Surviving New Payment Models and New Performance Measures Tom Simmer, M.D. Chief Medical Officer, BCBSM June 7, 2017

High Value Acronyms (Abbreviated List of Abbreviations) CPC+ Comprehensive Primary Care Plus SIM State Innovation Model MACRA Medicare Access and CHIP Reauthorization Act MIPS Merit-based Incentive Payment System APMs Advanced Payment Models AAPM Advanced Alternative Payment Model ACO Accountable Care Organization MSSP Medicare Shared Savings Program (ACO)

Recommendations for Practitioners Forget the details, or—better yet---don’t bother to learn them. Work with an organization that keeps up with it, but avoid micromanaging practice processes to fit each program. Meeting payer ‘quality score’ performance expectations is primarily a process challenge— assuring that each patient consistently receives routinely recommended services and managing information flow. Meeting payer ‘cost of care’ performance relies on judicious decisions, thoughtful referrals, and implementing a pro-active care process.

Quality Score Performance Many measures rely on claims data supplemented by EMR information. Newer measures rely on laboratory results and information from the EMR. Identify your “panel” and keep up with the Active Care Relationship Service (ACRS) Implement “registry” functionality---a list of your patients with routine recommendations for care managed by office staff authorized to implement standing medical orders. Create a supplemental data and outreach process, preferably a continuous process instead of a catch up frenzy during the 4th Quarter. Generally, the work rests with the office manager and the medical assistant who own the process of gathering the information, carrying through on standing orders, and tracking patients with potential gaps.

Cost Performance Cost of care generally includes all the medical services provided to your patients in any setting of care. Hospital and Emergency Department services are managed through follow up to ADT messages that your practices should be receiving real-time. Generic prescribing is a given. Avoid facility based laboratory, imaging and ambulatory surgical procedures whenever possible. Employ a team-based pro-active care model.

The Chronic Care Model Patient role changes from passive user of services to an informed, activated health steward. Patient Centered Teams care for patients across time and settings of care. (4) The goal is not a compliant patient. The goal is an engaged and activated. PCMH has been shown to improve quality and decrease costs.(1,3) It frequently has to be facilitated for real transformation to occur. (2)

Summary Most payers have unique quality and cost programs and practitioners should have a familiarity with their programs. Practices should undertake cost and quality performance using consistent processes throughout the year. There should not be a different process for each payer. Quality performance relies on ACRS, panel-wide information on recommended services available at the time of service, and supplemental information supplied in coordination with MiHIN. Cost performance relies on ACRS, ADT, Medication Reconciliation and a pro-active, team based approach to care. Focus on generic prescribing, judicious referral, and reducing ED and hospitalization for patient population.

Contact Information Tom Simmer, MD Senior Vice President and Chief Medical Officer Blue Cross Blue Shield of Michigan 600 E. Lafayette Blvd Detroit, MI 48226-2998 tsimmer@bcbsm.com