All Provider Meeting February 4, 2015

1. All Provider MeetingFebruary 4, 2015 Frederick Integrated Healthcare Network

2. FIHN Board of Managers • 13 Member Board (75% MSSP participants = 10) • 1 Medicare Beneficiary • 2 Health System Representatives (included in “participating MSSP provider” count) • 10 Physicians (at least 8 of whom are MSSP participating) • Physician composition: • 3 specialists: 2 independent, 1 Monocacy Health Partners • 7 PCPs: 6 independent, 1 Monocacy Health Partners • At least 8 providers are non hospital affiliated, independent practitioners

3. Frederick Integrated Healthcare Network Board of Managers Chair: Richard Gough Johnson Koilpillai Neil Waravdekar Kevin Hohl Wayne Crowder Sibte Kazmi Gaffar Syed Lakhvinder Wadhwa Saeed Zaidi Mark Soberman Michelle Mahan Jennifer Teeter Richard Holz Credentials Committee Clinical Integration and IT Committee Neil Waravdekar - Chair Wayne Crowder Manny Casiano Gaffar Syed Leonard Kinland Michael Costello Johnson Koilpillai Jennifer Teeter Finance Committee Richard Gough - Chair Dawei Yang Lakhvinder Wadhwa Johnson Koilpillai Andrew Donelson Gerard Delgrippo Paul Feinberg Mark Chilton Jim Trumble Manny Casiano David Quirke/Phil Stiff Heather Kirby Jennifer Teeter Saeed Zaidi – Chair Mark Soberman Kevin Hohl Amy Jones Dave Bromberg Richard Gough Michelle Mahan Jennifer Teeter Governance and Membership Committee Johnson Koilpillai - Chair Sibte Kazmi Vincent DiFabio Jennifer Teeter

4. Network Participation Non par Future provider contracting strategy – Preferred SNFs, HH Agencies, Radiology, Urgent Care, Lab

5. Contracts for 2015 2016 and beyond Frederick Integrated Healthcare Network (FIHN) Commercial Payors: AETNA, United, CIGNA Does not interrupt fee for service contracts and billing shared savings contracting CY 2015 MedicareShared Savings/ACO FMH Employee Health Plan

6. Medicare ACO participant practices for 2015 • MONOCACY HEALTH PARTNERS AND FMH • Center for Chest Disease • Center for Breast Care • Frederick Urology Specialists • Mononcacy Health Partners Immediate Care • Monocacy Health Partners Pain and Palliative Care • Monocacy Health Partners Wound and Hyperbaric Specialists • Monocacy Health Partners Behavioral Health Services • Monocacy Health Partners Endocrine and Thyroid • Orthopaedic Specialists of Frederick • Oncology Care Consultants • Parkview Medical Group • Surgical Specialists • Union Bridge Family Practice • Frederick Memorial Hospital • FMH Home Health Services • Hospice of Frederick County • FMH Rose Hill, Mt. Airy, Urbana and Crestwood locations for lab, radiology and rehabilitation services • FMH Diabetes Center Sajjad Aziz Anusha Belani Cardiovascular Specialists of Frederick Centers for Advanced Orthopedics – MMI Jeff Cowen Mark Coyne Frederick Medical and Pulmonary Frederick Gastroenterology Associates Frederick Kidney Care, Drs. Nahar and Rengen Frederick Oncology Hematology Associates Syed Haque Irfan Hassen Internal Medicine Specialists, Tyra Kane William Johnson, MD, PA Sibte Kazmi David Kossoff Julio Menocal Middletown Valley Family Medicine Cynthia Moorman Hitesh Patel Banislav Romanic Jalal Saied Gaffar Syed Saeed Zaidi Practices can be added to ACOs during the year, but PQRS reporting is not done through the ACO unless a practice was participating prior to the start of the calendar year for ACO reporting.

7. What is an ACO? • Providers working together under a payor contract to improve the quality of care and reduce avoidable costs for a defined population • Medicare calls these organizations “accountable care organizations” (ACOs). • Frederick Integrated Healthcare Network is an ACO (organization under contract with MC) • There are approximately 424 ACOs under contract with Medicare nationwide • 15 in Maryland: AAMC, GBMC, Meritus, Carroll, Shah, Universal American (3), Adventist, Hopkins, Lifebridge

8. How are Medicare beneficiaries “attributed” to an ACO? • Medicare reviews 1 year of claim data to see which beneficiaries received plurality of primary care services (E&M services) from ACO providers: • Primary Attribution – PCP visits (FP, IM, GP, Geriatrics) • Secondary, if no PCP – Specialist providing E&M visits • If the tax ID/physician practice is part of an ACO, the ACO is attributed that practice’s beneficiaries • 5,000 attributed beneficiary threshold requirement • FIHN achieved 10,061 attributed Medicare beneficiaries • The attributed provider may be accountable to report quality measures • Providers in the ACO report PQRS through the ACO quality measures • If the practice leaves the ACO, the beneficiaries leave as well over time

9. How is success measured? • Quality measures/metrics – quality can not be sacrificed for cost savings • Care of chronic conditions • US Preventive Health Services Task Force Measures • Customer service • Quality measures reported through EHR integration, CG-CAHPS surveys and Claim data • Cost efficiency measures/metrics • Comparison of historical overall costs/patient

10. MSSP ACO Quality measuresUpdated Customer service Care coordination

11. MSSP Quality measuresUpdated (continued) Prevention Chronic Disease Management

12. MSSP Quality measuresUpdated (continued) • 8 customer service measures reported via CG-CAHPS surveys • 7 measures reported via claim data from ACO providers • 18 measures reported via practice EHR data collected by ACO and reported via PQRS Group Practice Reporting Option (GPRO) • If the ACO does not successfully report, the practices within the ACO do not successfully achieve PQRS reporting

13. Quality Measure Reporting • ACOs integrate Electronic Medical Record data from practices to report on quality measures • EMR surveys by ACO IT staff are necessary to facilitate extraction from EMR fields • Medicare shares claim data on attributed lives • Data mined by ACO to see gaps in quality and report opportunities to ACO providers for action

14. Medicare wants physicians to join ACOS and participate in CMS Innovation Center Pilots like MSSPMedicare incentives…

15. CMS Value Based Purchasing Value Based Modifier Program – 2016, adds efficiency measures to PQRS • Cost - per capita spend for patients with 4 chronic conditions: COPD, HF, CAD and Diabetes • Quality 6 domains – harm, patient experience, coordination of care, prevention, best practice, affordability of care • 2012 pilot reports given to physicians in select states • 2015 – modifier for groups 100+ physicians (-1%) • 2016 – modifier groups 10+ physicians(-2%) • 2017 all physicians (-2%) PQRS negative adjustments not applicable for providers in an ACO 2015-2017 so as not to disturb physician investment in initiatives that work toward similar triple aim goals, ACO reports PQRS measures

16. CMS Value Based Purchasing continued • 2018 Merit Incentive Payment System (MIPS) currently “proposed” next step for CMS Value Based Payment - likely to pass. Replaces “pay to report” with “pay to perform” on quality measures. • Permanently eliminates physician fee schedule sustainable growth rate reductions (26.5% threatened) and Provides a (.5%) physician fee increase 2015 through 2018 • Combines PQRS, Value Based Purchasing and Meaningful Use • Creates national objective for interoperability of EHRs by 2017 • ACO providers receive 1% fee schedule increase instead of .5% for all other physicians 5% bonus for alternative payment methodology participation • MIPS supported by AMA, AAFP and American College of Physicians and likely to pass

17. Medicare Regulations • Poster in PCP offices explaining ACO participation • Beneficiary Notification - right to opt-out of CMS sharing historical claim data • Notification via 2 methods • Face to Face physician office visit, record in EMR • Beneficiary mailing by ACO, ACO tracks • Beneficiary can use Form to opt out or call Medicare directly to declare opt-out choice • Medicare will send ACO claim data on any attributed beneficiary who does not opt out of data sharing • ACOs benefit from data to develop actionable plans to meet goals

18. What is different for patients, why agree to data sharing? Patient experience is improved through ACO investments • Support outside of physician office visits – • Care Managers, social workers, navigators • Pharmacists – medication reconciliation, fewer adverse drug interactions • Home monitoring, catch problems before they happen • Shared medical record data – improved communication between providers, reveals gaps in care, reduces duplication and out of pocket cost Proactive outreach reduces acute episodes and out of pocket cost for patients, better care over time

19. Priorities for Success

20. Population Health Management Priorities • Engage contracted lives – Beneficiaries, FMH Employees, encourage data sharing • Select Analytics Platform • Establish ACO communications plan - physicians & patients • Identify high risk/utilizers and strategy • Capture Quality Measures – CMS 33 and Employee HP • PCMH strategy - improve access and patient support • Implement Care Management Plan • Identify Leakage opportunities to grow market share • Assess Post acute provider quality/cost, use best in class • Develop shared savings distribution methodology Strategy underway

21. ACO Reduction of Avoidable Utilization/Cost Where to start? • MSSP Goal: 3.5% cost reduction, $3.8M estimated • Equivalents: $400 per beneficiary, 379 admissions • Data from CMS • FMH Employee Health Plan: Up to 13% savings will be shared, $840,000 • Equivalents: $455 per member, 84 admissions • Data from TPA/UMR reports underway • MSSP/ACOs experience data delays due to – • Beneficiary mailing opt out notice timing • CMS delays in sending claim data • Challenges of incorporating CMS data into analytic tool

22. High Utilizer Reports – Let’s get started!

23. Data Solutions –Behind the scenes work in progress • MD Hospitals have access to new HSCRC/CRISP data: Potentially Avoidable Utilization: • Readmissions: Inpt, Observation & ER revisits • Admissions for “preventable” acute exacerbation of chronic conditions that should be managed outpatient • Plan: Review Medicare high level data – Top 25 • Distribute patient level data by PCP accompanied by resource list to begin matching high utilizer patients to solutions • PCP Revenue Opportunities – Transitions and Complex Care Management (2015 CMS physician fee schedule) • Medicare Wellness visit - capture 33 measures and identify rising risk patients

24. Physician Report Overview • Data Source: • HSCRC Potentially Avoidable Utilization Report • Case level, Inpatient data only • Data Period: • Calendar Year 2014 YTD data through September • Included Cases • Medicare FFS patients only • Comparison groups: • Primary Care Physician (MC FFS) • FIHN MSSP Providers (MC FFS) • All FRHS MC FFS

25. Admission Statistics • IP Admissions = Count of Inpatient cases for physician • Average LOS (Length of Stay) = Sum of total Inpatient days / IP Admissions • Average SOI (Severity of Illness) = Sum of total SOI (severity level assigned to each Inpatient case) / IP Admissions • SOI ranges from 1 (least severe) to 4 (most severe) • Unique Patients = Count of distinct patients • High Utilizer Patients = Count of distinct “High Utilizer” patients, with: • >= 2 Inpatient stays, and • >= $50,000 total charges

26. Readmissions and Revisits • Readmissions • Inpatient Readmissions = Inpatient cases that occur within 30 days of an initial Inpatient stay • Cases Eligible for readmission = All Inpatient cases, excluding: • Deaths • Transfers to another acute hospital • Readmission Rate (%) = Inpatient Readmissions / Cases Eligible for Readmission • Expected Readmissions • Target line on Readmission Rate graph • Expected calculation = Physician cases by DRG severity of illness x State average readmissions by DRG severity of illness • Revisits • Emergency Department or Observation visits that occur within 30 days of an initial Inpatient stay. The Initial visit must be Inpatient.

27. Potentially Avoidable Utilization (PAU) • PAU is volume that can be potentially avoided though improved ambulatory care PAU includes: • Prevention Quality Indicators (PQIs) as defined by AHRQ – 13 diagnosis • Inpatient (IP) 30-day readmissions (intra and inter-hospital) • Outpatient (OP) 30-day revisits to ER/Observation (after an IP stay)

28. Hospital Potentially Avoidable Utilization Preventable Admissions – Prevention Quality Indicators - diagnosis for which strong primary care would reduce rates of hospitalization. National Quality Foundation endorsed measures used by state agencies. Lower extremity amputation in patients with diabetes Uncontrolled Diabetes, Long Term Diabetes, Short Term Diabetes Adult Asthma Angina Urinary Tract Infection Bacterial Pneumonia Dehydration COPD Hypertension CHF Perforated Appendix Red are high volume among FMH Medicare patients

29. Sample Report – Dr. Gough

30. Patient names

31. Names

32. Further data forthcoming • Emergency Room High Utilizers • Imaging Utilization – FMH off site location use appropriateness compared to best practice • Data on FMH Employee Health Plan Utilization • ACO claim data from Medicare – April timeframe

33. Planned Population Management Interventions Source: Geisinger

34. Planned Population Management Interventions (cont’d) Source: Geisinger

35. Population health interventions by time to ROI and impact on quality Large Utilization – end of life care Post-hospital transition management Post acute care management Disease management Patient access Case management Impact on quality Utilization – discretionary procedures Utilization - pharmacy Leakage - inpatient Leakage – OP procedural Utilization - imaging Leakage – OP non-procedural Small Leakage - imaging Long Time to Return on Investment Quick ROI – Return on Investment, OP - outpatient

36. Toolbox of resources Care Managers - help manage high risk patients, develop care plans, education, navigation, access and affordability for services and resources Dietitians – educate patients about linkage between diet and disease management Pharmacists – Medication reconciliation, access and affordability of the most efficacious medication plan, and Medication Therapy Management Social Workers – social needs assessment, connection to community resources, coaching (housing, medications, meals, transportation, in-home support, etc). Home tele-Monitoring – identification of early warning signs/triggers for early home/office based intervention to avoid  unnecessary emergency room or acute episodes Lay Navigator - training and patient support of nonclinical individuals to increase patient self-care/management and to facilitate/navigate available supportive resources Behavioral Health resources Home Health capabilities listing and resources SNF capabilities listing Emergency Room Case Management Disease Specific intensive education for patients with COPD, CHF, Diabetes Interpreter

37. Other resources Telemedicine Beneficiary communication (newsletters, web site, lectures) regarding disease process management, resources Patient portal for communication with FIHN providers, access to records, adding information about health history IT resources for integration of EMR data to improve communication and reporting Primary Care Redesign resources to help practices transform to highly accessible practices that make use of evidence based medicine and EMR resources to measure and improve patient health Clinic services for coordinated disease management education, support, navigation, social services, and various other supportive services to improve overall health status. CME Training for providers on up-to-date evidence based care for specific diseases

38. What we should do now – • Focus on High Risk/High Cost – • PCPs Review High Utilizer Report – review for patients who could be helped through care management • Manage Transitions – whether or not you bill for TCM codes, contact patient within 72 hours of discharge, use CRISP data to learn of transitions • Access to Care – is the practice open evenings/weekends? Consider options to improve access and reduce ER use • Get patients in for their MC Wellness Visit – collect Quality measures in your EMR, engage with FIHN IT in data integration • Specialists – more to come when we have CMS data • Encourage patients to have a PCP (quality measures) • Review Choosing Wisely recommendations from your specialty • Consider use of Generic Prescriptions • All – Advanced Directives, end of life care

39. MSSP/ACO PCPs taking new Medicare patients Middletown Valley Family Medicine Parkview Medical Group Dr. Aziz Dr. Zaidi *** double check Dr. Kazmi Dr. Syed Union Bridge Family Practice Dr. Menocal X’cel Primary Care – Jalal Saied Internal Medicine Specialists – Tyra Kane

40. Transitions in Care Contact within 72 hours with patients who are transitioning from one level of care to another is a key factor in reducing readmissions CRISP can send notifications to the practice when your patients are discharged FMH care management reaches out to any discharged patient who through screening is determined to be at high risk of readmission to help schedule follow-up appointments Create capacity to see these patients

41. Chesapeake Regional Information System for Patients (CRISP) • Maryland statewide information exchange • Currently houses: lab, x-ray, hospitalization and ER use data • Physician alerted when a patient is hospitalized or visits the ER, view medical record. Direct encrypted e-mail to your practice. • Supports meaningful use and PCMH • RxHub shows medication fill information • Free to physicians affiliated with a MD hospital • 1-877-952-7477 or HIE@CRISPhealth.org

42. CMS Transparency Requirements • Web site – approved by CMS www.fihn.org • ACO Name, Address, Primary Contact • Composition – Partnership or Joint Venture between hospitals and ACO Providers • Participants (Practice names) • Governing Body Names • Committee names and Chairs • Shared Savings Methodology (high level) • Results of any Savings reconciliations to date • Quality Performance Results

43. Next Steps Implementation of 1st FIHN Payor contracts – 1/1/2015 • FMH Employee Health Plan • Medicare Shared Savings All Provider Meetings – education and implementation sessions: care management, patient notices, reporting Mailing to Medicare Beneficiaries – data sharing opt-out Selection of Population Health IT software solution – Integration of practice EHR data on quality measures Deployment of medical management strategy using available data on high risk patients Medicare Patient Visits / Wellness visit – collect quality measures! Contract CG-CAHPS vendor – customer service survey

44. FMH Employee Health Plan FIHN Shared Savings Agreement

45. Timing • Concept work with TPA and FIHN: April – June • Legal review and contract development: August, ERISA issues evaluated by special council: Sept. • Fair Market Value Assessment: October • FMH Fiduciary/Board Approval: October • FIHN Board Approval: October • Opt-out mailing to FIHN Network: November, 0 opt-out • Final 2014 baseline numbers from TPA: January • Implementation: January 1, 2015 • Hurdle with TPA – HIPAA concerns over patient identifiable data, aggregate reports for now

46. Quality Measure Considerations • Areas where health plan scores poorly compared to UMR book of business and Healthy People 2020 goals • Measures that can be reported via claims data in lieu of having EMR access established • Measures crossing prevention, utilization and quality domains • Measures that cross over into other shared savings programs, continuity of effort

47. Measures selected with FMH Human Resources and FIHN Medical Directors

48. PCP Practice Survey • Purpose – to obtain a network baseline • Accessibility to Primary Care services • Interest in PCMH • Practice capabilities care management, tracking and reporting referrals • Health Plan Participation • Different than IT Survey for EMR quality measures

49. Next Steps both contracts Physicians – • High Utilizers- Strategy development and deployment – care management or other tools & patient access • Transitions in Care Management – 72 hour appointment • Patient visits – collect and report quality measures – identify rising risk • Participate in EHR Integration with FIHN IT • Specialists – Choosing Wisely and ensure patients have a PCP • End of Life/Advanced Directives FIHN – • Credentialing of network providers • Web site development – beneficiary and FIHN physicians • Beneficiary Mailing – find addresses, opt out tracking • Claim reports – quality, cost; network and provider level report cards • Financial Management – Progress on savings goals • CG-CAHPS vendor contracting • Use integrated EMR data to report on quality measures – report cards • Future provider contracting strategy –Preferred SNF partners, lab, xray • Participation Fee – FMV assessment, paid from savings • Payor contracting – future Agreements