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	James L. Holly, M.D.

About SETMA Joint Commission Contact Information History Mission Statement Medical Home Scope of Services I-CARE Initiative Infusion Center The SETMA Way - What is it? SETMA's Model of Care Patient-Centered Medical Home The SETMA Approach to Patient Care	In The News Letters Vital Signs - Examiner Publication SETMA's Providers as of January, 2015 SETMA Knows - Abraham Lincoln and Healthcare Analytics SETMA – 1999 – Four Seminal Events PC-PCC Award January, 2015 Vital Signs Spring 2015 Vital Signs Q&A for PC-PCC Award Links to SETMA 2012 eHealth Innovator Award for LESS initiative Handout for Attendees eHealth Conference January 12, 2012 eHealth Initiative 2012 Award Program Application The eHealth Initiative's 2012 Award Letter 2012 National Quality Forum National Healthcare Improvement Award Effective prioritization of performance improvement goals Dashboard to Measure and Manage Whole System Performance Commitment to transparency Date-driven improvement of NQS priorities Demonstration of readiness to assume responsibilities of an ACO Demonstrated results on publicly reported performance measures Public Reporting Quality Metrics for 2009, 2010, 2011 Internally Tracked Reporting Quality Metrics for 2009, 2010, 2011 Complete Application in PDF Format SETMA's Medical Home Pilgrimage 2009 Medical Home Series I 2010 Medical Home Series II 2011 Medical Home Series Two 2009, 2010, 2011 Medical Home Miscellaneous Articles The Dr. and Mrs. James L. Holly Distinguished Professorship Universal American Letter of Transmittal for Support Dr. Holly's Acceptance Address for the 2012 Distinguished Alumnus Award CMS Medical Home Feedback Report Qualify & Cost SETMA questions Influenza Data SETMA I - October 2011 SETMA II - October 2011 Mark A. Wilson Clinic SETMA West - October 2011 SETMA and Fox 4 News - Healthy Living Videos SETMA Advertisements - Display and Video SETMA Announcements Featured Content Archive	Syllabus PC-MH Externship SETMA's MS4 Patient-Center Medical Home Selective Syllabus Introduction to SETMA's Senior Externship and Syllabus An Introduction to the Origins and Beginnings of Southeast Texas Medical Associates, LLP Patient-Centered Communication PC-MH Health Affairs August 15, 2013 Policy Brief -- Health Gap SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement SETMA Provider Training 8.20.13 during First Senior Medical Student PC-MH Externship Medical Home Coordination Review Tutorial 2011 Medical Home Series Two Teaching Tool for PC-MH Course - Patient Care Activation, Engagement, Shared-Decision Making	Patient Information What Does Patient-Centered Medical Home Mean to You? What Does Patient-Centered Medical Home Mean to You? Health information exchange Patient Rights and Responsibilities Patient Directions Contact SETMA – Secure Texting What is HIPAA? Authorization To Release or Obtain Medical Records Complete Privacy Policy Website Privacy Policy	Presentations Invited Presentations SETMA Provider Training
Governance Board Governance Board Responsibilities Governance Board Leadership Training The SETMA Team and The SETMA Culture SETMA's Mission, Vision and Goals: Patient Safety and Quality Care Harassment, Neglect, Abuse, Exploitation - Role of HCAHPS & CAHPS Healthcare Provider Standards Providers Responsibility Medication Refills, Reconciliation and Maintenance Provider and Leadership Use of Data and Analytics Commitment To All Patients -- Ethnic Disparities Kaizen - Board Creates Culture of Safety and Quality SETMA's Policy and Practice for Advanced Directives SETMA's Policy on Completion of Medical Records Care Guidelines : Improve processes to evaluate and treat Integrated patient safety program (Sentinel Events) Effectively Manages all programs, services or sites Provides Patients with information about Primary-care Medical Home Organization-wide Planning to Maintain Focus on safety and quality Organization-wide Planning to Maintain Focus on safety and quality SETMA's Performance Quality & Safety Judged by CMS SETMA's Performance Quality & Safety Judged by CMS SETMA Awarded by HIMSS for Quality and Safety 2011 John M. Eisenberg Patient Safety and Quality Awards Application Healthcare Quality Award 2012 Principles of Quality and Metrics Principles Contacting SETMA & Secure Texting PC-MH Mission, Vision, Goal, Access, End-of-Life Communications and Public Reporting Change Existing Processes to Improve Performance Team Members Focused on Safety and Quality	Your Life Your Health View Articles by Subject Aging Well Behavioral Health Cardiovascular Disease Risk Care Coordination Care Transitions Children's Health COGNOS Project Diabetes Exercise Healthcare Reform:Public Policy HIPAA & Security Labor Day Less Initiative Medical Home Medical Records Men's Health Mental Health Nutraceuticals Nutrition Smoking Cessation Thanksgiving Weight Management Women's Health All Articles	Public Reporting Public Reports by Year (2009-2017) Public Reports by Type Fall Risk, Pain, Functional, Wellness, Stress Assessment Fall Risk, Pain, Functional, Wellness, Stress Assessment for 2011 AND 2012 Core Measures: SETMA & Baptist Hospital Core Measures for January to December 2011 PQRS Diabetes Measures - Blood Pressure Diabetes Measures - Glyco and LDL Diabetes Measures - Nephropathy Screening, Foot Exam, and Eye Exam Preventive Measures - Screening (BMI, Colorectal Cancer, Mammography, Osteoporosis) Preventive Measures - Influenza, Pneumococcal, Urinary Incontinence Preventive Measures - Tobacco Use NQF Care for Older Adults Comprehensive CHF Care Diabetes Measures Diabetes Measures - Blood Pressure Control Diabetes Measures - Glyco and LDL Diabetes Measures - Smoking Cessation Female Measures General Health Measures Medication Measures Persistent Medications Medication Measures Pediatric Measures HEDIS (NCQA) Effectiveness of Acute Care Effectiveness of Chronic Care - Clinic/Hospital Effectiveness of Chronic Care - Clinic Only Effectiveness of Chronic Care - Diabetes (Smoking Cessation) Effectiveness of Chronic Care - Diabetes (Glyco and LDL) Effectiveness of Chronic Care - Diabetes (Blood Pressure Control) Effectiveness of Preventive Care Effectiveness of Preventive Care - Older Adults Effectiveness of Chronic Care - Diabetes Measures Effectiveness of Chronic Care - Persistent Medications (MPM) NCQA Diabetes Recognition Program Audit LESS Initiative PCPI PCPI Hypertension PCPI Diabetes PCPI Chronic Stable Angina PCPI Care Transitions PCPI CHF PCPI Weight Management PCPI CKD Stages IV V SETMA Lipid Audit Lipids Treatment Audit Tutorial Lipids Tutorial AQA COGNOS Project SETMA Audit for CKD Stages I III Patient Satisfaction Survey	Accreditations/Awards Achievements which have Advanced SETMA: The Time-line, Philosophy and Principles which Underlie that Advancement Awards	Diabetes Center of Excellence Education Diabetes Order Referral Form Seven Stations 2011 Advances in Diabetes Diabetes Tutorial Diabetes Prevention
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A Tutorial for Utilizing SETMA's Deployment of the STARS MA Program Specialized Tools Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Association of Medication & Diagnosis Chronic Conditions Tutorial Chronic Care Management Code (CCM) Tutorial Depression Tutorial Drug Interactions Tutorial Electronic Tickler File Tutorial Evaluation Lower Urinary Tract Symptoms in the Male Fall Risk Tutorial Future Labs Tutorial Hydration Assessment Tutorial HCC Risk Training Tool Hypertension: Fulfilling Quality Metrics for the PCPI Program Laboratory Results - Signing Off: Why and How Medication Module Tutorial Medication Reconciliation Tutorial Nutrition Tutorial Pain Management Tutorial Problem List Reconciliation Tutorial Progression to Type 2 Diabetes Referral Skin Care Tutorial SOAAP Opioid Risk Assessment Stratifying End-of-Life Risk for Hospice Services Tutorial Texas State Reportable Infectious Diseases Tutorial Transitions of Care Management Coding (TCM Code) Tutorial	Transforming Your Practice Library Introduction to SETMA's TCPI Library Transforming Your Practice (TCPI) Summary Document of TCPI CMS Quality 12.2015 TCPI Leadership and Governance Care Coordination HIPPA and Security Data Analytics Care Transitions LESS Initiative Medical Records Clinical Decision Support Hospital Care Tools Disease Management Tools Preventive Health Tools Behavioral Health Transformation Tools New Transformation Tools Patient-Centric Care Nursing Home Medical Home Display and Explanation of SETMA's Patient-Centered Medical Home Tools	Medical Home The Story and the Ideals Introduction to Preventive Health Tools PC-MH Patient Engagement & Alternative Payment Models Preventive Care: The Best Way to Treat Illness is Don’t Get it Coordination of Care Patient-Centric Care Population Health Transition of Care - One form of Care Coordination HCAHPS - Hospital Consumer Assessment Of Healthcare Providers and Systems CAHPS - Consumer Assessment of Health Care Provider and Systems Teaching Tool for PC-MH Course – Patient Care Activation, Engagement, Shared-Decision Making Display & Explanation of PC-MH Tools SETMA's Medical Home Pilgrimage Concierge Medicine not Medical Home Medical Neighborhood Security & HIPPA Referrals Patient Web Portal Health Information Exchange Medication Reconciliation The Automated Team Coordination of Care Medical Home Description & Standards AAAHC Joint Commission NCQA Planetree URAC NCQA Interview February 14, 2014	Facebook	Letters

Letters - The Requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

The Requirements of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) which is the basisfor the Merit-Based Incentive
Payment System (MIPS) SETMA’s Analysis of and Preparation for MIPS And CMS’s Assessment of SETMA’s Past Performance

A Brief Overview of the MIPS: Scoring System - Effective for 2019 Payments Based on 2017 Provider Performance

A Detailed Review of MACRA and MIPS

SETMA’s Medicare Fee-for-service Results of CMS Quality Resource Utilization Report (QRUR) for the First Half of 2015

MACRA and MIPS: An Analysis of the Final QRUR for the Full Year 2015

The second document under number three is the finalized 2015 Quality Resource and Utilization Report (QRUR) for SETMA. This was released September 27, 2016. In 2014 our Quality Composite Score was 0.18 and increased to 0.30 for 2015. This represents an increase in our quality performance. We have designed a tool described below which should enable us to improve this score significantly. Our goal is to at least exceed one deviation above the mean.

In 2014 our Cost Composite Score was 0.47 and increased to 0.57 for 2015. This represents a deterioration in our cost performance. We have designed tools for helping us decrease our rate of admissions which should improve our overall coast performance in 2017. Our goal is to get at least down to the mean on cost.

We still fall within the “Average Cost” and “Average Quality” categories which means we will see no change in our Medicare reimbursement in 2017.
In the following material there is additional analysis of how we can improve our performance and description of two new tools which will support that improvement:

This link is to SETMA’s tutorial for how to refer patients to our outpatient infusion clinic because we have close to 2,000 long-term residential care patients, many get sent to the hospital for urinary tract infections, bacterial pneumonia and dehydration making our rate of admission and ultimately our cost for these conditions to be higher than the benchmark. The infusion center can help us decrease those admissions

Outpatient Infusion Center for Intravenous Antibiotic Therapy and Other Meds

The following link is to SETMA’s tutorial for SETMA’s Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial. This tutorial. The function described in this tutorial will allow SETMA’s providers to efficiently meet the metric standards. SETMA’s performance as seen in the 2015 Final GRUR above is very good but our goal is for all metrics to be at least above one standard deviation from the mean.

SETMA's Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial

SETMA’s Prescient Preparation for MACRA and MIPS As Of September, 2016

Four Categories of MIPS’s Scoring System

An Analysis of SETMA’s QRUR report for the first half of 2015 (link number three above) gives us direction for how to improve our performance in 2017. 2916 data will be analyzed by CMS in 2018 to determine healthcare providers “Composite Performance Score” (CPS). The analysis of our QRUR report shows SETMA’s performance on the four categories (Quality, Cost/Resources Utilization, Advancing Care Information -- MU, Clinical Practice Improvement Activities -- PC-MH) of the MIPS Scoring System are:

Quality, represents 50% of the MIPS “Composite Performance Score,” quality is the residual of the PQRI and PQRS programs:

SETMA’s Use of Quality Metrics 1998-2016

Clinical Quality Measures (CQM) - Part of the Future of Healthcare PQRI and PQRS - Part of the Past which Created the Future

SETMA’s Performance is shown on a “scatter plot” which reflects that for 2014 we had average quality and average cost

MIPS September 2016 Advanced Care Information (MU) & Clinical Practice Improvement (PC-MH)

Quality Also is Reflected by Outcomes Measures in SETMA’s QRUR’s “Calculated Quality Outcome Measure Performance.” SETMA is shown to have a high rate of admissions per thousand patients in three categories: bacterial pneumonia, urinary tract infection, dehydration. The following addresses why we think this is the case for SETMA and the steps of action, we will take to improve our performance. The major cause of this result is that SETMA treats almost 1700 patients in long-term-residential-care where these diagnoses are frequent.

MIPS September, 2016 Nursing Home Population - Pneumonia, Urinary Tract Infection, Dehydration

Cost/Resources Utilization - Cost/Resource Utilization contributes 10% to the MIPS Score -- SETMA’s Resources Utilization high in Emergency Room Utilization and in Post-Acute Care

What is Post Acute Care?

The below Exhibit from SETMA’s QRUR shows that in ten categories our cost is below the benchmark which is considered positive and in four categories it is high. However, it is never however than .48 of a standard deviation and it is never high in a category which would reflect that resources are being used for the financial advantage of the healthcare providers. SETMA has put into place processes for improving resource utilization in the ER and in Post-Acute Care.

Advanced Care Information - category of the MIPS’ Scoring System is based on electronic patient records and reflects the values and functions of the standards previously known as Meaningful Use. This category is valued at 25% of the MIPS Score. SETMA meets all of the parts of this category of MIPS’s Scoring.

MACRA MIPS Where Does SETMA Stand

Clinic Practice Improvement Activities - this category is valued at 15% and is fully met by a practice being recognized by NCQA as a Tier 3 Medical Home. SETMA’s PC-MH recognition by NCQA has been the highest from 2010-2019.

Summary by standard deviation for quality and cost and by scatter plot and MIPS assessment of payment for 2014 data

The following is the scatter plot for SETMA’s Performance for the full year of 2015. This is the data which will be used to calculate our Quality and Cost Composite Scores for payment in 2017. Year over year between 2014 and 2015, SETMA’s quality went from 0.18 standard deviation above the mean to a 0.30 standard deviation above the mean. In quality measurement, the higher the positive number, the better. Our goal as previously stated is to improve our quality measures to at least 1.0 standard deviation above the mean. This will place SETMA in the high quality range.

Between 2014 and 2015, SETMA’s cost went from 0.48 standard deviation above the mean in 2014 to 0.57 standard deviation above the mean for cost. Relative to cost, positive scores reflect a higher cost than a negative score. For 2017, SETMA’s goal is to move our cost to the mean or slightly below it.

Related Articles

	Clinical Quality Measures (CQM) - Part of the Future of Healthcare PQRI and PQRS - Part of the Past which Created the Future Part I Four categories defined by MIPS Correlate with Four Strategies SETMA Defined in 2000-2005 Part II Four categories defined by MIPS Correlate with Four Strategies SETMA Defined in 2000-2005 Part III Four categories defined by MIPS Correlate with Four Strategies SETMA Defined in 2000-2005 SETMA’s Innovations Over the Past Twenty Years Have Prepared Us for MACRA & MIPS What are MACRA and MIPS? Why Should I care?
Related Tutorials

	SETMA’s Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial
Related Letters

	CMS Quality Resource and Utilization Report (QRUR) data for 2015 for SETMA CMS Quality Resource and Utilization Report (QRUR) data for 2015 for SETMA - Final Four Categories Defined by MIPS Correlate with SETMA’s Four Strategies for Transforming SETMA and Healthcare In 2000 SETMA Anticipated Four MIPS Categories MACRA and MIPS: An Analysis of the Final QRUR for the Full Year 2015 MACRA MIPS Where Does SETMA Stand MIPS Payment Adjustment in 2019 MIPS September 2016 Advanced Care Information (MU) & Clinical Practice Improvement (PC-MH) MIPS September, 2016 Nursing Home Population – Pneumonia, Urinary Tract Infection, Dehydration SETMA's Prescient Preparation for MACRA and MIPS September 2016 SETMA: MACRA and MIPS - October 3, 2016 What is Post Acute Care?

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