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Centers for Medicare & Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration Lynn Riley, MSN, MA, RN, Director, Div. Health Promotion, CMMI, Centers for Medicare & Medicaid

  1. Centers for Medicare & Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice (APCP) Demonstration Lynn Riley, MSN, MA, RN, Director, Div. Health Promotion, CMMI, Centers for Medicare & Medicaid Services Suma Nair, MS, RD, Director, Bureau of Primary Health Care Health Resources Services Administration

  2. Goals of the Demonstration • Transform Primary Care Practice • 90% of participating FQHCs achieve Level 3 PCMH recognition through NCQA by the end of the demonstration 2

  3. Purpose • The purpose of the demonstration is to determine the value of providing financial and technical assistance to selected cohort of FQHCs in achieving Level 3 PCMH recognition through NCQA • The demonstration is a research project designed by CMS to examine the causes and effects of practice transformation 3

  4. Expectations • Change will occur • Participants will remain in the demonstration for the duration • Participants will cooperate with the evaluation contractor (may involve providing additional data) • Participants will comply with stated Terms and Conditions 4

  5. Expectations • Participants complete semi-annual Readiness Assessments Survey Update timely • Participants will comply with terms of random audits, if required • Participants will achieve Level 3 PCMH recognition through NCQA by the end of the third year of the demonstration 5

  6. Health Resources Services Administration (HRSA) Role in Medicare FQHC APCP Demonstration • HRSA supports the Medicare FQHC APCP Medical Home (MH) demonstration • Participating FQHCs will be supported in the transformation process • Ongoing conversations with colleagues at CMS to ensure maximum success for the FQHCs 6

  7. Payment • Quarterly prospective payment ($18 per quarter) per attributed beneficiary (over and above all-inclusive payments • Paid automatically (without a claim) via EFT through National Government Services (NGS) • Not a true per-member-per-month (PMPM) but rather an estimated payment for the Fee-For-Service (FFS) Medicare beneficiaries seen 7

  8. Payment (cont.) • Attribution is based on look-back of previous year Part A claims • No retroactive adjustments will be made (+/-) • Quarterly Payment Report will show the total number of beneficiaries attributed and for whom FQHCs were paid, as well as the number of beneficiaries dropped since the last quarter (i.e., died, went to Medicare Advantage) 8

  9. Quarterly Care Management Fee Payment Schedule Pmt # Svcs From Date Svcs To Date 1 11/1/2011 1/31/2012 2 2/1/2012 4/30/2012 3 5/1/2012 7/31/2012 4 8/1/2012 10/31/2012 5 11/1/2012 1/31/2013 6 2/1/2013 4/30/2013 7 5/1/2013 7/31/2013 8 8/1/2013 10/31/2013 9 11/1/2013 1/31/2014 10 2/1/2014 4/30/2014 11 5/1/2014 7/31/2014 12 8/1/2014 10/31/2014 9

  10. Monitoring Activities • CMS will monitor the progress of participating practices toward Level 3 PCMH recognition • Monitoring Activities will include: 1. Readiness Assessment Survey Updates 2. Random Audits 3. Feedback from CMS 4. Update of FQHC information 10

  11. 1. Readiness Assessment • NCQA 2011 PCMH Readiness Assessment Survey will be used to monitor FQHC progress • FQHCs are required to update their Readiness Assessment Survey every six months; the first deadline is May 1, 2012 • FQHCs must review and update responses to all survey elements and conduct medical record abstraction to complete “Comment Needed” fields for elements 3C, 3D, 4A 11

  12. 1. Readiness Assessment (cont.) • FQHCs will use the same NCQA 2011 PCMH Survey Tool they used for the application • NCQA will work with practices to confirm the survey license that will be used for this demonstration • NCQA will also work with sites that are part of multiple site FQHCs to transition to the Corporate Survey Tool, if appropriate 12

  13. 1. Readiness Assessment (cont.) • Upcoming Readiness Assessment Survey Update Deadlines – May 1, 2012 – November 1, 2012 – Other Dates TBD • Failure to complete update by deadline jeopardizes continued participation in the demonstration 13

  14. 2. Random Audits • Ten percent of FQHC participants will be randomly selected for audit after each Readiness Assessment Survey Update  First audit: May 2012 • FQHCs will be notified of the survey elements that are subject to audit, as well as the documentation necessary to substantiate results 14

  15. 2. Random Audits (cont.) • If selected for an audit, your site will: – Receive an email outlining next steps – Gather documentation to substantiate survey responses to specific elements – Upload documentation to NCQA via a secure portal within the specified timeframe • NCQA will review documentation provided • Results of the audit will be provided to the FQHC 15

  16. 3. Feedback from CMS • CMS will provide participating FQHCs with Feedback Reports including: – Changes in survey scores – Survey scores compared to other participants – Claims-based cost and utilization data on attributed-Medicare beneficiaries (quarterly) 16

  17. 4. How to Update FQHC Information • Update contact name/email, practice site address(es), and list of physicians via NCQA Application portal: https://recognitionportal.ncqa.org/rponlineapp/login.aspx • Will be reminded to update information • Contact Thomson Reuters if your FQHC closes, merges, or wants to discontinue participation: FQHC.MedicalHome@thomsonreuters.com 17

  18. Technical Assistance and Applying for PCMH Recognition • The next series of slides will review: – Demonstration Technical Assistance – Applying for formal PCMH Recognition – PCMH Survey Tool Scoring and Review Process 18

  19. Technical Assistance (cont.) • Mock Surveys – No decisions will be made on mock surveys – Provides extensive feedback on documentation and self-assessment – Provides an opportunity to have your documentation reviewed – Site can request a mock survey • Also working with PCAs to provide service 19

  20. PCMH Recognition • FQHCs will achieve Level 3 PCMH recognition by the end of the demonstration – FQHC determines timing – Six-month Readiness Assessment Survey Updates are required regardless of recognition status 20

  21. PCMH Recognition (cont.) • How to initiate the Recognition process: – Update/Submit Pre-Populated Application for Recognition – Attach supporting documentation to Survey Tool – Submit PCMH Survey Tool to NCQA 21

  22. PCMH Survey Tool Scoring • Reviewer assesses responses/documentation – Provides notes about assessment for each element • Executive Review by NCQA staff • Final Review by Recognition Oversight Committee – Physician peer-review panel • Entire process takes 30 – 60 days – Current average is 43 days 22

  23. Technical Assistance Practice Transformation Aim of the Technical Assistance / Learning System: • To support FQHCs in primary care transformation to PCMH, with NCQA Level 3 recognition as the primary metric. 23

  24. Technical Assistance Practice Transformation 1. Align with and support existing work in PCMH and primary care transformation 2. Work with those the FQHCs look to for support (i.e. PCAs and HCCNs, others as FQHCs indicate) 3. Measure to guide the work of transformation and improvement and inform the TA / Learning System 4. Guided by experts in the FQHC world and in the world of primary care transformation 5. Learn from each other and from experts in the Health Center world 24

  25. Technical Assistance Practice Transformation • Development of the TA / Learning System • CMS Innovation Center – Program / Rapid Cycle Evaluation / Learning and Diffusion Group • American Institutes for Research (AIR) – CMS contractor supporting Technical Assistance / Learning Systems • HRSA 25

  26. Evaluation Purpose • To assess the effects of the advanced primary care model on access, quality and cost of care provided to Medicare and Medicaid beneficiaries served by FQHCs • To study the process and challenges involved in transforming FQHCs into APCPs 26

  27. Data Collection Activities • FQHCs will be expected to participate in data collection activities for evaluation purposes – Complete NCQA’s PCMH Readiness Assessment Survey update (every six months) – Clinician and staff survey (year 3) – Interviews with practice leaders of 30 FQHCs (years 1&3) – Site visits to five FQHCs (year 3) 27

  28. Data Collection Activities • Medicare and Medicaid beneficiaries attributed to FQHCs also will be asked to participate in data collection activities for evaluation purposes – Patient experience survey (years 1 & 3) – Focus groups with Medicare and Medicaid patients and their caregivers (year 3) 28

  29. Key Contacts Questions and Assistance CMS: Demonstration design and participation • FQHC_MH_Demo@cms.hhs.gov NCQA: PCMH Survey Tool technical assistance • PCMH-GRIP@ncqa.org Thomson Reuters: Other inquiries • FQHC.MedicalHome@thomsonreuters.com 29

  30. Demonstration Websites CMS Demonstration website: http://innovations.cms.gov/areas-of-focus/seamless-and- coordinated-care-models/fqhc/ Public Demonstration website: www.FQHCMedicalHome.com NCQA PCMH Government Recognition Initiative website: http://www.ncqa.org/gri 30

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