Winter 2019 Newsletter
- Overview of Anthem and United Contracts
- Quality Payment Program: MIPS Exception Applications due December 31
- Care Coordination: Why and How to Refer
- Check Out the New Provider Portal and Help the Community!
- Is Your Practice Info Current?
- New Hypertension Management Campaign Supports Ambulatory Quality Goal
Overview of Anthem and United Contracts
SJQCN is now contracted in two different value-based agreements (VBAs). VBAs are the foundation of our clinically integrated network’s managed care strategy and provide the opportunity to demonstrate quality and cost effectiveness, while sharing in the cost savings with the payer. The goal of all our agreements is to improve the quality of the members’ care while reducing the total cost of their health care.
If we reduce the total cost of care for our attributed patients, there is an opportunity for shared savings. There is no downside risk with any of these contracts. Our newest contract with United Healthcare recently kicked off in October and is very similar to our existing Anthem agreement.
As a reminder, many of you in SJQCN’s clinically integrated network already had existing contracts in place with these payers prior to the formation of SJQCN. Those contracts are not impacted by SJQCN’s negotiations unless you actively work with the payer to opt into SJQCN’s contract.
Here’s what you need to know about these contracts:
- PPO accountable care organization (ACO) with United Healthcare that kicked off in October.
- Attribution is based on claims.
- Quality gate and cost targets impact shared savings.
- You should have received a list of your attributed members to review with a request to address any outstanding care opportunities or allow our Care Coordination team to reach out to them.
- United Healthcare has provided an opportunity for SJQCN providers to receive an additional Quality Bonus based on the quality measures listed below:
|Breast Cancer Screening||Women 50-74 years of age who had a mammogram to screen for breast cancer in the past two years|
|Cervical Cancer Screening||Women who were screened for cervical cancer using either of the three years or age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every five years|
|Colorectal Cancer Screening||Patients who had appropriate screening for colorectal cancer|
- PPO accountable care organization (ACO) with Anthem was effective Jan. 1, 2019.
- Attribution is based on claims.
- Quality gate minimum threshold of 50% must be met for the network to achieve shared savings.
- In September, PCPs should have received a list of your attributed members to review with a request to address any outstanding care opportunities or allow our Care Coordination team to reach out to them.
ANTHEM BLUE CROSS PPO ACO: Quality Measures
|Medication Adherence: Statins||NQF 0541|
|Urine Protein Screening||NQF 0062|
|Hba1c Testing||NQF 0057|
|Imaging for Low Back Pain||NQF 0052|
|Asthma Medication Ratio||NQF 1799|
|Appropriate Treatment for Adults with Acute Bronchitis||NQF 0058|
|Appropriate Testing for Children with Pharyngitis||NQF 0002|
|Appropriate Treatment for Children with URI||NQF 0069|
|Childhood Immunization – MMR||NQF 0038|
|Childhood Immunization – VZV||NQF 0038|
|Well Child ages 0-15 months||NQF 1392|
|Well Child ages 3-6 years||NQF 1516|
|Chlamydia Screening||NQF 0033|
|Breast Cancer Screening||NQF 2372|
|Cervical Cancer Screening||NQF 0032|
|Potential Avoidable ER Visits||–|
|Brand Formulary Compliance Rate||–|
If you have any questions or would like more information about these agreements, please contact Susan Rutherford, Quality Management Nurse, at (209) 956-4415.
Quality Payment Program: MIPS Exception Applications due December 31
If you are interested in applying for a Promoting Interoperability Hardship Exception or Extreme and Uncontrollable Circumstances Exception for the 2019 Performance Year of the Merit-based Incentive Payment System (MIPS), you must submit your application by Dec. 31.
If you feel you qualify for an exception this year:
- If new exception: Submit an application prior to Dec. 31.
- If filed for an exception last year: Check your status on the QPP website using your NPI number
- If the exception is still valid, you do not have to do anything else.
- If the exception is no longer valid: Submit a new application if you feel the exception is still warranted.
MIPS-eligible clinicians, groups and virtual groups may submit a Promoting Interoperability Hardship Exception Application citing one of the following specified reasons:
- You’re a small practice.
- You have decertified EHR technology.
- You have insufficient internet connectivity.
- You face extreme and uncontrollable circumstances such as disaster, practice closure, severe financial distress or vendor issues.
- You lack control over the availability of CEHRT.
If you’re already exempt from submitting Promoting Interoperability, you do not need to apply for this application.
For more information:
- Exceptions FAQs
- Automatic Extreme and Uncontrollable Circumstances Policy Fact Sheet: Learn who automatically receives the exception
- Contact QPP@cms.hhs.gov or 866-288-8292 (TTY: 877-715-6222)
Care Coordination: Why and How to Refer
Many types of patients can benefit from Care Coordination, which strives to meet the comprehensive medical, behavioral health and psychosocial needs of each individual patient while promoting high-quality care and cost effective outcomes.
To help you care for complex patients, the Care Coordination team is taking a proactive approach, reviewing daily reports on high utilizers and high-risk patients — in particular, patients with three or more ED visits in a six-month period, patients who are readmitted within 30 days, any hospital admissions and those with certain chronic diseases as their chief complaint(s).
In these cases, the team screens to determine the patient’s need for Care Coordination, reviewing the patient’s medical chart as well as available information on their social determinants of health. They will reach out to the patient — with communication to the primary care physician as well — to explain the Care Coordination program and invite them to enroll.
Patients may also self-refer to the program, and as a physician, you may recommend that they enroll in Care Coordination. To refer a patient, simply call (209) 956-4422.
Better Understand Care Coordination
You can find the Care Coordination Toolkit and additional information on the secure Provider Portal under Network Highlights. These materials will help you and your staff better understand the services provided by Care Coordination and their importance in improving patient health and satisfaction.
Plus, be sure to send patients to the SJQCN website to learn more as well.
To refer a patient to Care Coordination, call (209) 956-4422.
Check Out the New Provider Portal and Help the Community!
The new SJQCN website includes an updated Provider Portal that’s easier to navigate and contains enhanced features.
Now is the perfect time to explore the portal, too, because for every new profile created on the Provider Portal between Dec. 16 and Jan. 17 (physician, nurse, office manager), we will donate to the local 211 organization. 211 connects millions of Americans to social services, resources and information to address needs from housing instability to food insecurity to crisis.
Here’s what you need to do to help 211 and take advantage of the benefits of the Provider Portal.
- Log in at https://secure.sjqcn.org/login.aspx. (This can be found under the SJQCN Physicians tab at www.sjqcn.org.)
- Create an account
In the Provider Portal, you can access secure documents, tools and resources, including:
|Provider Portal (Login-only Access)|
|Search Tools||Physician List|
|Conical Integration Tools||Athena Health Info Exchange|
|Provider Practice Data||Coming Soon|
Care Coordination Request
|Provider Resources||Clinical Spotlight
|News, Events & Communications||Archived Physician Emails
News & Announcements
|ACO Information||Contact ACO/Help Desk
Is Your Practice Info Current?
Please remember to notify us of any practice changes (new providers, providers leaving, etc.).
Contact Susan Rutherford, Quality Management Nurse, at (209) 956-4415 with updates.
New Hypertension Management Campaign Supports Ambulatory Quality Goal
For the first time ever, an ambulatory quality measure will be included as part of the FY2020 CommonSpirit National Clinical Goals. Tasked with identifying a meaningful ambulatory measure that is capable of being shared and measured across CommonSpirit Health, a team of clinicians and quality leaders convened and selected control of hypertension for patients aged 18-85 to maintain blood pressure at less than 140 systolic less than 90 diastolic.
Better control of blood pressure has been shown to significantly reduce the probability of downstream sequelae. In clinical trials, antihypertensive therapy has been associated with reductions in stroke incidence (35-40%), myocardial infarction (20-25%) and heart failure (>50%).
To support this goal, the Physician Enterprise Ambulatory Quality Council has developed a campaign centered on hypertension management. The initiative will include a variety of communications that provide context and clarity regarding how the goal was determined, how it will be measured and reported on and how CINs can help further these efforts.
In addition, a number of resources and tools are available, including but not limited to:
- Evidence-based information for provider and staff education and communication
- Improvement strategies with supporting tools
- Collaborative activities to share and scale best practices
Recently released resources include a Hypertension Management Toolkit, Hypertension Management Ambulatory Quality Measure FAQs and hypertension-related updates to the Clinical Resource Guide. Check out all of the materials on our SharePoint page, and learn more about the hypertension goal on our FAQ page.
The slide deck from our recent Hypertension Town Hall is now available on the secure provider portal. During the call, we discussed hypertension as our first national ambulatory clinical goal and provided an overview of the national measure as well as our enterprise baseline performance and HTN management improvement strategies. If you missed the Town Hall or if you wanted to review anything from the meeting, download the slides today.