ACQAADVISOR
Fall 2017
FEATURE ARTICLES:
2
The Worst Epidemic in Modern Medical History
5
Excellus BCBS Joins Fight To End Aids By 2020
EVERY ISSUE:
6
Improving Documentation for Health Status codes
7
Pathways Can Create Conduit, Partnerships, Better Health Outcomes
ACQA Advisor is a quarterly newsletter dedicated to sharing news, updates and best practices with our ACQA partners.
‘THE WORST
EPIDEMIC IN
MODERN MEDICAL HISTORY’ Opioid overdose, abuse and dependence in America have a total economic burden of
How can we get a handle on the opioid crisis? Excellus BlueCross BlueShield data was analyzed recently to determine whether the seven-day initial opioid prescribing limit, enacted in New York on July 22, 2016, led to changes in opioid prescribing habits. Here’s what was found: w The average quantity for a new opioid prescription was largely unchanged. w The average day supply per opioid prescription was unchanged.
annually, according to the National Center for Injury Prevention and Control.
AVERAGE DAYS SUPPLY PER OPIOID PRESCRIPTION 16.9%
Commercial
16.8%
17.4% 21.9%
Medicare Pre-Legislation
More than
17.1%
Medicaid
21.8%
Post-Legislation
w There was a 5 percent improvement in the percent of patients who $20,000 did not fill a second opioid prescription (63 percent vs. 68 percent). $15,000
This legislation is a step in the right direction, but more action needs to $12,000 be taken. So, what factors should be considered before $12,023prescribing an opioid to a patient who presents with non-cancer pain? Here are some $9,000 best-practice guidelines for prescribing: $8,015
$78.5 billion
90
Americans die each day from an opioid overdose, including prescription opioid and heroin. This problem has been referred to as the worst man-made epidemic in modern medical history.
$6,000 $3,000 $1,336 $0
2014
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2015
(continued on next page)
Consider Physical Dependence and Addiction
Recommend Non-Pharmacologic Therapies
When prescribing opioids, it is important to understand the differences between physical dependence and addiction.
According to the Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain, use of non-pharmacologic therapies, such as exercise; cognitive behavioral therapy;and non-opioid pharmacologic therapies, such as anti-inflammatories for chronic pain, should be considered.3
w Opioid dependence (need to continually take an opioid to avoid withdrawal symptoms) typically resolves in a few days to a few weeks following drug discontinuation. w
Opioid addiction develops over time and does not typically resolve simply by discontinuation. Addiction involves the inability to control drug use despite the possible harm to themselves or others. It is difficult to decrease or discontinue use of opioids in a patient who has been using them for years.1
Evaluate the Patient
Start Low, Go Slow Another approach for initiating opioids is starting low and going slow, which includes: w Prescribing the lowest possible dosage w Starting with immediate-release opioids
Patient assessment is recommended prior to initiating opioid therapy:
w Providing only the quantity needed for the expected duration of pain
w Consult the New York State Prescription Drug Monitoring Program at: health.ny.gov/professionals/narcotic/ prescription_monitoring.
4 Recent studies suggest that the probability of long-term opioid use increases in the first days of therapy, particularly after the first five days or one month of therapy.4
w Perform a urine drug screen prior to prescribing an opioid to assess for other drugs that may suggest a high risk of opioid use disorder and overdose. w
Use a risk-assessment tool, such as ORT, DIRE or SOAPP-R. A review found that these tools have good validity, but more research is needed to determine their impact on clinical outcomes.2
For additional information on best practices for opioid prescribing, check out: w SAMHSA Opioid Overdose Prevention Toolkit: samhsa.gov/capt/tools-learning-resources/opioid-overdose-prevention-toolkit w The Community Principles of Pain Management: compassionandsupport.org/index.php/for_professionals/pain_management
References: 1. Volkow N, et al. Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies. N Engl J Med 2016; 374:1253- 1263March 31. 2. Chou R, et al. Opioids for chronic non-cancer pain: prediction and identification of aberrant drug- related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009 Feb;10(2):131-46. 3. oregonpainguidance.org/wp-content/uploads/2014/04/OPG_Guidelines.pdf 4. cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm
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Workplace Biometric Screenings Often Open Doors to Better Heath Why would anyone get a biometric screening in a factory rather than a doctor’s office? Likely, it was because his or her employer offered it at work. As the field of workplace wellness has evolved, so has the role of biometric screening. While some employers have moved away from the practice of on-site clinical programs, many others are taking a more strategic approach by tying incentives to health outcomes or participation in lifestyle programs. Excellus BlueCross BlueShield’s Workplace Wellness team works with employers on all elements of program implementation and development, and has built a portfolio of vendors, resources and strategies to deliver evidence-based solutions. Key solutions offered include a comprehensive approach to delivering and maximizing the value of biometric screening programs. Due to employers’ high demand for biometric screening services, the health plan has partnered with four highly qualified screening vendors, each offering different program models. A rigorous vetting process ensures the highest quality and adherence to clinical guidelines and standards, with both finger stick and venipuncture testing options available. The value of these screening programs goes beyond the event held at the workplace. In fact, the true value of the programs lies in the opportunity to drive members to engage with their own care providers. Mechanisms for encouraging participants to share results with their personal physicians are built into all of the screening programs and strategies. Several vendors include the option of sending an individual’s results directly to the physician office. The health plan is exploring ways to build in an option that allows individuals to submit screening results obtained through a recent doctor visit. Ideally, health care should be delivered in a medical office; however, for many people, it’s that wellness program at work that opens the door. The Workplace Wellness team works to ensure that the next door those people walk through is yours.
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On-site biometric screening events have been a cornerstone of workplace wellness programs for two reasons: (1) to provide employers with a snapshot of employee health status in order to identify opportunities for targeted wellness programming, and
(2) to nudge employees into health-status awareness and action.
EXCELLUS BCBS JOINS FIGHT TO END AIDS BY 2020 Excellus BlueCross BlueShield has joined national and state efforts to end AIDS by 2020. As we work toward that goal, the health plan has embarked on an initiative to use claims history to identify members with HIV/AIDS who have not had viral load testing. All New York State Department of Health Protected Health Information requirements are followed. Members have been identified for outreach and the health plan is committed to meeting initiative goals for 100 percent of the identified member population. These members will be provided assistance in scheduling appointments, including any necessary arrangements for transportation. Case managers will educate members about the importance of treatment and will monitor treatment plan compliance. Members also will be educated about the benefits of enrollment in Health Homes programs. Details of the NYS Health Homes program can be found at: health.ny.gov/health_care/medicaid/program/medicaid_ health_homes/ Providers will receive a list of identified patients and will be asked to provide recent viral load compliance information for each. Once that information is provided, linkages can be made with Health Homes or Excellus BCBS’ case management delegate, Envolve-NY. Envolve staff will encourage and monitor ongoing treatment plan adherence where needed. Contact Envolve Case Management at: 1-844-694-6411.
For more information, contact Terry C. Bruno at 585-231-6894 or
[email protected]
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The initiative includes:
Engaging members in the health care system
Promoting viral load testing
Educating and assisting members with medication compliance in order to achieve a viral load suppressed status
Assisting members in overcoming barriers to treatment and medication compliance
IMPROVING DOCUMENTATION C FOR HEALTH STATUS ODES Health status codes originate from the ICD-10 CM code set, Chapter 21 (Z00-Z99), Factors Influencing Health Statistics and Contact with Health Services. These codes document the continuation of a past condition. The information from the previous year does not carry through from year to year. These status conditions should be reported at least once a year, usually in the Annual Wellness Visit. w Status codes indicate that a patient is either a carrier of a disease or has the sequelae or residual of a past disease
or condition, including such things as the presence of a prosthetic or mechanical device resulting from previous treatment. w A status code is informative, because the status may affect the course of treatment and its outcome. A status code is
distinct from a history code. The history code indicates that the patient no longer has the condition.
ICD-10
Common health status conditions that should be reported when applicable:
ICD-10
DESCRIPTION
Z21
Asymptomatic HIV infection
Z49.-
Encounter for care involving renal dialysis
Z68.--
Adult Body Mass Index (BMI)
Z79.4
Long-term insulin use ( current)
Z89.--
Lower limb amputation
Z93.-
Ostomy status
Z94.-
Transplant status
Z99.1-
Ventilator status
Z99.2
Dialysis dependence-presence of AV shunt
Important Tips w A status code should not be used with a diagnosis code from one of the body system chapters if the diagnosis code
includes the information provided by the status code. For example, code Z94.1, heart transplant status, should not be used with a code from subcategory T86.2, complications of heart transplant. The status code does not provide additional information. The complication code indicates that the patient is a heart-transplant patient. w Health status codes should be billed annually. w Dialysis status code Z99.2 can be billed when patient has the presence of an arteriovenous shunt. w Be sure to document the BMI and other clinical findings related to obesity in the assessment.
For more information, please contact our Practitioner Education Manager Caroline Mei at 585-453-6465. 6 ACQA Advisor
Pathways Can Create Conduit, Partnerships,
Better Health Outcomes
The pathway concept is garnering much interest and attention nationally as exhibited recently when Excellus BlueCross BlueShield was invited to speak about its spine pathways program at Stanford University’s prestigious academic medical conference. Pathways create the infrastructure to get best evidence, practices or new technologies and tools to patients more rapidly. Any care approach, such spine care, is inefficient when it has more than 200 treatment options and 24 provider types with high variation within those providers. Now, consider adding a new technology or tool in to that often chaotic system. How well will it be received? Will it even be given a look? Who has the time to vet and implement? The barriers seem insurmountable, but, when you have a well-tuned care pathway, new technologies can be added, implementation kinks worked out, and provider time can be saved. The process is in place; therefore, a conduit for discussion, sharing and implementation exists. We are excited by the positive reception and significant downstream savings our spine pathway has delivered to our ACQA partners. The physician burnout rate is at an all-time high, and patient contact time is frustratingly low, so focusing on new technologies that save provider resources (time, cost) should be a priority. Pathways bring processes that simplify quality decision-making. A pathway that is highly functioning is a vehicle for sharing information from clinicians, patients, administrators, payers, employers and communities. The result is optimized care value. This deeper level of co-commitment brings a wealth of information, support and technologies that best serve our patients. Some of our ACQA partners are seeing the benefit of a co-created, co-supported spine care pathway. Patient and provider satisfaction can increase while episode costs drop. (See cost comparison table) Let’s continue to work together to improve communication, process, decision tools, and whatever else is needed to bring value-driven health care to our communities.
ACO Spine Comparison (Subset of Measures) Line of Business Commercial Incurred 1/1/2017 – 12/31/2016 paid trough 2/28/2017
Average Risk Score $1.20
Relative PMPM
Treatment Group New ACO
Note: significant PMPM savings, decrease in utilization/1000, and shift of PMPM from surgery to more patient active care. These are relative comparisons, as seen in risk scores and percentage of patients presenting for spine care.
Trained ACO
$ 0.89
PMPM % of Total New ACO
Trained ACO
% of members with spine care 23.90%
16.50%
Utilization per 1,000 New ACO Trained (Risk Adj) ACO
Surgery Total
$1.00
$0.23
35.3%
19.6%
3.85
2.05
Chiropractic Treatment
$1.00
$0.60
15.6%
22.9%
1,111.71
629.40
Physical Therapy
$1.00
$0.45
9.3%
10.2%
378.79
304.26
Imaging Total
$1.00
$0.26
12.4%
7.9%
150.28
68.77
Specialist Visit
$1.00
$0.80
2.9%
5.7%
90.01
61.72
Emergency Department Visits
$1.00
$0.30
3.9%
2.9%
13.38
6.66
Total
$1.00
$0.41
100.0%
100.0%
2,198.48
1,430.00
Non-Surgery Total
$1.00
$0.50
64.7%
80.4%
2,194.63
1,428.35
For further information about the spine health program, or the Continuing Medical Education- accredited PCP (1-2 CME) or PT/DC (24 CME) training sessions, contact Associate Medical Director Brian Justice, DC, at
[email protected] 7 ACQA Advisor
ACHIEVING
HYPERTENSION CONTROL THROUGH A
TEAM-BASED APPROACH As health care transforms to value-based purchasing or quality-based models in which reimbursement to health-care providers is linked to the quality of care, programs are helping advance goals for population health improvement, health-care quality, and cost reduction. A Performance Improvement Quality Metrics Workgroup (PIQM), Data Analytics Team (DAT) and Performance Improvement Executive Council (PIEC) established at Bassett Healthcare successfully manages and improves performance in quality indicators, as well as patient outcomes and experience. The workgroup, using improvement methodologies of the Institute for Healthcare Improvement Plan, Do Study Act Model for Improvement and the Kotter 8 Step Change Model, implements performance improvement initiatives for electronic clinical quality measures (eCQMs) that measure and track the quality of health-care services provided by clinicians. eCQMs that are accurate and reliably built in the electronic health record are essential to success in quality measure performance improvement. Subject-matter experts selected by clinical leadership were engaged in building the eCQMs used to achieve EHR Incentive Program or Meaningful Use Stage 2, defining the workflows and clinical decision support tools used to boost decision-making. The workgroup prioritized these quality measures for intervention through a comprehensive cataloging of greater than 76 eCQMs, then applied an
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internally developed criteria-based prioritization process. Hypertension was the initial measure selected for improvement. The workgroup assigned smaller teams to complete surveys, define processes and workflows, and perform site visits and observations, which included such details as when and how a blood pressure is taken and how and where it is documented. Other workgroup interventions, led by physician and quality leaders, included publishing clinical support tools.These included a clinical guideline and a protocol for hypertension; a Performance Improvement Advisory newsletter that includes information on the quality measure and recommendations to support performance improvement; EMR Tips and Tricks for documenting measure adherence in discrete fields; and a Frequently Asked Questions reference that offers strategies for performance improvement and contacts for more information. Stakeholders were provided access to accurate and current data. The workgroup developed a Performance Improvement Quality Dashboard and a Patient-Level Analysis Tool to identify and manage patients with gaps in care. Establishment of a communication plan to support implementation of initiatives was critical to success. Workgroup meetings were structured to provide a routine and expectations of accountability and feedback. Workgroup updates were brief and presented using
the situation, background, assessment and recommendation (SBAR) format. Several lessons were learned as a result, such as the importance of getting and keeping the right people at the table (alignment) and working within an organized and steady structure (communication) to achieve planned and effective change. The team also learned that physician leadership and engagement was critical, as was executive leadership support through establishment of a Performance Improvement Executive Council (PIEC) developed to ensure resources, guidance, and sustainability.
Outcomes were measured by comparing 2015 to 2016, and demonstrated increases that are significant considering the number of patient lives impacted and widespread geographic area covered: w Hypertension Control: (2015 YTD 69.9 percent; 2016 YTD 77.6 percent) an 11 percent increase w Hypertension in the Diabetic Patient: (2015 YTD 72.9 percent; 2016 YTD 80.4 percent) a 10 percent increase Based on these results, a clinically relevant reduction in strokes, myocardial infarctions (MI), and complications related to diabetes within our patient population is
anticipated.
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BMG Overall Performance Goal: 76.0% Lookback: 365 As of: 2017-02-25
80.0% 78.0% 76.0% 74.0% 72.0% 70.0% 68.0% 66.0%
69.8%
71.8%
70.3%
71.8%
75.3%
77.2%
77.4%
64.0%
2015-02-28
2015-09-30
2015-12-31
2016-03-31
2016-06-30
2016-09-30
2016-12-31
HT: BP<140/90 - BMG Overall Perfor-
HT:BP<140/90 - Goal
Polynomial Trend Line
BMG Overall Performance Goal: 77.0% Lookback: 365 As of: 2017-02-25 85.0% 80.0% 75.0% 70.0% 65.0%
72.5% 2015-02-28
73.8%
74.8%
78.7%
81.5%
80.2%
2015-12-31
2016-03-31
2016-06-30
2016-09-30
2016-12-31
74.9% 2015-09-30
HT: BP<140/90 - BMG Overall Performance
HT:BP<140/90 - Goal
Polynomial Trend Line
This process for improvement has the potential for replication by all organizations. Steps are: w Choose priority measure based on organization impact and population impact
w Plan for communication (PIA, protocols, FAQ, data roll out-quarterly)
w Initiate in-depth analysis (DAT)
w Completed tools to toolbox on PI quality dashboard
w Working groups as needed (PDSA)
w Continue to provide access/skill and comfort in dashboard utilization for front-line staff and clinicians
w Initiate/build performance improvement advisory (PIA) w Build/validate dashboard w Assess need/build guidelines/protocols with subject matter experts
w Monitor progress-address issues as needed w Continue to align work with other incentive programs w Outreach and participation in evidenced-based programs and research opportunities
The workgroup’s approach is innovative and addresses population needs while supporting organizational goals of advancing staff knowledge, skills and abilities in the use of performance improvement methodologies. The same approach now will be used to achieve improved outcomes for diabetes.
Editor’s Note: the following was submitted by Anna Gaeta, RN, BSN, MS, CPHQ, CPPS
Bassett Healthcare senior director performance improvement and Marie Maxson, RN, BS, CHCQM Bassett Medical Center, director quality management and clinical effectiveness 9 ACQA Advisor
FUNDUSCOPIC PHOTOGRAPHY FOR DIABETIC EYE EXAMS
A diabetic eye exam is a quality metric included in the HEDIS, QARR, and Medicare Star measure sets. This metric is also included in the ACQA and RPE quality grids. As provider groups engage in value-based payment programs, this metric has been identified as an opportunity for improvement by almost all and, to that end, many groups have been exploring various interventions to drive improvement. One such intervention is the use of funduscopic cameras located in the primary care physician’s office that allow for images to be taken and transmitted for reading and interpretation by an eye care specialist. This intervention provides the opportunity to close the eye exam gap for members who do not routinely see an eye care specialist. The exam can be completed during the PCP visit with no dilation required.
Guidelines for provider billing and reimbursement Using the Welch Allyn RetinaVue Program and RetinaVue Retina Specialist Network
Using the Welch Allyn RetinaVue program without the RetinaVue Retina Specialist Network
Using another vendor program or purchasing cameras directly
PCP group bills the global code 92250 and 2022F; OR
PCP group bills the global code 92250 and 2022F. Specialist bills PCP group for agreed upon payment; OR
PCP group bills the global code 92250 and 2022F or 2024F accordingly. Specialist bills PCP group for agreed upon payment; OR
PCP group bills the global 92250, but with the specialist as rendering provider. Specialist must be linked to the PCP group’s taxpayer identification number.
PCP group bills for the technical component (92250 TC) and specialist bills separately for the professional component (92250 26)
PCP group bills for the technical component (92250 TC) and specialist bills separately for the professional component (92250 26)
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