FIHN Provider Meeting - February 22, 2017 Agenda

1. All Provider Meeting February 22, 2017

2. Agenda • Call to order Richard Gough, MD • Contract Performance CY2016 Johnson Koilpillai, MD • 2016 Quality Reporting Update Sean Shillinger • Board Resolutions - participation Richard Gough, MD • Transition from MU to MIPS ACI Sean Shillinger • 2017 FMH Employee HP Goals Jennifer Teeter • Care Alerts and Care Plans Jennifer Teeter • Contracting Update Jennifer Teeter • Imaging Utilization Project Richard Gough, MD • Patient HCC or Risk Coding Richard Gough, MD • Adjourn Richard Gough, MD

3. Contract Performance – CY2016 Johnson Koilpillai, MD FIHN Co-Medical Director

4. FMH Employee Health Plan2016 Preliminary Year end results

5. 2016 FMH Employee Health Plan – Q4 Performance FIHN did not meet Quality or Cost goals for CY2016 Performance Year

6. Medicare Shared Savings Program 3rd Quarter Results,4th Quarter due in February

9. 2.6% reduction

11. Medicare Shared Savings Program Comparison to other ACOs as of 3rd Quarter 2016

14. 4Q 2016 MSSP Performance Pending – preliminary result due in February, final results in August 2017Financials – on trackQuality – currently reporting

15. MSSP Quality Measure Performance Improvement efforts as of December 31, 2016 – Sean Shillinger, IT Analyst

16. 2016 Low Performance ( data found in Discrete EHR Fields) 12/31/2016 from NextGen & eClinicalWorks

17. 2016 Medicare Shared Savings Program Annual Quality Measure Reporting Update

18. Timeline • FIHN and abstraction vendor Primaris began quality reporting on 1/23/2017 and will submit final results to CMS by 3/10/2017. • Currently 59% completed, 15 days remaining! • Primaris is actively outreaching to practices for log-in connectivity and abstraction questions – please respond promptly! • Meditech Abstraction – helping to find data… • Fall Screening, Influenza and Pneumonia Vaccination, Mammogram, Colonoscopy, and Diabetic Composite (A1c)

19. Calendar Year 2016 – Quality Measure ACO #11 Percent of PCPs who attest to Meaningful Use Definition - Percentage of ACO’s PCPs who successfully meet Meaningful Use (MU) requirements. What you can do? • Attest as early as possible – ensures that providers’ attestation data will be available when measure is calculated in late spring. • The Medicare EHR Incentive Program attestation system is open through March 13, 2017 (extended 2 weeks). • Providers must attest by the deadline to avoid a 2018 payment adjustment. Link to CMS’ EHR Incentive Program - https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/

20. FIHN Participation and Shared Savings Requirements Richard Gough, MD Co-Medical Director

21. FIHN Participation Agreement Exhibit 4 E.Physician Responsibilities. Physician shall carry out the following activities with respect to health care services provided to fee-for-service Medicare beneficiaries: (3) Implementing data systems that are compatible with the data systems used by FIHN for collecting and reporting data to CMS. (7) Physician shall take all reasonably practicable actions to transition to an electronic medical record system compatible with the information technology system in use by FIHN within one (1) year of the effective date of the MSSP Participation Agreement. If Physician is a Primary Care Physician, Physician agrees to take all reasonably practicable actions necessary to receive incentive payments through the CMS EHR Incentive Payment program.

22. FIHN Participation Requirements Decision from December Board Meeting - • For any practice wishing to join FIHN and for the current practices without an EHR – • Practices agree to use a 2014 CEHRT EHR by 6/30/17 with plans to transition to 2015 CEHRT and demonstrate exchange of patient information via an HIE using a C-CDA summary of care record • Paper Practices - Belani, Coyne, & Mann & Henry Tabled Items • Define “Plan to be 2015 CEHRT” • Define “Ability to exchange data via and HIE using a C-CDA summary of care record”

23. FIHN Board Decision – Shared Savings Quality Abstraction Citizenship = 40% • Facilitating Timely Abstraction = 20% • All Provider Meeting Attendance 2/4 meetings = 20% Board Decision from 1/19/2017 • For the 2016 Quality Reporting Period any practice that hasn’t completed the Remote Access Form and created abstractor EHR user accounts by 1/31/2017 will be ineligible to receive their 20% for Facilitating Timely Abstraction. • For future reporting years any practice that hasn’t completed the Remote Access Form and created abstractor EHR user accounts within 30 days of original request will be ineligible to receive their 20% for Facilitating Timely Abstraction

24. FIHN Shared Savings Distribution Methodology 50% Savings Payor 20% 80% Shared Savings to Network Providers • IT Systems and Analysts • Medical Director, Operations Dir. • Legal/Compliance/Consulting • Quality and Service Reporting • Budgeting/Finance • Contracting 50% Savings to FIHN FIHN Infrastructure Cost repayment, Administrative Services Fee CIN costs covered include: 50% 25% 25% PCPs Hospital Specialists • Citizenship • Attending meetings 2/4 • Quality/Utilization • Ambulatory Sensitive Condition COPD/Asthma Admissions/1000 • Citizenship • Facilitating timely extraction of quality measures • Attending meetings – 2/4 • Quality/Utilization • Measure Capture and Reporting • Attribution - number of patients • Citizenship • Facilitating reporting of quality measures or transition to PCP • Attending meetings – 2/4 • Number of unique patient encounters Benchmarks: MSSP ACO ratings, Milliman or AHRQ/other

25. Transitioning from Meaningful Use to MIPS requirements for Use of Certified EHR Technology

26. MIPS Categories of Performance Measurement • Quality – 50% weight 2017, declines to 30% 2019, 60 points • Report minimum of 6 PQRS measures ACO participants receive the ACO Quality Reporting Score • Resource Use – 0% weight 2017, increases to 30% 2019 • Cost per beneficiary; Cost per episode, claim data used, no reporting ACO Participants meet through ACO cost goals • Clinical Practice Improvement – 20% weight, 40 points • 90 Activities to choose from, must report 4 activitiesACO participants meet requirements through ACO activities • Advancing Care Information – 30%, 100 possible points • EHR, electronic access and data exchange requirements ACO participants receive weighted average score for ACO providers 26

27. 2017 Performance Year – ACO#11 Use of Certified EHR Technology Definition – Percentage of eligible clinicians participating in the ACO who successfully meet the Advancing Care Information (ACI) Base Score. Final Score= Average of all Providers in ACO See handout ACT NOW!!

28. ACO Providers without MU Attestation – 2015 Reported Data • Anusha Belani (Paper) • Cardiology Associates (Patel) • Critical Care Associates • Diane Ford • Frederick Urology Associates • Internal Medicine & Primary Care (Gaffar Syed) • Internal Medicine Specialists of Frederick (Tyra Kane) • Irfan Hassen • Mann & Henry (Paper) • Mark Coyne (Paper) • Mckenna Surgical Associates • Mid-Maryland ENT • Radiology Associates (? non-pt facing) • Syed Haque • Urology Consultants of MD (Moorman) • X’Cel Primary Care (Jalal Saied) • MHP – Center for Chest (Hardship) • MHP – Oncology Care Consultants (Hardship) • MHP – Wound and Hyperbaric (Hardship) • MHP – Orthopaedic Specialists of Frederick (Hardship) • MHP – Behavioral Health (Hardship) • MHP – Pain & Palliative (Hardship) Bold are PCPs

29. MU/MIPS Participation – Cost Impact (Starting Performance Year = 2012) • Dr. Medicare PCP - Average Annual Medicare Payments of $111,400 • Total Incentive possible $43,480 • Total Penalty 2016-2018 $6,684 • Total Negative Impact $50,164 • Total penalty through 2025 if no participation in MIPS= $64,612 • Dr. Medicare Specialist - Average Annual Medicare Payments of $682.670 • Total Incentive possible $43,480 • Total Penalty 2016-2018 $40,960 • Total Negative Impact $84,440 • Total penalty through 2025 if no participation in MIPS= $241,706 • Dr. Medicaid • Total Incentive= $63,750 • No penalties at this time, not subject to sequestration • May skip a year • Last year for full incentive was 2016, incentive available through 2021

30. Impact to Medicare Payments **Based on Medicare Reimbursement 2017 Reconsideration Application based on 2015 reporting year due February 28, 2017 https://www.cms.gov/Regulations-and-Guidance/Legislation/EHRIncentivePrograms/Downloads/PaymentAdj_ReconsiderationFormEP.pdf

31. 2017 Goals FMH Employee Health Plan Jennifer Teeter Executive Director

32. 2017 FMH Employee Health Plan Goals – pending HP approval Diabetes Eye Exam – Patients age 18 – 75 years, with type 1 or type 2 diabetes whom had an eye exam performed in the measurement year or the year prior (24 months).

33. New Quality Measure Performance – Quarter 3 New Quality Measure Monitor and provide feedback

34. Upper Respiratory Measure Specifications Number of patient’s encounters where antibiotics were neither prescribed nor dispensed on or within three days of the episode for URI over the total number of encounters in the denominator (patients aged 3 months through 18 years with an outpatient or ED visit for URI.)

35. Board Motion Approved: Board voted and approved the following recommendations: • Approved the FMH Employee Health Plan quality measures for 2017 Performance Year to include the addition of the following new measure • Diabetes Eye Exam • Approved monitoring the Upper Respiratory Infection without use of Antibiotics measure for 2017 and provide patient level detail to practices to ensure practice guidelines are met, but don’t score performance due to low denominator size.

36. CRISP Care Alerts

37. Care Alerts and Care Plans • HSCRC requiring hospitals to create Care Alerts or Care Plans for “high utilizer” patients with a goal of improving coordination of care across settings • FMH has 586 Medicare high utilizers • Approximately 70 attributed to FIHN • Care Plans will be created in Meditech by the Care Manager (with input from the PCP and specialist as appropriate) • Care Alerts are brief statements that providers in an emergency department might want to be aware of about a patient

38. Care Alert vs. Care Plan Care Alert: Care Plan: Improve the management of the high-risk/high utilization patient Executive summary of prior utilization and testing Identification of the key drivers for hospital utilization Recommendations from the multidisciplinary team for consideration in the ED Consistent identification of the care team (including specialists, family support, community services, etc) • High-value, need-to-know information about a patient to support better decision-making at the point of care • Instantly accessible • Brief • Guidance from a clinician who knows the patient • Convey baseline • Identify clinician, care team with contact info • Intended to inform the decision to admit

39. Mrs. X – sample alert • Mrs. X routinely calls 911 on weekends complaining of shortness of breath. She does have COPD and baseline exam is notable for wheezes and rhonchi. • Chest x-ray will show a LLL infiltrate, that has been stable for 15 years • Is a DNR and would benefit from palliative care, however not agreeable at this time • Please call her PCP, Dr. K, on his cell at 240-566-6666 if you are considering invasive testing or admission. • Please note the PCP office has walk in appointments available daily and can be seen next day • You can reach his care manager, Heather at 240-566-3679 she will assist with follow up care and ensure he gets to Dr. K after discharge

40. Next Steps .. Care managers are actively working thru the list of 586 and will be reaching out to you for input in developing care alerts The Care Alert will be standardized to include the following: • Most frequent reason/presentation for ED visit • Recommendations/comments response to prior treatments • Special instructions from PCP/Provider – i.e. pain contract or treatment • Active with hospice or palliative care • Access to community follow up / support • PCP contact name/# • Care manager name/# • Transportation name/# • DNR/MOLST

41. Contracting Update Jennifer Teeter Executive Director

42. Advanced Health Collaborative II (AHC II)

43. Advanced Health Collaborative II Hopkins Partner Health Systems: Adventist HealthCareAnne Arundel Medical CenterFrederick Regional Health SystemLifeBridge HealthMercy Medical CenterPeninsula Regional Health System Johns Hopkins Medicare Advantage 37

44. Status Update…. • AHCII Agreements sent to FIHN Providers • Hopkins received FIHN list. Vetting providers for receiving invitations to join JH Medicare Advantage • Providers will receive direct Agreements from Johns Hopkins late Spring/early Summer • Hopkins sales in Frederick Co. late Fall for 2018 • Future AHCII FIHN level Agreement once Frederick County has critical mass of members • Medical Directors attended first AHCII Board Meeting in January, approved 8 Clinical Pathways for chronic diseases • AHCII Medical Directors meeting with Hopkins Medicare Advantage Medical Director in March 38

45. AETNA Contract Update • ACO Total Cost & Quality – FIHN does not qualify • AETNA changed attribution model, too few patients • Already at top quartile for cost efficiency • Pay for Performance Agreement negotiation underway • If FIHN meets quality and efficiency measures, than bonus payment • Aligning quality measures with other contracts, claim based • AETNA shares patient level detail, measure gaps • Efficiency measures: episode of care costs, generic rates, in network laboratory use, e-prescribing medications • Aiming for 7/1/2017 implementation

46. What are we doing to improve Performance under the FMH Employee Health Plan? • Emergency Room Utilization – Patient specific detail provided to PCP. Use educational tool, refer to care management, inform patient of options and office hours. Employee Health Clinic use continues to increase during business hours and should help drive down ER use. • Reviewing the impact of changes to the hospital allowed charges under the global budget contract with the state • Imaging utilization – joint and back pain data correspond to FIHN’s approved clinical pathways • Working with health plan to expand available data on gaps in care such as diabetes and high cost areas for development

47. FIHN Advanced Imaging Data Richard Gough, MD Co-Medical Director

48. Office Includes outpatient radiology testing centers Medicare ACO Data

49. CaroMont ACO – Successful Advanced Imaging Improvement Efforts • Engaged PCPs in standards of care, such as Choosing Wisely, for over utilized tests in that setting • Tried to engage urgent care providers in same way, especially sites with imaging onsite.  • PCP leads met with the community radiology providers • Discussed main points of ensuring documentation of need for ordered procedure, and discussion about duplicative testing • Lead to them establishing/developing/increasing their own internal quality review and protocols.  • This was mutually accepted because it was on the basis of what is the best point of care and decision for the patient and not because ACO administration said “do this”

50. Advanced Imaging Data Analysis 1. Medicare Population – Review of all claims for FIHN attributed patients and Meditech ordering physician to analyze CT, MRI, and PET • Utilization by Ordering Provider • Modality • Beneficiary 2. FMH Employee Health Plan – Review UMR Data by top procedure and diagnosis 3. Compare to Choosing Wisely Guidelines for diagnoses with high volume studies 4. Provider education and peer mentorship with Guidelines.