries and making sure that they have, you know, the opportunity around transparency and that, you know, they are participating in these programs, and we'll talk a little bit more about, you know, some of how that looks. So, again, just, you know, making sure that people understand there are some different models within the ECO reach, and, you know, there are models around where we have a partial, you know, downside shared savings risk where it's about a 50-50, where you have total savings and loss, and then you can move it, which is known as the professional arm, and then there's the global arm, which is really a high-risk sharing arrangement where there's 100% shared savings and losses, you know, between the two. Both of the models have, you know, quality measures that have to be maintained, and we'll go through those here in a second. And then, again, there are going to be some financial incentives, and we'll talk about on the next slide, for those that are willing to take some risk for some really, really sick patients, such as our end-stage renal disease. And then, again, you know, when we start talking about risk coding, when you go into some of these models, you know, they'll be looking at some of the risk coding you had prior to this. They'll kind of give you your baselines, and that's how we move forward with some of these models. So, next slide. So, there are a couple, three different areas, part of the ACO reach. The first one is going to be the standard ACOs, which are ACOs that have experienced serving beneficiaries in the traditional Medicare model, and they've had beneficiaries that have been assigned to their practices. The other one is the new entrant ACOs, which are for people who have not traditionally provided services to the traditional Medicare fee-for-service population, or who may not have participated in any type of fee-for-service value based arrangements. And beneficiaries, you know, they can be aligned primarily based on voluntary alignment. And then, the high-needs population ACO was the one I was talking about, where they have ACOs that serve Medicare fee-for-service beneficiaries, but have very complex needs around, you know, where they need, you know, other services that may be needed, and those are kind of similar to the PACE, you know, All-Inclusive Care for the Elderly, or the PACE organization that was out there. And again, I think that, you know, we're starting to see that, you know, even small to mid-sized practices, you know, are getting approached by ACOs. So, you may be getting approached by a health system like UCSF that says, hey, we don't have this type of access for our patients. We have, you know, 30,000 beneficiaries that are assigned to us, and we want to partner with you guys to be able to help care for some of our patients if you're in an independent model. So, this one, though, does have each group has requirements. So, for the standard ACO, you do have to have a minimum of 5,000 lives. If you're a new entrance ACO, there's going to be a ramping period where you can start at 1,000, but you have to ramp up by 2026 to 5,000 patients, and then the high needs population, those are much smaller numbers because, again, these are pretty sick patients that have a lot of chronic disease and illness that are typically high cost, and those start, you know, at the 250 range but go up to a maximum of 1,400. Next slide. All right. So, the requirements, obviously, Medicare is going to require development and implementation of a health equity plan, which you do have to provide a progress report to CMS on an annual basis, and we did talk a little bit earlier just when we were doing our HCC stuff coding around, you know, the social determinants of health, and this is going to be a really big thing because we are going to need it because what I'm hearing is down the road Medicare is going to actually require us to be reporting out on some of this data, and in order to report out on it, just like I said, Medicare doesn't typically take a flat file from, you know, hundreds and hundreds of different practices, so they want to see it on the claims data. So, really, you know, going into this model, they're really encouraging right now the collection of social determinants of health data, especially in our underserved population, and really making sure that we add the Z code to our claims so we get that on the patient claims. So, part of this model, there are two different groups that can participate or the way you participate within this group. The first one is just the participating, which is, you know, usually a group of providers that form some type of an ACO or some type of a consorption, typically made up of primary care providers that are providing a lot of the bulk of care to our patients, and then you also have groups that are your preferred, which are, you know, your facilities, your ancillary services, and really what they're doing is they are becoming in-network providers where providers can run testing through them, do, you know, a variety of different things, and so forth, and with the ACO reach, there we go, yep, with our ACO reach stuff, there also comes, like some of our other value-based programs, these incentives that you get being part of these programs, and, you know, some of those include, you know, the extension of the telehealth arrangement that we've had during the pandemic, during the emergency order. A lot of times you can get home care homebound waivers. That means you don't necessarily have to meet the same criteria of being homebound for a patient to be able to get home care services. I think the big one is the three-day SNF waiver. It's nice when you participate in this program because, as you know, in order to get a patient into a SNF, we have to have a three-night length to stay in the hospital, and sometimes it's hard to even justify a patient being in the hospital for three nights because they're not, you know, actually qualifying from, you know, a utilization perspective. They also have other, you know, some of these allow you to have concurrent hospice benefits going on at the same time. Sometimes there's Part B cost sharing. There's also, depending on your state, your nurse practitioners have some expanded scope of practice where they can order hospice, you know, or other things that in some states they're not allowed to order under this model. So there's just a variety of, I call it, the carrot that they wave in front of you to be able, you know, to have you have some of the benefits of being part of this program. Next slide. So we talked a little bit about most of these models have quality and performance metrics. Again, for this model, you know, they do monitor your standardized all-condition readmissions, making sure that, you know, utilization has been acceptable, all-cause unplanned admissions for patients with multiple chronic diseases, days at home, so high need, that's really for your high needs only patients, those ones we talked about, and then timely follow-up after an acute exacerbation of a chronic condition, which again is meaning that, you know, they leave the hospital, they get in to see you as a provider within that 7 to 14 day window to make sure that, you know, discharge planning is appropriate and then avoiding any additional utilization. And then I think the biggest one is just your CAHPS survey, and this is, you know, usually done by a third-party vendor, but, you know, you do have to have patient experience measurements, and you do have to submit those to Medicare, and again, a lot of times that patient experience is going to look at timeliness of care, how providers are communicating with them, they're going to rate their providers, you know, did they have access to specialists, you know, to health promotion education programs, did they have any shared decision-making with their healthcare, and then, you know, their overall health status, and do they feel like their providers are helping them with their goals of care. Next slide. All right, so the next one we're going to talk about is the primary care first alternative payment model, and again, this is a voluntary alternative model that's a five-year payment model that really rewards value and quality by offering, you know, additional payment structures to support how you can deliver advanced primary care to your patients, and really what they're looking at is, you know, they want to prioritize, you know, the relationship between the clinician and the patient. They want to make sure that, you know, there's enhanced care management programs being offered to patients who have complex chronic needs, and then there's really a focus on financial incentives on health outcomes. So, within this program, you know, right now, there's about 26 regions in the United States that are participating. There's been a couple cohorts now that are currently participating in what's known as a capitated model, which means they have full financial risk-bearing for the care of the total population that's attributed to them. So, it makes up about 3,000 practices that are currently participating, and in the model, you do have to show or prove that patients do have 24-7 access to care to your care teams in real time, either to the EHR, they have an on-call program, you have a telehealth program, or so forth. You do have to have care management services and be able to risk stratify your patients and know their acuity, must have comprehensive care coordination and care management, and be integrated with some type of behavioral health services to be able to assess and support patients who have psychological needs. You do have to have a process for patients and caregivers to advise on practice improvement. So, a lot of times, there are patient and caregiver advisory councils that people that go into this model have developed so they can get feedback from patients, and then they need to make sure that they have, you know, good planned care so they have set goals, you know, and objectives for their care. Next slide. So, requirements for this is, you know, the primary care practitioners have to be licensed and credentialed providers who are in good standing with CMS, so MDs, DOs, CNSs, NPs, and PAs. You must have a minimum of 125 Medicare beneficiaries attributed to you, and your primary care services account for, you know, 50% of the practice collective billing based on your revenue. You're going to have to demonstrate experience with the value-based care programs. So, a lot of times, if you've been in other shared savings models, some type of performance-based incentive models, you do have to follow the CEHRT guidelines, which are the 2015 edition certified electronic health record technology. You have to do, you do have to utilize the HAIE for advanced data exchange, and then, again, you do have to attest that patients have access and advanced primary care capabilities in order to participate. And your HAIE is your health information exchange data. Next slide. We've seen kind of a similar slide with this prior to here, but so, the way the payment model works for here is they're really going to look at, you know, adjusting for, you know, the higher-risk populations, and they're going to give you that base rate. And essentially, what's going to happen is we talked about the HCC coding, where you can see that you have a variety of groups here, and where your patients fall into that. And this is where, you know, you're going to get your base per month beneficiary payment. And then in addition to that, you're going to get a flat primary care visit fee for that in-person treatment applied to the fixed rates. And Amanda, I can't remember, I know we talked about this, but the telehealth currently still, I believe, is still under this model. So that face-to-in-person visit, I believe, within this payment model, you can still do telehealth visits, I believe, and get that 40.82 per encounter, I believe. Yeah, my understanding is when the public health waiver, you know, goes away that you can't do telephonic, but you can do video and voice. Yep. Yep. Okay, great. So essentially then, you know, what's really good about this is specifically when you get your baseline data from Medicare, essentially what happens is this is really kind of help how you kind of build your budget, right, in your practice and be able to predict a little bit about how much you're going to be making, you know, beneficiary when you have this. Now, we talked a little bit about this leakage adjustment and what does that mean? And again, because these, you know, are members that are actually attributed to you and your practice, you have to be really careful, especially if you're in an area and, you know, Amanda probably experiences this a little bit with the snowbirds that leave Minnesota and probably go somewhere in the south to get out of the snow. But what happens is, is if you have a really sick, complex member that's attributed to your practice and now all of a sudden they go somewhere for four or five months and they start utilizing another service or another primary care provider down in that area, Medicare is going to come back and take some of that money back from you because they're not going to continue to pay other providers to do it. And that's what that leakage adjustment is. So it is really important that if you are attributed beneficiaries that aren't in your area 12 months out of the year, that you have a plan with that patient on either a virtual way of them consulting with you. And, you know, what happens is it makes it a little bit harder with your care management program because now your care managers have to be building relationships down in areas, you know, in other states to probably help coordinate care with your patients. So it is something just to keep in mind when you go into some type of a model like this. Next slide. So in addition to those other payments that we talked about, the professional population-based payments plus the primary care, in addition to that then there's performance-based measures. So you get that fixed rates that are sitting out there. Plus then there's opportunities for you to increase revenue up to almost 50% for your total primary care payment base on key performance measures, which include your acute hospitalization utilization, and then your total per capita costs depending on the practice risk group. So essentially when you look at this formula, you know, did the practice succeed their quality, their gateway, and that quality gateway, remember we talked a little bit about some of those in the other model, but for this one really measures you on your patient satisfaction scores, and then around your care gaps, around your hemoglobin A1C control, your hypertension control, colorectal cancer screenings, advanced care planning, and then if you're in the higher level model or that real high-risk model, then it looks at other things around advanced care planning and your days at home. And then what happens is they adjust all of this based on if you are exceeding or not, and if you're not exceeding it, then you get on the left arm of the branch here, and you may get a little bit of an incentive bonus, and if you are meeting your quality gateway, then it goes into this other percentile where they look at hospital utilization and then the total per capita cost benchmarks, and then they readjust you, and then that's where you can get your bonus with this. And again, a lot of times, you know, when I've talked to practices that are in this model, not so much your frontline providers understanding all of this, but they understand where they play a part in it, and as the administrative team or your finance team, you know, you're looking at where you have these opportunities, and then we, you know, we educate our clinicians based on, you know, where we're performing well or where we're not performing well in some type of a scorecard, and that really helps you guide, you know, your moving forward. Next slide. We kind of already talked about this, so again, for the quality metrics for that group one and group two, you have the cancer screenings that are included in here, and then for your threes and fours, it's the higher advanced care planning and days at home. Great. Any questions on those two models? I didn't see anything pop up in the chat. You know, I accidentally maybe dismissed one. Younglee asked how you, how the states got in, and I said, to my understanding, CMMI just approved approximately, I think it's 26 states, and like we're in a state where we couldn't do it, and so like the, you know, the state wouldn't approve, and so you can't participate, but it's state by state. Hopefully that answers your question. We'll keep the questions coming. Next slide. All right, I'm going to talk just about the Medicare Shared Savings Program. So, some key definitions, you know, the accountable care is doctors, health care providers, hospitals taking responsibility for the quality of care, care coordination, and health outcomes for a defined group of patients. Accountable care organization is now when we start to group these groups of doctors, hospitals, health cares that are responsible now for the quality, the care coordination, the health outcomes, and managing costs. They're probably and likely in a specific geographical area, and or they could focus on a specific condition, and so ACOs are, they popped up with the, like the term has been around for a long time. It became a little bit more mainstream with the Affordable Care Act, but ACOs are not just organizations who are accountable for total cost of care through the federal government. They can also be commercial plans. They could be entities that are organizing this way that have a certain set of parameters inside of them, but so that's kind of where we get the ACO term, and then value-based care is paying for health care services that directly links performance on cost, quality, and the patient experience of care here. So, can we get good quality care at a low cost? So, MSSP is called the Medicare Shared Savings Program. This was actually part of legislation, so Michael outlined earlier you either have CMMI programs or you have legislation. This is part of the Affordable Care Act legislation, and it is a voluntary program that again encourages these ACOs, the doctors, hospital health care providers, to come together to create high-coordinated, high-quality, financially responsible care to Medicare beneficiaries, and so the aim is to define the population and have accountability for that population for their outcomes, quality care, to coordinate services and items for Medicare fee-for-service patients, and to encourage investments in high-quality and efficient services, and to assume risk for population, and offer alternative payment methodologies. So, we don't go into a lot more on the MSSP. We're new to the offering in MSSP, so I'm happy to answer any questions, but the broad stroke of an MSSP is it's an opportunity to coordinate around patients. Unlike the ACO REACH plan where there are five tracts, and those all vary on size, there's really only one tract for the MSSP, or there's kind of one, yeah, one tract for the MSSP, if you will, of different kind of levels, and so the concept is you have to have 5,000 patients. You become organized in your region. You're, again, around a group of patients, a region, a general idea, and then you can choose like the kind of sub subtracts inside that. So, you can start with no risk, and by year three, you can start taking downside risk with floors that I talked about, or you could go directly into a risk and reward situation, and direct, I don't want to overuse the word direct contract, but it is a provider entity, an entity having a direct contract with Medicare for these patients. So, it does include original Medicare patients, or traditional Medicare patients. Slide. As you know, there are four parts of Medicare. There's Medicare Part A, which is the hospital services. Part B is the physician services. You're probably most familiar with that, and Part D is the pharmacy and meds program. Part C is Medicare Advantage, Medicare Part C. Sometimes they call it MA. MA can be used for Medicaid too, but Medicare Advantage and Part C are synonymous. These are one structure, and Medicare Part C wraps A, B, and D together. So, you cannot be on an MSSP if you're in a Medicare Part C program. Medicare Part C is kind of the umbrella for that, and so I'm going to kind of talk about that next, but that's essentially the idea is there's Medicare Part C, and then there's subs of that. Medicare replacement plans are responsible for their member population Medicare benefits. So, they replace the programs that Medicare is offering. You still are paying for the Medicare base benefit, and you're paying an additional possible premium, or you're paying no additional premium, but you would have a cost-share arrangement with the Medicare Part C managed care organization. Premiums are tied to the overall risk score of the member population. So, as Michael and Paul were talking about, they are tied to HCCs. They're tied to the RAF score, right? That's how the revenue is created for this population and passed on to the managed care organization who's holding that Medicare managed contract. They're accountable for the HEDIS measures and rated by CMS star ratings, and they really have kind of these five domains of care. You'll likely deal a lot with kind of the quality pieces inside of HEDIS or the inside of the HEDIS measures, and so that's the one you kind of think about the most, but these are kind of the CMS star rating five sections, and it's an ability to contract directly with providers and services to meet a population's needs. So, it's really a federal government saying, you know, when you are over 65 and you're buying Part A and B and D, you're really buying them through the federal government. When you buy Part C, you buy local. You buy a local plan, you buy a local network, you work with the provider and services within that network, and so the inverse is true as well. If you're the Medicare Advantage plan is you create that network and structure and provider and services inside for that specific population needs, and that's really where Medicare says, you know, to Michael's point, where everybody will be in some value-based care program by 2030. This is the federal government saying, let's make health care a little bit more local, and let's have the local providers really be at risk for that care. Slide. So, one of the subsets, I said there are kind of a couple of parts, there are a few more parts that we don't go into, but one of the subsets is the special needs plans, and you might have heard of these. There are really three types of special needs plans, institutional SNPs, dual eligible SNPs, and chronic condition SNPs. So, I'll go through briefly each one, but put questions at the chat if you have any questions on these or any work that you're doing in this space. But ISNPs are really for beneficiaries, Medicare beneficiaries living in a nursing home or meet a clinical criteria to live in a nursing home. When you fill out your application for a special needs plan with Medicare, there are four pieces that it's an NCQA structured application, and you, there are four sections inside of the NCQA piece, and the first one is defining your demographics. So, many ISNPs today are just nursing homes, so site of service 32, but you can make a little bit more broad definition of that and say, again, it's someone who has the clinical criteria to live in a nursing home, but maybe doesn't, maybe lives in assisted living, independent living, or even their own home, then they could qualify. You just have to find your demographics that way. Those patients are sometimes called institutional eligible SNPs. Those patients, it's actually a subset of the ISNPs. So, there are only three broad SNPs and ISNP and IESNP are kind of linked together. The second one is dual eligible SNPs. So, these are patients who are both on Medicare or on, excuse me, and on Medicaid. So, either you are over the, you're over 65 and you've spent down your money to now where you need to be on Medicaid, or you're on Medicaid and now you've turned 65, you're considered dual eligible. This is really state specific. So, each state, because it involves Medicaid, gets to decide how they administer their dual eligible SNPs. Some states don't administer these at all, and it really is just two separate plans that sit next to each other, and you have original Medicare, and then you have Medicaid, or you have a supplement plan, and then you have Medicaid. And some have fully integrated dual eligible special needs plans or fighting SNPs. So, there's a number of different alternatives depending on your state that you can kind of work within. The same idea is true, though, that all three of these are Medicare thinks that these are three areas of Medicare beneficiaries where they could fall through the healthcare cracks. And if we create a special program for them, a special care system, if you will, for them, we could better control costs and improve quality. So, it's still paid on the same RAF score. It's still paid the same way that Medicare Part C is paid. You're still risk adjusting these patients. There's no additional dollars for those pieces, but you can provide additional services and different care coordination benefits under those. The final one is the chronic condition special needs. So, there are about 15 diagnoses that are listed on the Medicare website. And so, a health plan might offer a chronic condition SNP. So, you would have to have that condition to be enrolled in that plan. So, one example is if you have dementia, you could be in the plan. If you do not have dementia, you could not enroll for the chronic condition special needs plan. And these, again, they are exclusionary at some level, right? There are people who qualify and do not qualify. And the chronic condition is a really interesting one. It's a really fantastic special needs program. It's smaller. And it works really well for states or managed care organizations that have large market share or states that have a large population and potentially not spread out that much, right? So, if you're Blue Cross of New York and you only have 10% of the New York City Medicare saturation, you still are going to have a significant number of beneficiaries. And then when you subset it by dementia or CHL or HIV, you might have enough patients to kind of fill this out. Larger states with very dispersed populations or rural populations or there's kind of everybody in a larger mid-sized state that nobody has severe market share on the payer side might not be all that interested in a chronic condition. So, you see these pop up specifically focused on can we provide supports for a diagnosis of disease and improve that outcome. So, again, they work similar to Medicare Advantage, but they're built for specific populations. And, again, throw any questions in there. We've participated in two of these types of SNPs before. Slide. So, you know, ask Michael and I a lot of questions, but there are a lot of vehicles that exist for Medicare contracting. Again, you can kind of work directly with Medicare. You can be a delegated provider inside of a network. You could be a sub-delegated provider inside of a network. But really, you know, understand the pros and cons of each of these models. If your organization is new to being in one or, you know, has a long standing history in one of these Medicare value-based care models. Details about these things change all the time. CMMI continues to create more vehicles. They would potentially remove a vehicle. They could retool it like they did with direct contracting to make it reach. But their ultimate goal is to pass the total cost of Medicare health care for the beneficiaries in this country and make it more local and pass the risk to more local entities that might be able to control for improved quality and higher costs. Because it would be one thing is if we had the most expensive, you know, the most expensive health care system, but, you know, and it was also the best quality of care. But with that global look of having very expensive health care, you know, as a country and not the top quality of care, there is a way that Medicare is saying as a single payer, let's see if we can improve this and to make that happen and care needs to be more local. So again, a lot of opportunities. There's a lot of space in here that things change all the time. So, you know, again, new vehicles are created, they're retooled or new rules are created for existing vehicles. So questions for us on Medicare contracting? Okay, we'll throw them in the chat if you have them. I'll keep monitoring the Q&A and I'll turn it over to Paul for work on specialists. Thank you. Thank you, Amanda. Yes, I think Amanda highlighted in her final comments about if it was one thing we're spending a lot of money as a country to provide care to our patients, if it was one thing that we're getting great outcome, but we're not. So Medicare is putting pressure on us as clinicians and Amanda talked about locally as maybe a clinician group or a physician group or health system to take more ownership regarding improving quality and controlling cost. Speaking of which, we're going to talk about when we face difficult challenges, challenging patients, that is unique to home-based primary care, because often we're the only people going into the homes. These patients are very sick and complex, and we don't have specialists that can provide care at the home. So I wanna talk about what that looks like through a couple of case examination, if you will. We're gonna talk about the logistics regarding coordination with care and specialists. Of course, we want to provide great care to our patients without sacrificing cost, but under a value-based model, if you will, it is about, there is a component of controlling cost, where that may have been less of a consideration when we operated under fee-for-service. And again, I talked about examples and how to manage medically complex at home, when to refer, and when to treat at home. Next slide, please. Start with a case, a 85-year-old patient, moderate to advanced dementia, residing in a group home. You see the past medical history there, hypertension, dementia. She does have eosinophilic colitis as a diagnosis. You see her medications there. Again, these diagnoses and medications should be all like second nature to many of us who are doing house calls. Next slide, please. So on the first visit, the patient really didn't have too many alarming symptoms or history. She had AFib. She was able to walk pretty reasonably well. She does have some impairment based on the Tuck score. And you can see that she has memory impairment with a MINI-COG of zero. So about a week later after my visit, the group home nurse calls and says, she's got this terrible diarrhea. She's not vomiting, no fever. Next slide, please. And I ordered some labs. I gave her some Imodium, but the diarrhea continues. And I ordered more tests, including electrolytes, stool studies with mild hypokalemia. So Imodium didn't work. So I graduated to a Lomoto, but the diarrhea continued up to eight BMs a day. I added a psyllium or Metamucil, and that was not ineffective. And then I thought maybe she's obstructed passing liquid stool. Did a KUB, no obstruction. Then I thought back to the eosinophilic colitis, and I tried some prednisone, but the diarrhea got worse. And the family's calling, very frustrated that cold nothing has been done for a week. Think about if you're facing this situation at home with a complex patient like Gertrude, what will be your next steps? Feel free to put them in the chat box and we'll be monitoring. And next slide, please. How about Elizabeth? She's 92, COPD, respiratory failure, HOMO-2, AFib, PEF-PEF. And you can see the rest of the history or the past medical history there. We're seeing her post-hospital for CHF exacerbation. Medication, you can see the list of her meds there. And on exam, you see her weight, her vitals, her pulse. And her lung exam, she had a little bit of swelling and relevant labs, you see them there. Next slide, please. Two days after hospital, the caregiver calls. Leg swelling, weight is up, she's more tired. So I increased the patient's furosemide for a couple of days and see if we can get her some relief. The caregiver calls back a couple of days later. Swelling continues, weight continues to go up. Patient is fatigued, no shortness of breath. Furosemide dose was increased furthermore. Now she's getting hyponatremic, hypokalemic, hypomagnesemic. BUN and creatinine are both up. Magnesium, potassium replaced, furosemide increased again. Next slide, please. A follow-up exam, I wanted to see the patient because the patient's not doing well. Again, we want to provide great care without reflexively telling these patients and say, you know, go back to the hospital for multiple reasons. As Dr. Cornwall said, sending these patients back to a fragmented structure of the hospital in the emergency room often may not be the best option for a patient, okay? On exam, weight is up, O2 sat is lower. She's got some RAILs, got some edema now. The patient is compliant with meds and low-sodium diet. Fluid restriction, follow-up labs, the BUN and creatinine are even worse. And the family's calling and, you know, what to do. Now you're facing somebody with kind of refractory heart failure, if you will, and is looking for some relief from her symptoms. One of the comment, reaching out to specialists if they have one referring, or the referring physician. And if scans have been completed, if negative and all other measures exhausted. Thank you for that comment. Yes, if your patient had been cared for by a specialist in the hospital, if you're able to get that information and either send a note electronically or phone call, fax, whatnot, and get some advice on the patient's care. For example, if Elizabeth was seen by a cardiologist, may want to reach out to the cardiologist and get some additional input as an example. Next step, please. So the two cases I hope highlight some of the unique challenges for HBPC providers. We are often, like I said before, we're the only clinician in. These patients have multiple advanced conditions and their competing priorities. Elizabeth's case is between heart failure and kidney failure, right? Mobility disorder, that means many of my patients have travel limitation. It is not easy for us, for the patients to go and follow up or see the specialist. And the goals are care for the patient. They may not want to see another provider or specialist or undergo more procedure or go back to the emergency room or the hospital. So those are some of the challenges that we face at home with our multi-complex patients. Next slide, please. RPM will be an excellent second case. Yes, absolutely. Report back to the cardiologist. Yes. So there are vendors that... And I'll talk for another time. There are vendors that you can work with in terms of setting up RPM regarding specific patients that you might be wanting closer monitoring eyes on, if you will, to keep them out of the high cost center of the hospital, the emergency room. So when to treat? Again, you're gonna have to look at your own personality and your own experience. To treat a patient like Gertrude or Elizabeth depends on your own personal knowledge, experience and confidence with a particular condition and your willingness to accept some degree of uncertainty, if you will, and the spirit of maybe trying something, even though it might be outside of your wheelhouse. Again, this comes down to not only knowledge and experience, but also maybe your own personality as well. To treat at home, obviously, if the diagnosis is really pretty certain, then you can feel confident going forward. And the final piece to this, to treat at home is patient preference. They may not want to see anybody else. They may just tell me, say, Dr. Chang, do your best, do the best you can, and we're gonna go with it. Next slide, please. When to refer or consult? Again, knowledge, experience, your own personal disposition. If you're uncertain about the diagnoses and if the condition of the patient is not responding to your current intervention, and if the patient requests, I would like to go see a hematologist about my condition. Or if a procedure or a specialty is not appropriate, or a specialist level knowledge is required, then definitely they should, for example, I have a message here about sending the patient back to interventional radiology to get the inferior vena cava filter removed because studies have shown that they can cause complications if they're left in long-term. So that's when a referral to a specialist is necessary because of the procedure that's needed. Somebody already mentioned a referred or a follow-up if the specialist has seen a patient in a hospital, especially if the patient is not doing well, may wanna reach out and provide follow-up or consult, consult the specialist. Again, the final point is about using different technology to reach out to your colleagues, whether it's by phone, whether it's through internal epic messaging or different formats that allows you to communicate in a HIPAA compliant fashion, perhaps with a specialist to get either a curbside consult or a formal consult, such as an electronic consultation that's available more to our patients as we live through the pandemic that has given us the opportunity to imagine care outside of the four walls of the hospital or the emergency room or the clinic. Next slide, please. When you do decide to refer to a specialist, let the family know why you're doing this. Explain what your concerns are, what was tried and the outcome of your intervention. It might be wise to call the specialist just to give this person a heads up, especially if the condition is urgent and tell the clinician or the office the reason for the consultation, such as refractory heart failure, for example, your office should have a referral logistics on how that is done or what should be done, I should say, when you refer a patient to a specialist. What is the work queue? What is the procedure involved in that? Let the patient and the family know who they are seeing, the office, and how to contact the specialist, their address, phone number, for example. And if you don't share records electronically with the specialist, send records, test results, and so on, it would really be, I know it is helpful to the specialist when they see the patient with some pre-visit information, if you will, rather than kind of depending on our patients or family members to explain what's going on because many of our patients have memory impairment, right? And they may not always understand why they are seeing a specialist. Next slide, please. Some additional considerations as we do this wonderful work of visiting patients at home, but also challenging work. As we know, having that special relationship with specialists is very important because we are gonna run into a situation like Elizabeth, like Gertrude, where I'm gonna be scratching my head, like, you know, what's next? What am I gonna do? Somebody already mentioned, actually it was an RPM, but explore telemedicine option if that's available to your patient and their family members. And think about transportation assistant information that you can provide for the patient or the family members because many of them, as stated earlier, have mobility challenges that getting to the doctor's office is very difficult. So having some of the information available for them can be stress reducing for the patient and the family. Next slide, please. Now, this is looking at the issue from the perspective of other providers that do come into the home that are trying to interact with home-based primary care providers on co-managing patients like Gertrude or Elizabeth. From the perspective of a home health nurse or a therapist, some of them, when they call with an update on the patient, some of them may lack the information or the knowledge because of, well, they may not be that experienced. For example, they may be less knowledgeable or they may lack the information that you and I have from the hospital or the SNF that the patient got discharged from so that when they call us and trying to engage us, they may come across less knowledgeable perhaps, but it may not be their fault, so to speak. So just keep that in mind as we engage with other providers that are coming to the home. There could be lack of clarity and order, especially when it relates to, say, wound management. What do I specifically want for the management of this sacred wound in Gertrude or Elizabeth? Be as specific as you can. That will help facilitate care for our patient and also prevent the wounds or our failure from deteriorating. Don't forget, we need these providers to help us take care of our patients. Let's talk in a collegial fashion with them and not talk down to them because it doesn't foster a group, a team effort when we talk down to the providers who are going into the homes and taking care of these complex patients. Also think about your office protocol as it relate to when a outside call is coming in and what kind of roadblocks they may run into. For example, if the home health nurse is calling you about an urgent condition like Gertrude or Elizabeth who is into heart failure, do they have to go from messages to messages, from prompt to prompt to actually finally get to a person? What barriers are there for them to communicate with you and get orders in a timely fashion, which leads to the next point, is that if there's too many barriers, like many of you, I'm sure I get to my inbox sometimes at the end of the day, 4.30, 5 o'clock, and by that time, the nurse is long gone from the patient's home and the opportunity to intervene has already passed and the patient might be driving to the emergency room because there was not a timeliness of a callback because of call center barriers, for example. So just keep some of these ideas in mind as we're trying to work with other clinicians who do come into the home space. Next slide, please. So what are some of the solutions to our predicament as highlighted by Gertrude and Elizabeth's case? One thing is to improve information exchange with home health agency by faxing over your entire note rather than just the after-visit summary, which can give you more complete analysis in your thinking rather than the very brief abbreviated AVS so the home health agency and the nurse or the therapist can have a better understanding of what your concerns are. Clear documentations, orders for lab, wound care, what do you want them to monitor? You can call or fax. Discuss your assessment and your concerns with a home health clinician in a professional manner. We talked about modifying a triage protocol to expedite urgent messages and alert house call providers urgent messages and needs prompt attention. Again, getting to these patient in a timely fashion to prevent them from going to the emergency room. Next slide, please. Some takeaways, just understand that there's some unique challenges that may contribute to our patient getting additional input from a specialist. There are clinical and logistical factors to consider when you think about fair coordination and evaluation by specialists who are trained in a particular field and providing clear documentation instruction to home health providers can improve the patient experience and patient outcome. Next slide, please. I will pause there and any questions from anybody, feel free to put them in the chat. If there are no additional questions, let me see here. Then let's move on to demonstrating value of HPPC to payers and partners and some of the key quality metrics that we should consider as we venture into the arena of value-based care. Next slide, please. We're going to talk about quality metrics that are important in value-based care and discuss an approach for implementing quality improvement efforts and leveraging data for potential partnership with your payers. Next slide, please. When we're thinking about quality improvement in HPPC and about quality metrics, one of the frustrations that I face with our health system is that some of the metrics that are being collected and measured, they don't necessarily have application in home-based primary care. For example, colon cancer screening or mammogram and so on. Our patients are much older, much more complex, and many of them, they really don't want to do any of those tests or be part of the quality improvement project. The National Home-Based Primary Care Learning Network is a collaboration of, I think now it's like 48 different practices across the country. They get together. They set standards. They evaluate what are meaningful metrics for HPPC providers or offices, and how can we continuously improve on our care and our metrics. Being part of this collaboration, there's a group support and group accountability process that's involved. I encourage you to take a look at their website and see if this, by joining this group, might be something that you're interested in. Next slide, please. One of the benefits of the work from the collaborative is that they have been able to establish some quality metrics that are relevant to HPPC, and they are counted for, if you're involved in a MIPS program, they do count for quality work. For example, cognitive assessment and plan of care in HPPC patients, or a functional assessment for HPPC patients. These are measures that are relevant to us. They count in your quality as you're measuring quality of your work. There are many other examples. I listed only two, but take a look at some of the other opportunities that may be available to you when you're looking at quality that are relevant for HPPC. Next slide, please. So here are just some metrics to consider as we try to go from, say, fee-for-service and into value-based care. Again, you don't have to do all of them. Pick one or two that might be important to you and the system or the payer that you're working with. Death at home versus SNF, number of visits per day and per month per provider, access as a whole, number of death on hospice, hospitalization rates, ICU stays, readmission rates, time to first visit, time to TCM visit. Again, these may be important metrics for you to demonstrate the responsiveness and a quality of your service to a high-need, high-cost group of patients. Next slide, please. Again, have numbers. As you tell the story, we talk about using ACC numbers to tell the story, and you need to equip yourself with other stories or other numbers, again, to tell the story. Amanda talked about the polypharmacy. More than 10 meds is almost 100%. There's going to be a problem. We published a study maybe two years ago now. The average number of medications our patients take is 17. Is that a quality measure that you can embrace as a group and see if we can reduce the number of pills that our patients are taking? Having numbers is going to be really important as you engage and move along in the value-based care conversation. Next slide, please. Again, having numbers are important, but don't forget, and Amanda talked about this, don't forget the patient stories. Numbers and stories tell both sides of why our work in the HPPC world is so important for the future of, you know, Michael talked about, you know, Medicare running out. I don't know if he talked about that, but tying to quality, Medicare is maybe running out of money, but tying the quality piece with the cost piece and telling the patient story, that could be a real strong selling point for why they should not overlook the care that you're providing, like to our 65-year-old patient, 12 chronic conditions, 16 pills. She was in the hospital, I think, 11 times in the past year before we got involved. Never married, two uninvolved kids, frozen meals, delivered meals, you get the rest, you know, non-adherence with medication, you've all seen patients like this. So after our intervention, getting home health, getting telemonitoring involved, the patient was in the following 12 months, she was only hospitalized twice. So having this story to tell, combining with data, again, makes a compelling selling point why they should really invest in the care that you're providing at home. Next slide, please. Amanda. Yeah. Thanks, Paul. Thanks for setting us up. I'm going to hopefully get into some nuts and bolts about thinking about quality measures. There are a couple of sources of quality measures in value-based care you're going to hear of, right? HEDIS, it's a tool for the Medicare Advantage plans to report to Medicare. You'll hear about STAR measures, that's really a combo of HEDIS, CAPS, HOS, prescription drug program, PDP, and the CMS administrative data. You can create process and outcome data within your own practice or with your partners. We'll go through the difference between those, but there are a lot of different ways information comes in. I'm big on being the person at the table that says, I don't want just all the information, I want to have all the information, and then I want to know what to do with it, and I want it to be actionable, and how do we create information that's actionable? When it'll be, here's all the information, it's like, let's make it actionable, let's make it comparable, how do we think about it in a different way? So when you start thinking about quality metrics and setting those up, evaluate the requirements of any new or existing contracts. So if there's something in your contract that you say you're going to do, and either they're providing you some of the information or you need to build your own quality measures, make sure that's at the base what you're doing. Understand if your tech has the capability of collecting that information, or if you need new tech or you need to change your tech, you need to buy a module, what do you need to support to be able to do that work? If your data is created by someone else, make sure you have a way to use the data in a meaningful way. I'll give an example. We can get claims data from payers, but we're a pretty small shop. We look at claims data and we don't have a real way to scrub it to make it actionable, so we could maybe scrub it to get some information, but not actionable. If you're going to work with Medicare, you're going to get monthly claims data once you get going. How do you put that into an actionable format? And there are tech companies that can help you with those things. Either a tech company or an actuarial firm can help make it actionable for you. But if you're going to have data from someone else, before you even request it from someone else, just say, what do I use it for? Is it actionable? What do I do with it? And then there's all the information that you collect today. There's the information you could collect, that you wanted to collect, that you want to ask for partners and payers about, and understand if it's process or outcome-based. I'm going to come right back to that in just a second. But fully research the detail of every measure. And I'll give an example here, but understand what is included and excluded inside of each requirement. For example, we have a payer where one of our measures that we said we were going to do for 2022 was breast cancer screenings. Well, that has some very specific included and excluded criteria. There's age. There's trans status is an exclusion. But one example is mobility is not an exclusion. So we worked really hard on this measure. We created all this work to get patients in to have breast cancer screenings. And we had a patient who they worked out transportation. They convinced the patient they should do it. They worked out transportation. They did all that work. They get the patient. And the patient cannot stand for the exam. Well, there's no exclusion for that. That's in your denominator. And it won't be included in your numerator. And it counts against you. And so we have found when we really dig into the quality measures that we're responsible for, especially the ones that are contractual, they're very detailed. And there's a lot included inside of those. There are things like follow up from an ER visit and the codes that they use on which codes count are really important. So again, understand the detail within each measure, especially if you're contractually held to it. And if not, if it's just a, hey, this is a measure that I want to collect today. There are a lot of different ways to collect measures, right? Make sure we're talking a common language. I still, after 10 and a half years of this organization, I'll ask, well, what's the numerator and denominator in that? And my understanding might not be exactly what someone else's understanding of the general idea of that measure was supposed to be. So we have to review that numerator, denominator definition one more time and make sure it's right. But we're all talking that common language because data can be really powerful. But you want to make sure that it's apples to apples with what a partner wants. You're doing something with it. You have the capability to do something with it. And certainly if you're contractually responsible for it, you're acting on it and understand the detail really well. Slide. So process versus outcome measure. A process measure is really, you know, they're used to identify certain activity that was accomplished. So, you know, and here are some examples. Six educational sessions were delivered. I create a new policy. There's a new form and now we're filling it out. An outcome measure really shows the impact of accomplishing that goal or the impact of all the processes that go into it, right? Lower hospitalization readmission rates. We lowered them 2%. We increased the total days at home by 5% over the next calendar year is our goal, right? We increased it by 4%. But next year we're trying to increase by six. So oftentimes process measures can be used on your way to outcome measures. But understand when you're measuring something, is it a process measure or an outcome measure? And if it's a process measure today, can it be an outcome measure tomorrow? Is it directly linked to the work you're trying to prove that you're doing? If it doesn't, certainly don't do it. But if it's just, hey, we don't have the tech. We don't have the data. We have the capability yet to get to a true outcome measure. We don't know how to begin to describe our outcome measure. Use a process measure first to try to move the dial still. Because, and I said this kind of at the beginning of our time together, we want to be able to show that you are working with partners. And in any value-based care arrangement, you have partners. So that, I mean, it's just a given. In a fee-for-service arrangement, you don't necessarily have to have partners. In value-based care arrangement, you have partners. They could be payers. They could be ACOs. They could be, you could be part of a big system in your division, right? You could be part of an academic system. You could be partnering in a joint venture. But you have partners in these structures. And so you want to really understand quality measures, ones you're held to, and then ones you're working on. And again, this process versus outcome is really important, especially for small organizations on their journey to outcome measures. Slide. And as you think of a measure, you know, whether it's process or outcome-based, really, once you create where you are, create a smart measure. And you've probably heard of these before. These are not specific to healthcare. They're just general ways to create measures. Is it specific? Is it measurable? Is it achievable? Is it relevant? And is it time-bound? And checking these things is really important. You know, all of them, we can kind of go through. I'd spend a moment just on relevant, right? Like relevant is a really good question to ask yourself as an organization year to year. We may have changed. I guarantee the quality measures and the goals and the smart goals that you were setting 10 years before today, you're not necessarily setting today or you're not necessarily capturing that in the same way. So one example is increased practice mammography screenings. As I was talking about the breast cancer screening from 78% to 82% in the next 12 months, right? We have a time. It's very specific. It's measurable, right? We understand the data source behind this. It is achievable. It doesn't say 78% to 100%. It's certainly relevant. We have a contract that says we have to do it. And again, it's time-bound to this next 12 months. It could be calendar, fiscal year time-bound, quarter time-bound, slide. So using them in practice. So once you understand your requirements and your current state, focus on your process of disseminating information in an actual way. So once you say, okay, here's exactly what I know. How does it get to information? Who does it get to? And how does it then create action? And sometimes it can happen in your technology, right? It can be built into your EHR or your pop health system. Sometimes it's more about, I have a dashboard for our practice, for the board, for our providers or our team. And once they see X, we work on Y. And have regular meetings for discussing your performance and set goals for next steps with your measures, right? These measures don't have to end. They can continue to grow and evolve to meet your long-term goals. So here's a quality metric dashboard. You can see in the top, you have very specific clinical metrics, right? We're trying to track what percentage through the last week, right? So it's very clear what the timeframe is. Has it been captured? What percentage have received Medicare annual wellness through the last week, right? And then if you kind of go down, you can see your RAF score and you can see your program specific quality measures. And so this is just one sample of a dashboard of a clinical quality measure dashboard that's giving you a bird's eye view of where you are with your clinical goals. Typically in a tech system, this is printed out of a tech system. If in a technology-based system, you can go in and you can click and you can keep digging down and tip. And then you can get to a list of here's the denominator of patients and the numerator of patients. This is a great way to start thinking about your work. We, at my organization, have a scorecard for the board. Then that filters down to dashboards for departments. And then departments are responsible for their dashboards and they're responsible for their outcome and process measures inside of their dashboards for getting work done. So as you think about your internal process, you may need to create new process to manage specific data, right? When we were working on our breast cancer screening and this is new for us, relevant for us in the last 18 months, it required a heavy resource allocation to meet. What we did is we did a quick ROI for understanding what it was worth. In our contract, we had a financial number that it was worth if we could meet it. We certainly saw the quality value if the patients included and excluded were appropriately tracked and the ones that were included received a mammogram, we could see the value there. And we said, here's the kind of resource allocation to meet this goal. And what is it gonna take? And if there isn't just an upside, there might also be a downside. So think about if there's a downside or penalty, if you don't do this work and review it annually for changes. So certainly any metric that is up to the federal government, up to your state or another contract could change on a regular basis. Typically, it's not gonna change more than annually, but you wanna review an annual review of all the measures and all the detail. And then make sure that you create processes that are specific, not just specific to one person or one outset and are written down. That's right, slide. So key takeaways, use these quality measures to negotiate with your payers, your partners. Utilize three to five meaningful measures that directly talk about quality and cost and link them together. And again, even if you have to extrapolate some of your costs goals or your cost savings, that's okay. Use a mix of process and outcome-based measures, especially as you are trying to build your outcome-based measures and you're working towards an idea. Utilize the Medicare reported data on your practice, especially as you start thinking about contracting with Medicare. Medicare is gonna give you a lot of great data. I've seen the data. It's really confusing to interpret on its own. You really need to have a partner to think about interpreting that information, whether it's an internal resource or you outsource it. And then try to find a HEDIS measure. Every payer is responsible for HEDIS measures. So if you're like, where do I even start? Try to look up the HEDIS measures and try to find one that you would excel at or you're really good at today, you're already doing and work with a payer to get information on how you're doing on those. So Paul and I will take questions for quality measures. Thank you. Thank you, everybody. Well, thank you, Paul, Amanda, and Michael. We really appreciate the time you take to speak on these topics. And thank you for our attendees for joining us today. Just as a reminder, we will have the second installment of the series next Thursday, April 20th. Same time, same place, 12.30 p.m. Central. And we'll be discussing managing costs of care and value-based care. The presenters for that will be Paul Chang, Michael Kingan, who is a geriatric nurse practitioner with Johns Hopkins House Call Program, and Dr. James Ellison, who's a geriatric psychiatrist with ChristianaCare. So they'll be talking about conditions of specific concern in value-based payment arrangements, including COPD, congestive heart failure, polypharmacy. They'll also be going over comprehensive wound care plans and accurate documentation, as well as managing mental health conditions in homebound patients. If you have any questions, feel free to email us at education at hccinstitute.org. Excuse me. And thanks again for joining us. We look forward to seeing you next week.

Margaret Cordes

HCCI

workshop

value-based care

recorded

Q&A box

John A. Hartford Foundation

home-based primary care

clinical models

coordinating with specialists

leakage adjustment

Medicare

quality metrics

HEDIS

STAR measures