1 / 46

Texas DSRIP Category 3

Texas DSRIP Category 3. February 24, 2014. Summary. Components of Category 3 Valuation Reporting by demonstration year Selecting outcome measures Technical assistance and additional resources Timelines. Components of Category 3. RHP Planning Protocol Framework Outcome measures

irma
Télécharger la présentation

Texas DSRIP Category 3

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Texas DSRIP Category 3 February 24, 2014

  2. Summary • Components of Category 3 • Valuation • Reporting by demonstration year • Selecting outcome measures • Technical assistance and additional resources • Timelines

  3. Components of Category 3 • RHP Planning Protocol • Framework • Outcome measures • Alternate improvement activities • Compendium • Tools (e.g. surveys) appendix • Key information on measures • Measure type (P4P or P4R) • Stand-alone or non-standalone • Measure specifications (definitions for how to report)

  4. Framework • All providers are required to verify or select Category 3 outcome measures for each Category 1 or 2 project. • If you want to keep your originally proposed Category 3 outcomes for a project and they are on the current Category 3 menu, you may do so. • Providers will continue to choose either at least 1 standalone measure or 3 non-standalone measures for each project. • Each measure is designated as Pay for Performance (P4P) or Pay for Reporting (P4R). • A Category 1 or 2 project may have a mix of P4P and P4R measures. • P4P measures are required, if appropriate to the Category 1 or 2 project and provider can meet specification requirements. • If a provider cannot use a P4P measure for a Category 1 or 2 project a P4R measure may be used.

  5. Framework, 2 • Some measures require prior authorization. • All P4R require prior authorization. If you had previously selected the measure for a project, this constitutes prior authorization. • Certain P4P measures are grandfathered for providers that have already selected them for a project, but may not be newly selected. • If a provider needs to use a P4R measure, alternate improvement activities are required in DY 5.

  6. Framework, 3 • All measures, P4P and P4R, must be reported to specifications (any approved modifications are noted in the menu and compendium). • In most cases, denominators will be broader than the patients served in the Category 1 or 2 project. • CMS has allowed providers to tailor denominators to appropriate subsets. • The DSRIP monitoring contractor will verify that providers are conforming to measure specifications.

  7. Framework, 4

  8. Framework, 5 • Decision tree • Review revised Category 3 menu (spreadsheet) to determine the measure(s) that best fits a Category 1 or 2 project. • Is there a P4P measure appropriate to your Cat 1 or 2 project that you can report to specifications? • If YES, select P4P. • If the answer to #2 is NO, select a P4R measure along with an alternate improvement activity • Reporting on achievement related to a population-focused priority measure is the preferred activity, if a provider can report to specifications. • If a provider cannot use a population-focused priority measure, then the provider selects a stretch activity.

  9. Framework, 6 • If your originally proposed Category 3 outcomes for a project are on the revised menu, and you can report them to specifications, you may keep them, but check the revised menu to see if the IT # has changed (and fill in the required info on the Category 3 selection tool).

  10. Framework, 7 • HHSC and CMS will review Category 3 selections to determine: • If a P4P measure could have been selected and/or • If a P4R measure is needed, and the provider selects a stretch activity, whether a population-focused priority measure could be used instead of a stretch activity in DY 5. • HHSC encourages providers to seek technical assistance prior to submitting Category 3 selections regarding which Category 3 measure(s) may fit a Category 1 or 2 project.

  11. Outcome Measures • Key outcome measure information • Organized by outcome domain (OD) • Measure type designated as P4P or P4R; some require PA (Prior Authorization) • Target setting is IOS (Improvement Over Self) or QISMC (Quality Improvement System for Managed Care) methodology if benchmark information is available • Standalone (SA) or Non-standalone (NSA) • Measure specifications (definitions) include: Identical, Modified, or Custom • Appropriate care setting as identified in measure specifications • Benchmark information

  12. Outcome Measures, 2 • Measure specifications are included in the menu in three forms: Identical, Modified, or Custom (as designated by HHSC/CMS) • Identical measures – These measure specifications are included in the Category 3 menu as described by the measure steward. • Modified measures – These measure specifications have been slightly modified to reflect DSRIP provider focus (e.g. HEDIS measures included, with revisions to language describing population [member  patient]). • Custom measures – These measures are based on clinical guidelines and/or standard measurement definitions (e.g. prevalence) and were created to accommodate approved DSRIP projects when there was no existing evidence-based measure available.

  13. Care Settings • Types of care settings include: Ambulatory, Inpatient, Both, Emergency Department • These setting designations describe where and from what types of data the measure is validated for collection. E.g., HbA1c control measure is an ambulatory sensitive measure and is not appropriate for acute hospitalization episodes. All cause readmissions is an inpatient setting measure as the denominator includes all patient discharges and the benchmark reflects this type of data. As such, the measure is not written for collection in the ambulatory setting. • Providers should review the setting designations to make sure the measure setting fits the project setting and/or aligns with the types of data available to the provider.

  14. Target Setting • QISMC methodology • Nationally recognized “Quality Improvement System for Managed Care” • “Hybrid” method: high performance levels (HPLs) are 90th percentile and minimum performance levels (MPLs) are 25th or 10th percentile of state or national benchmarks. • Benchmarks are a “proxy” for performance and may not be an exact match to the population or delivery system. • If baseline is at MPL or above, achievement level is 10% gap reduction between baseline and HPL in DY 4 and 20% in DY 5. • If baseline is below MPL, target is MPL in DY 4 and 10% gap reduction between MPL and HPL in DY 5. • If provider’s baseline is above the HPL, the provider works with HHSC to select a new outcome.

  15. Target Setting, 2 • Improvement Over Self (IOS) • Used for P4P measures without QISMC benchmarks (90th/25th percentiles) • 5% improvement over baseline in DY 4 • 10% improvement over baseline in DY 5 • For all P4P measures (QSMIC and IOS), HHSC will work with CMS on policies for a provider to request lower achievement levels in certain instances. • A provider may request a lower achievement level based on a big difference between the size of the project and the denominator or complexity of project population. • Requests to deviate from the standard achievement levels will occur with DY 3 October reporting; more details will be provided by then.

  16. Alternate Improvement Activities • Used with P4R measures. • P4R requires prior authorization. • 1st option is to select a Population-Focused Priority measure specific to provider type. • If a provider cannot report a Population-Focused Priority measure to specifications, then it may select a “stretch” activity.

  17. Population-Focused Priority Measures • Hospitals – subset of potentially preventable admission and readmission measures (PPAsand PPRs) • Community Mental Health Centers • Academic Health Science Centers • Lists available on HHSC waiver website • http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml • Tailoring of denominators cannot be used for these measures as there is not a specific intervention population. These measures are not tied to a Category 1 or 2 project but are intended to reflect improvement priorities across all of a provider’s DSRIP projects.

  18. Stretch Activities • Link to list: • http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml • The selected stretch activity should relate to the type of P4R measure and/or provider type, such as measure validation or ability to exchange information with other providers in order to report to specifications. • HHSC has specified documentation required for reporting for each stretch activity.

  19. Compendium Content • Detailed measure specifications • Whether measure requires prior authorization • DSRIP approved modifications • Measurement period guidance • Benchmarks

  20. Tools Appendix • Describes additional information about the tools (e.g., surveys) used in the Category 3 menu • Intended populations for use • Administration and scoring guidelines • Validity and reliability testing of the tools (when available) • Resources to obtain the tool and how to request additional information from the tool developer

  21. Valuation • DY 3-5 Category 3 valuation will be determined as follows: • HHSC totals up the provider funds allocated to Category 3 for each DY in DY 3, 4 and 5 and also totals up the provider’s Category 1 and 2 projects. • Each provider decides what percentage of its total Category 3 funds will go toward a given Category 1 or 2 project (this single percentage will be applied to the funds allocated for each DY).

  22. Valuation, 2 • DY 3-5 Category 3 valuation (continued) • Once the provider decides the percentage of its funds to allocate to each Category 1 or 2 project for DY 3-5 for Category 3, based on the number of outcomes selected for that project, HHSC will allocate an equal amount of Category 3 funds to each outcome measure in a given demonstration year • Funding then will be equally distributed between milestones for each measure in a given DY (such as for a P4P measure in DY 4, 50% of the DY 4 funds for that measure will go to reporting and 50% for measure improvement)

  23. Valuation, 3 • Category 3 valuation distribution minimums • Divide the total number of Category 1 and 2 DSRIP projects into 100.  Example: 5 Category 1 and 2 DSRIP projects = 100/5 = 20.  If the provider divides its Category 3 funds equally across the 5 Category 1 or 2 projects, each of those projects would be allocated 20% of its Category 3 funding. • Within the provider selection tool, this equal distribution will be the default allocation displayed. Providers are able to modify this amount as long as the minimum is still met.

  24. Valuation, 4 • Category 3 valuation distribution minimums (continued) • A provider must allocate at least 50% of that “average” Category 3 funding to each Category 1 or 2 project, e.g. 50%*20% = 10%. • Across its 5 Category 1 or 2 projects, in this example, the provider must allocate at least 10% of its Category 3 funds to each Category 1 or 2 project, and in total the percentages allocated across the 5 Category 1 or 2 projects must equal 100%. • CMS encourages providers to consider the relative Category 1 or 2 valuation of each project when deciding the amount of Category 3 funds to allocate to a project. • If a provider has Category 1 or 2 project valuations that vary greatly and needs to go below the minimum % specified in its workbook to have proportional Category 3 valuation, it should contact HHSC to request a revised workbook.

  25. DY 3 Reporting • Two process milestones will be used in DY 3. • 50% of the Category 3 allocation for each outcome measure will be available for April 2014 reporting based on providers submitting a status report. • 50% of the Category 3 allocation will be reported in October 2014 for providers submitting/validating baseline rates – baselines will be reported for both P4P and P4R measures. • A certification will be required with submission of baseline rates from the head quality officer of the provider organization or another executive level officer. This will also be required for DY 4 and 5 reporting.

  26. DY 2 Carry-forward • For those providers that had DY 2 achievement that was carried forward into DY 3, providers will still have to demonstrate that achievement to receive DY 2 payment. • To demonstrate DY 2 achievement, providers will have two options • (Recommended) Submit DY 2 status report in DY 3. Providers will simply fill out DY 2 status report and submit it in addition to the DY3 status report • Document achievement of DY 2 process milestone (e.g., project planning, validation of data systems, etc.) and submit during DY 3 reporting.

  27. DY 4 Reporting • P4P Measures • 50% of funding available to earn for successful reporting to specifications • Carry forward applies • Partial payment does not apply • 50% of funding available for reaching achievement level • Standard performance is 10% with QISMC methodology or 5% IOS over baseline reported in DY 3 October reporting • Carry forward applies • Partial payment applies

  28. DY 4 Reporting, 2 • P4R Measures • 100% of funding available to earn through successful reporting to specifications • Carry forward applies • Partial payment does not apply

  29. DY 5 Reporting • P4P Measures • 100% of funding available for reaching target • Standard performance is 20% with QISMC methodology or 10% IOS over baseline reported in DY 3 October reporting • Carry forward applies • Partial payment applies • Performance target based on % over baseline set by October 2014, not from DY 4 reporting

  30. DY 5 Reporting, 2 • P4R Measures • 50% of funding available to earn through successful reporting to specifications • Carry forward applies, partial payment does not apply • 50% of funding available to earn through alternate improvement activity • Population-focused priority measure is outcome improvement target • 20% achievement with QISMC, 10% IOS over baseline • Carry forward and partial payment apply • Stretch activity is process milestone • Carry forward applies, partial payment does not apply

  31. Category 3 Partial Payment • Providers may receive partial payment for making progress towards, but not fully achieving, an outcome improvement target. The partial payment would equal 25%, 50% or 75% of the achievement value of the outcome improvement target. Based on the progress reported, each outcome improvement target will be categorized as follows to determine the total achievement value percentage: • Full achievement (value = 1) • At least 75 % achievement (value = .75) • At least 50% achievement (value = .5) • At least 25% achievement (value = .25) • Less than 25% achievement (value = 0)

  32. Category 3 Partial Payment, 2 • Example: • Outcome improvement target for 5% IOS in DY 4 and 10% IOS in DY 5 over baseline. • In DY 4, the provider achieved a 3% improvement, short of its goal of 5%. • For partial payment, the provider would be reimbursed 50% of the incentive payment associated with the target, because achievement was 60%. • The performing provider may earn the remaining DY 4 incentive payment in DY 5. • In DY 5, this provider can earn remaining DY 4 funds for reporting additional achievement above 60% (either at least 75% or 100%) as “carry forward.”

  33. Selecting Measures • The provider selection tool will replace the Category 3 narratives in the RHP Plan. Providers will have the opportunity to update the Category 1 or 2 narrative with the updated Category 3 selection. • Providers may select P4R measure(s) only if a P4P measure is not available and a P4R measure is more appropriate for the project. • HHSC must prior authorize use of P4R, which will occur once providers have submitted selected measures. • HHSC will review all P4R measures to determine if a P4P measure could be selected. • For providers already approved by CMS for use of a P4R measure that was on the original Category 3 menu (does not include “Other” measures proposed) for a specific Category 1 or 2 project, that original approval constitutes Prior Authorization.

  34. Selecting Measures, 2 • All providers will either verify measures already selected, change measures previously selected or select measures for those Category 3 projects with a previously to be determined (TBD) designation using the numbering in the revised menu. • Some “Other” outcome measures initially proposed are now on the menu and can be selected. • “Other” outcome measures initially proposed that are not included in the revised Category 3 menu must be replaced. • If a provider had stated during Phase 1 that they would replace or add an additional measure to Patient Satisfaction to maintain valuation, this must be done in March. • Each provider should review its Category 1 or 2 milestones to select Category 3 outcome measures that do not overlap with Category 1 or 2 milestones (providers can request TA from HHSC as needed). If there is a concern around overlap, the provider will have the opportunity to revise its Category 1 or 2 milestones during the next plan modification opportunity (scheduled for this summer).

  35. Selecting Measures, 3 • For OD 6 and 10, it is recommended that providers use these tool measures complemented with another measure, and not as single outcomes. • Some P4P measures that were on the original Category 3 menu are designated for PA because they are not considered the strongest P4P measures. • Providers that originally proposed these measures for a particular project may keep them (grandfathered). • Providers may not newly select these measures for use.

  36. Selecting Measures, 4 • Providers must select for each Category 1 or 2 project at least 1 standalone or 3 non-standalone measures. • Non-standalone measures can cross domains. • In the tool, providers can either choose to keep, delete or replace existing measures as well as add up to 3 additional measures associated with each Category 1 or 2 project. • Providers will have the opportunity to tailor the denominator to reflect a target population that best aligns with the Cat 1 or 2 project through the use of approved denominator subsets. • Appropriate “facility level” populations or subsets can be selected as follows as appropriate to the measure: payer source (Medicaid/indigent), target condition, age, race/ethnicity, gender or facility(ies) where services are delivered.

  37. Selection Tool – Tab 2 • Category 3 Historical Valuation • First section is identifying information and has some cells for providers to populate (yellow cells). • Second section describes historical Category 3 allocation amounts for DY3 – DY5 by Category 1 or 2 project. This is to allow providers to see where the total Category 3 funding was previously allocated. No action needed from providers in this section. • Last section contains detail about the outcomes historically proposed for each Category 1 and 2 project including prior valuation for each Category 3 project and relevant Phase 1 review comments. • Providers will indicate for each Category 1 or 2 project which outcomes they will be retaining, replacing or deleting (yellow cells). • Providers also will have the option to add up to three additional outcomes to the number previously proposed.

  38. Selection Tool - Tab 3 • <Category 1 or 2 project ID> Outcome detail. • Each Category 1 or 2 project has a separate tab for outcome detail that is pre-populated based on the provider’s responses in the first tab. • Brief measure specifications will be populated for each outcome. • Provider will use this tab to: • Provide rationale for outcome selection • Request denominator subsets • Indicate alternate improvement activities for P4R measures • Indicate if there is potential overlap between outcome and Category 1 or 2 project milestones. (HHSC will work with providers to resolve potential overlap issues.) • Indicate baseline availability and proposed measurement period. • Optional forecasting for P4P measures to determine what DY4 and DY5 performance goals may be. **This is just a guide and actual goals will be determined in October based on baseline submissions and final benchmark rates. • Provider will respond to all yellow cells, with the exception of the optional forecasting section, for a complete Category 3 submission.

  39. Selection Tool - Tab 4 • Category 3 valuation • Contains information around the new Category 3 allocations. • Providers will indicate, for each Category 1 or 2 project, what percentage of the total Category 3 amount to allocate to the outcomes associated with that project. • The tool will default with equal allocations to each Cat 1 or 2 project, however, providers may change these percentages, adhering to the minimum requirement of 50% of the average percentage listed. • Contact HHSC to request an exception to this minimum based on Cat 1 / 2 values. • Providers are encouraged to take into account the Category 1 or 2 valuation of each project when deciding Category 3 valuation. • After provider has indicated % allocation, the tool will populate DY 3-5 values for each of the outcomes and milestones associated with the project.

  40. Selection Tool - Tab 5 • Category 3 IGT data • This tab will list current IGT entities for each project as well as allow providers to make any changes to the IGT entities for any of the listed Category 3 projects. Note: All Category 3 projects (current, replacement, and 3-year projects) are included in the selection tool. If a project does not receive CMS approval, HHSC will proportionally adjust the Category 3 funding associated with the provider’s remaining Category 1 or 2 projects.

  41. Selection Tool-Tab 1 • Progress Tracker • Indicator to providers that required fields are populated for each of the tabs within the Selection tool. • Will change to green and state ‘Complete’ when required fields are completed.

  42. Helpful Resources • Provider selection tool - this is how providers will select and HHSC and CMS will review and approve Category 3 outcomes. • Companion - describes the mechanics of Category 3 in greater detail as well as walks providers through the process of selecting outcomes. • Compendium - detailed measure specifications for each outcome. Providers must review these specifications for their selected outcome to determine the appropriate inclusion and exclusion codes for the measure. • Decision tree - visual representation of the outcome selection process. • Risk adjusting document - contains a high level description of risk adjusting methodologies that may be used for the Category 3 outcomes that require risk adjusting. • Denominator one pager - brief description of working with outcome denominators, including denominator subsets and collecting outcomes on intervention populations. • Reporting templates for DY3 - April status report and October baseline report. • Updated RHP Planning Protocol – date TBD. • Updated PFM Protocol – date TBD.

  43. Technical Assistance • For measure specifications, please review compendium information. • The RHP Anchors and provider associations have been involved in the development and mechanics of Category 3. Providers are encouraged to reach out to these groups for assistance. • For assistance with specific tools, provider may wish to reach out to the tool developer - contact info is listed in the tools appendix and compendium. • Providers may also reach out to like provider types to discuss understanding of measure specifications as well as data availability.

  44. Technical Assistance, 2 • Providers may also reach out to the HHSC team through the Waiver mailbox. We ask that providers include “Category 3” in the subject line using following designations so that the emails can be triaged appropriately: • Category 3 – selection tool • Category 3 – select measure(s) to fit Cat 1 or 2 project • Category 3 – population-focused priority measures • Category 3 – stretch activities • Category 3 – achievement methodology • Category 3 – data collection processes • Category 3 – tools/surveys • Category 3 – other • HHSC anticipates a large volume of TA requests, so responses may take several days.

  45. Review Process and Timelines • Provider selection – March 10, 2014 • HHSC’s initial feedback will be specific to measures requiring PA – goal of April 1, 2014 • DY 3 April Reporting – status template will provide information to inform HHSC review and additional feedback will occur as needed • DY 3 October reporting – baselines and any proposed exceptions to standard achievement levels for outcome targets based on guidelines under development. DY4 and DY5 performance goals will also be determined at this time.

  46. Contact information • Find updated materials: • http://www.hhsc.state.tx.us/1115-waiver.shtml • Submit questions to: • TXHealthcareTransformation@hhsc.state.tx.us

More Related