Frederick Integrated Healthcare Network All Provider Meeting January

Frederick Integrated Healthcare Network All Provider Meeting January 13, 2016 1

Agenda • Call to Order Dr. Gough • Laboratory Utilization and Cost Dr. Gough • MSSP & FMH Contract Dashboards Jennifer Teeter • 2016 FMH Contract Quality Measures Jennifer Teeter • Shared Savings Methodology Jennifer Teeter • ACO Reporting to Medicare Phil Stiff • Annual Wellness Visit Dr. Koilpillai • Care Management update Heather Kirby • Specialist Follow-up Visits Dr. Gough • Palliative Care/Advanced Directives Dr. Gough • DVT Protocol Dr. Gough • 2

Board of Managers 3

Frederick Integrated Healthcare Network Board of Managers Chair: Richard Gough Johnson Koilpillai Neil Waravdekar Kevin Hohl Wayne Crowder Sibte Kazmi Gaffar Syed Credentials Committee 1. 2. 3. 4. 5. 6. 7. 8. Neil Waravdekar - Chair Wayne Crowder Manny Casiano Gaffar Syed Leonard Kinland Michael Costello Johnson Koilpillai Jennifer Teeter Governance and Membership Committee 1. 2. 3. 4. Johnson Koilpillai - Chair Sibte Kazmi Vincent Di. Fabio Jennifer Teeter Saeed Zaidi William Johnson Mark Soberman Michelle Mahan Jennifer Teeter Richard Holz Clinical Integration and IT Committee 1. Richard Gough - Chair 2. Dawei Yang 3. Lakhvinder Wadhwa 4. Johnson Koilpillai 5. Gerard Delgrippo 6. Paul Feinberg 7. Mark Glass-Royal 8. Vipul Kela 9. Jim Trumble 10. Manny Casiano 11. Phil Stiff 12. Heather Kirby 13. Jennifer Teeter Finance Committee 1. 2. 3. 4. 5. 6. 7. 8. Saeed Zaidi – Chair Mark Soberman Kevin Hohl Amy Jones Dave Bromberg Richard Gough Michelle Mahan Jennifer Teeter 4

Network Participation Report 20% increase since 11/2014 PCPs Specialists Total 95 177 272 (90% of available) Non par Future provider contracting strategy – Preferred SNFs, HH Agencies 5

Welcome New FIHN Members! Comprehensive Neurology Services Comprehensive Neurology and Sleep Medicine Critical Care Associates Tracy Culbertson Diane Ford Mann and Henry Podiatry Stephen Mc. Kenna Medical Emergency Professionals Mid-Maryland Ear Nose and Throat Mohammed Mohiuddin Progressive Podiatry, Julie Jurd Radiology Associates of Frederick Sound Physicians Yalamanchili Brain and Spine Network Gaps: Allergy OBGYN Opthalmology Outpt Psych 6

Laboratory Cost Data 7

Lab Orders • Electrolyte Panel • Glucose • BUN • Creatinine • SGPT (ALT)

Lab Orders Cost • Electrolyte Panel 9. 55 • Glucose 5. 12 • BUN 5. 37 • Creatinine 6. 33 • SGPT (ALT) 6. 32 $32. 69

Lab Orders Cost • Electrolyte Panel 9. 55 • Glucose 5. 12 • BUN 5. 37 • Creatinine 6. 33 • SGPT (ALT) 6. 32 $32. 69 Comprehensive Metabolic Panel $14. 37

CPT 80053 Description Comprehensive metabolic panel Medicare Fee 80048 Metabolic panel total ca 11. 51 80051 Electrolyte panel 9. 55 80076 Hepatic function panel 11. 11 82040 Assay of serum albumin 5. 85 82247 Bilirubin total 6. 83 82248 Bilirubin direct 6. 83 84075 Assay alkaline phosphatase 7. 04 84155 Assay of protein serum 4. 46 84450 Transferase (AST) (SGOT) 7. 04 84460 Alanine amino (ALT) (SGPT) 6. 32 84295 Assay of serum sodium 6. 55 84132 Assay of serum potassium 6. 26 82374 Assay blood carbon dioxide 5. 6 82435 Assay of blood chloride 4. 74 84520 Assay of urea nitrogen 5. 37 82565 Assay of creatinine 6. 33 82947 Assay glucose blood quant 5. 12 82310 Assay of calcium 7. 02 14. 37 11

Year in Review – What did FIHN Accomplish? 12

2015 Accomplishments • Network Growth -20% • Attributed lives under contract – 10, 838 and 1, 425 • Financial – as of 3 Q 2015 • Medicare achieving 4% savings (MUST REPORT) • FMH Employee Health Plan achieving 11% savings • Utilization – Detailed reports – next set of slides • What have we done to contribute to these results? • PCP Dashboards and actionable patient level data • Tools to educate patients, ER use, High Tech Imaging • Provider best practice education CMEs, Premier data • Embedded Care Managers – Sept. start, not in data yet • FMH Transition in Care follow-up • Palliative Care and hospice criteria for referral 13

2016 Priorities • Provide IT data integration to report/perform on measures! • Engage select Specialists with patient level detail on high utilizing patients • Help PCPs with Annual Wellness Visits – best practice • Continue work on readmissions, transitions of care • Improve communication between sites of care • Engage beneficiaries – disease management, embedded care managers, frail/home bound with home visiting PCP • Reduce Skilled Nursing Facility Length of Stay – preferred facilities, transparent dashboard , SNF-ists • Provide End of Life care in the most appropriate setting • Reduce overutilization of office based imaging, procedures 14

Other payor contracts for shared savings continue to be negotiated • AETNA • United 15

Medicare Shared Savings Contract Dashboard Q 3 2015 16

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MSSP - PCP Report Card 20

Comparison to other ACO Network Performance Premier benchmarking data 21

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Trend is toward higher cost • FIHN is achieving savings over the 3 -year benchmark, however comparing 2014 to 2015 costs have risen 1. 3% per beneficiary • Highest areas of utilization opportunity in comparison to Milliman Standards for loosely managed populations: Inpatient Laboratory, Outpatient Imaging, Office Procedures • Inpt Admission areas of focus: COPD, Pneumonia • Preference sensitive admissions – PTCA/Angioplasty • Skilled Nursing Facility Length of Stay, specifically admissions over 21 days, FIHN ALOS 27 days. • Part B drug costs – injectables, oral anti-cancer, infused 25

FMH Employee Health Plan 26

3 rd Quarter 2015 Performance 27

Employee Health Plan Measures New for 2016 28

Philosophy Keep measures consistent with MSSP where quality measures/employee health issues overlap Use measures that are not difficult to capture due to issues abstracting from multiple EMRs Do not make the goals so challenging that they are unachievable, keep providers engaged through incentives Help the Employee Health Plan make a difference for our most important resource, our employees/colleagues 29

Employee Health/Utilization Priorities Advanced Imaging Costs Diabetes Depression Coronary Artery Disease Emergency Room Utilization 30

Goals for 2016 High Tech imaging - reduce CT/MRI/PET utilization by 5% ER Visits/1000 - reduce another 5%, still very high compared to Milliman loosely managed standards PQRS/ACO-27, A 1 c poor control – improve this measure by 5% PQRS/ACO- 28, Controlling high blood pressure – improve this measure by 5% ACO 27 and 28 measured by the employee and spouse completing biometric screening lab testing annually. Patient specific information on each measure would be provided to the PCP at the start of the year. 31

Shared Savings Methodology Work 32

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GPRO Reporting to Medicare January – March 2016 Please open your door Work with our abstractors And we’ll complete PQRS together! 34

Abstractors / Reporting Team • Della Benford • Sandy Bair • Doris Baisey Nurse and/or Abstraction / Coding Backgrounds • Joseph Mc. Kinney • Premaris – 3 rd party vendor • Sean Shillinger, Information Services • Aron Fejes, Information Services • Phil Stiff, Information Services • Jean Havrilla, Information Services • Jennifer Teeter, ACO Executive Director 35

Draft High Level Workflow CMS sends patient names FIHN looks for provider affiliation Ec. W or Next. Gen? Other EMR Assigned to FIHN Ec. W Team Assigned to Primaris No No Reporting data found? Yes No EMR Paper Assigned to RN Manual Abstractors Data audited and put into xml file for reporting 36

GPRO Reporting - Process Group Practice Reporting Option • ~3, 000 patient records in our sample file • Jan – Feb: FIHN to come to your practice to ask: • Review charts for measures • OR, to establish remote access to your EHR • Including Premaris • 75% of answers = Next. Gen and e. Clinical. Works • Early-March - Final GPRO upload due to CMS • Successful reporting triggers CMS payment of savings if savings are achieved and avoids PQRS penalty for all FIHN MSSP participants! Your support (expedient access to EMR data) is required! 37

Primary Distribution of Samples Practice MHP PARKVIEW MEDICAL GROUP CENTERS FOR ADVANCED ORTHOPAEDICS or MMI MIDDLETOWN VALLEY FAMILY MEDICINE CARDIOVASCULAR SPECIALISTS OF FREDERICK DR. SAJJAD AZIZ FREDERICK ONCOLOGY HEMATOLOGY ASSOCIATES UNION BRIDGE FAMILY PRACTICE DR. ZAIDI, PRIMARY MEDICAL SERVICES, PC DR. TYRA KANE, INTERNAL MEDICINE SPECIALISTS OF FREDERICK, LLC SIBTE A KAZMI MD LLC X'CEL PRIMARY CARE FREDERICK MEDICAL AND PULMONARY ASSOCIATES CARDIOLOGY ASSOCIATES SYED HAQUE, MD MHP IMMEDIATE CARE FREDERICK GASTROENTEROLOGY ASSOCIATES MHP ORTHOPAEDIC SPECIALISTS OF FREDERICK MHP ONCOLOGY CARE CONSULTANTS # Patients 725 352 293 173 164 151 139 138 110 109 96 88 82 67 60 43 41 40 # Measures 2043 1005 781 543 454 369 355 271 323 312 268 300 185 186 94 141 116 38

Primary Distribution of Samples (cont’d) Practice MHP ENDOCRINE & THYROID SPECIALISTS FMH CENTER FOR ADVANCED WOUND CARE & HYPERBARIC MEDICINE DR. GAFFAR SYED, INTERNAL MEDICINE AND PRIMARY CARE FREDERICK KIDNEY CARE ASSOCIATES FREDERICK CENTER FOR ADVANCED CARDIOLOGY HOSPICE OF FREDERICK COUNTY KIDNEY CENTER OF FREDERICK & HAGERSTOWN MENOCAL FAMILY PRACTICE MARK X. COYNE M. D. , P. A. MHP FREDERICK UROLOGY SPECIALISTS MHP INTERNAL MEDICINE ASSOCIATES UROLOGY CONSULTANTS OF MARYLAND BRANISLAV ROMANIC, MD DAVID KOSSOFF, MD IRFAN HASSEN MD ANUSHA BELANI MD MHP CENTER FOR BREAST CARE MHP SURGICAL SPECIALISTS MHP CENTER FOR CHEST DISEASE # of Patients 36 32 27 27 27 26 23 22 20 19 19 17 16 8 7 7 7 3 2 Measures 119 53 68 93 93 40 58 48 51 58 42 61 68 47 10 21 31 5 5 39

Progress to date capturing ACO Quality Measures from Electronic Medical Records Update 40

Electronic Data • Estimate of electronic opt-in charts found • Next. Gen: 6, 500 • e. Clinical. Works EHR: 1, 300 • TOTAL Attributed 7, 800 % 5 7 10, 800 Other potential sources for charts: • Paper charts & other practices • Meditech • SNF • MMI/CAO 41

What does data show? 2016 Performance efforts may want to focus on: Documenting past results and immunizations And focusing on Diabetic , pre-hypertensive, and Cardiac risk population -- need follow-up -- high number bad 42 Involves both practice and IS resources

Important follow-up • Collect the measures • Put information in the correct/discrete field in your EHR • Collaborate with FIHN IT Analyst Sean Shillinger - free assistance to improve reporting from your EHR FIHN can help your practice improve reporting to PQRS for Medicare and other payors under performance based contracts 43

Medicare Annual Wellness Visits 44

91% of FIHN patients have not had their Annual Wellness Visit Increasing Annual Wellness Visits is an ACO best practice for achieving savings and improving care 45

Annual Wellness Visit Benefits • Catch medical problems early • Collect Quality Measures – improve our PQRS reporting score for next year • ACO Attribution of patients • Revenue for practice • Improve ACO population risk score which increases our benchmark cost, greater savings potential Keep open appointments weekly for scheduling a set number of AWVs, use data collection tools, midlevels 46

PCP meeting planned • February 25, 6: 00 -8: 00 p. m. FMH Crestwood Conference Center • Catered Dinner • Work on Annual Wellness Visit best practice 47

Care Management Update 48

Care Management Patient Engagement Practice Name Attributed Medicare Beneficiaries Patients # of Pts Goal 15% Actice with who (attributed Care MGMT Care decline Beneficiares service Management CM engaged) Care Manager Gaffar A Syed, MD, PA Internal Medicine Specialists of Frederick, LLC (Kane, Tyra) 151 Onsite 29 23 363 Telephonic 30 54 Irfan Hassen, MD 71 Onsite 13 11 TBD 110 Internal Medicine Assoc Leigh Hunter Angels Mills. Ball CM Phone 240 -457 -3314 240 -446 -3066 Diane Tomasky 240 -457 -2590 Angels Mills. Ball 240 -446 -3066 X'cel Primary Care, Dr. Saied Middletown Valley Family Medicine, PA 389 Onsite 50 58 Kim Masser 240 -4457 -2531 1011 Onsite 132 152 240 -457 -3314 Parkview Medical Group 3585 Onsite 313 538 Leigh Hunter Angels Mills. Ball & Beth Downs Union Bridge Family Practice Dr. Zaidi, Primary Medical Services, PC 551 Telephonic 8 83 343 Onsite 43 51 Sajjad Aziz, MD 399 Onsite 1 60 Sibte Kazmi, MD 355 Onsite 53 Kim Masser 240 -457 -2531 Syed Haque, MD 258 Onsite 39 Beth Downs 240 -457 -2433 Total 7476 1121 15% of attributed lives engaged 55 98 27 908 81% of 240 -446 -3066 240 -457 -2433 Diane Tomasky 240 -457 -2590 Kim Masser 240 -457 -2531 Diane Tomasky 240 -457 -2590 49

Care Management Team: • 5 FIHN Care Managers: • Onboarding additional CM to support Internal Medicine Associates • Care Management Coordinator – support funtions • Pharmacist pilot – Parkview Mt. Airy • Engaging beneficiaries: • Provider referrals – visibility makes a difference • Daily hospital activity reports • Handoffs from hospital / ED care management 50

Updates on Priority Focus Areas: • Friday “Tuck-in” Calls • End Stage Renal Disease: • The Coordinating Center – intensive community base care management • Capital Coordinated Medicine: • Home based medical management for the frail and home bound – can manage short/long term • Potomac Case Management: • Intensive home/community based interventions for individuals with a mental health diagnosis • Skilled Nursing Facility Preferred Provider Agreement • Palliative Care consult referral initiative • Advanced Directives and Life Planning 51

What’s next? : • Support quality reporting/data gathering efforts • Transition from Meditech to e. CW - to ensure CM documentation is available in practice based EMR • Health Coach education / certification • Expansion of Heart Bridge Clinic (FMH CARe Clinic) – chronic disease clinic focused on: • Medial Management • Education - Comprehensive disease management for individuals and groups • Care management and community navigation 52

Specialist Follow-up Visits – delays can lead to readmission Neurology Pulmonary Gastroenterology 53

Advance Directives 54

Why Do We Care About ADs? • Reduces unwanted hospitalizations at least once during last six months of life in 72% of the people • Reduces costs of care in last two years of life on average by $79, 000 • Reduces inpatient days in last two years of life by 16. 7 days • Reduces hospital deaths by 25% • Reduces percent of decedents seeing 10 or more different physicians during the last 6 months of life by 42% • Reduces percent of decedents spending 7 or more days in the ICU during last 6 months of life by 15% • Reduces percent of decedents admitted to ICU in which death occurred by 18. 5% The Dartmouth Atlas of Healthcare (2014). Care of chronic illness in the last two years of life.

Most Importantly…. An advance directive gives the patient control over their healthcare and quality of life. It gives them choices!

Advanced Directives “AD” is now in the Summary Section in the EMR “Special Indicators” section of Meditech patient summary screen Summary Section in the EMR Physician List View on their Patient List RN Status Board

Issue: Patients think that the hospital automatically has their Advance Directive if they have shared it with their primary care physician. Recommendation: Sending the Advance Directive to FMH Health Information Management (Medical Records) for filing in Meditech should be part of the office workflow for the FIHN physicians. This way any health care provider is aware of the document and patient’s wishes are honored. 58

How to relay a patient’s Advanced Directive information to FMH for clinicians to view in the patient’s record • Fax to FMH Medical Records: 240 -566 -3619 • Email a scanned copy to: #FMHHIM-Analysts@FMH. org and #FMHHIM-Clerk@FMH. org • FMH intraoffice mail • US postal service mail to: Frederick Regional Health System Medical Records Department 400 West 7 th Street Frederick, MD 21701 See Handout 59

DVT Protocol 60

2016 All Provider Meeting Dates April 13, 2016, 6: 00 -7: 30 p. m. August 10, 2016, 7: 00 -8: 00 a. m. December 14, 2016, 6: 00 -7: 30 p. m. 61