Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Payment Models and Provider Collaboration SYNC: Transforming Healthcare Leadership September 16, 2016 Agenda • Overview of Payment Model and Structure • Mandatory Programs Across the Continuum • Voluntary Programs Overview of Payment Model Structure HHS Goals • January 2015, directional goals set for advancing payment reform. 2016 2018 Value Based Payments 85% 30% 90% Alternative Payment 50% 4 HCPLAN Framework: January 2016 Source: Alternative Payment Model Framework and Progress Tracking Workgroup, “Alternative Payment Model (APM) Framework”, HCP-LAN. 12 Jan 2016. Web. 31 Jan 2016 . 5 Where Are We Going? Source: Alternative Payment Model Framework and Progress Tracking Workgroup, “Alternative Payment Model (APM) Framework”, HCP-LAN. 12 Jan 2016. Web. 31 Jan 2016 . 6 CMMI Programs 7 Continuum Emphasis Acute Post Acute Ambulatory 8 Transparency Focus • • • • Physician Compare Star Ratings Patient empowerment State efforts 9 Mandatory Programs Across the Continuum Mandatory Payment Reform is Everywhere VBP PQRS/VM SNF VBP RRP MU HH VBP HAC MIPS/APM CJR Cardiac Bundles* * These are in proposed form at this time. 11 Acute: VBP/RRP/HAC Base of $100,000,000 of Medicare Part A Revenue $7,000,000 $6,000,000 $6,000,000 $5,000,000 $4,000,000 $3,000,000 $2,000,000 $1,000,000 $4 $0 ($1,000,000) Readmission Hospital Acquired Condition Value Based Purchasing ($1,000,000) ($2,000,000) ($2,000,000) ($3,000,000) ($3,000,000) ($4,000,000) Current Total Incentive 12 Performance Periods 13 MACRA • Known as the “SGR Fix” • Created the Quality Payment Program • Choice of two paths for each physician practice: APM vs MIPS – Most physicians in MIPS path by default • Proposed rules have program starting in 2019 with performance period effective 1/1/17 • Recently offered flexibility in timing of implementation 14 What is MIPS? 9% 10% 7% 8% 6% 4% 4% 5% 2% 0% -2% 2019 2020 2021 2022+ -4% -6% -4% -5% -8% -7% -10% -9% Upside Downside Source: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPSand-APMs/NPRM-QPP-Fact-Sheet.pdf Decision Tree for QPP Am I in an APM? No No Neither Yes Yes Is it an Advanced APM? Do I meet minimum criteria? No Yes Do I meet the volume or revenue criteria? No (Option of Partial Qualifying, if not, then MIPS Path) Yes 16 MIPS Optimization A sample practice with $25M in Medicare fee schedule payments Incentive $2,500,000 Penalty 10% Bonus $2,500,000 $2,500,000 $2,500,000 $2,250,000 $1,750,000 $1,250,000 $1,000,000 2019 2020 -$1,000,000 2021 2022 -$1,250,000 -$1,750,000 -$2,250,000 Does not include the adjustment factor of up to 3X per year 17 Significant Strategic Implications • What should you be doing now by type of entity? • How are you performing now on QRUR? • How prepared are affiliation as well as employed practices? • What are your market dynamics? • How does this tie to system wide initiatives? 18 Skilled Nursing VBP • To start in 2019 with 2% of Medicare reimbursement at risk • 2014 SGR fix used part of the 2% to pay for the fix so facilities can’t earn it all back • Key metrics are readmissions • Published on nursinghomecompare 19 Home Health VBP • 5 year pilot in 9 states: Virginia is not one of them • 4 domains with shifting metrics • At risk reimbursement starts at 4% and goes to 9% in 5 years 20 Voluntary Programs ACOs • Currently 434 Medicare Shared Savings Programs • Other Medicare ACOs: Pioneer ACO, ACO Investment Model, Next Generation ACO • Modifications continue to the models • Annual classes of ACOs 22 Financials: MSSP Track 2 $100,000,000 $98,000,000 $98,100,000 $96,900,000 $96,000,000 $95,000,000 $94,000,000 $93,400,000 $93,100,000 $92,000,000 $91,228,000 $90,000,000 $88,000,000 $86,000,000 Historical Spend Actual Spend Year 1 Q: 100% 2% Min Savings Rate Year 2 Q:80% Year 3 Q: 90% 2% Min Loss Rate Assumes no changes in target or risk adjustments for simplicity 23 Let’s Do The Math Did the spend exceed the MSR or MLR? How much savings/loss Year 1 Year 2 Year 3 Yes No Yes $3,772,000 ($3,100,000) What is the quality score? 100% 90% What is the share rate? 60% 1-(60%*90%)=.46 Total savings/loss shared $2,263,200 ($1,426,000) 24 Bundled Payments • Prometheus (Provider payment Reform for Outcomes, Margins, Evidence, Transparency, Hassle Reduction, Excellence, Understandability and Sustainability): 21 bundles • State Medicaid Programs: – Initiated as part of reform efforts: Arkansas, Ohio, Tennessee, and more under planning stages. • Commercial Programs – Largely cardiac and orthopedic in nature and not pervasive geographically • Medicare Programs: – Bundled Payment for Care Improvement (BPCI): 48 bundles – Comprehensive Care for Joint Replacements (CJR): 1 mandated bundle Medicare Bundles (finalized) Bundled Payment for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) # of Providers Participating Over 1500: Across providers 789 Hospitals Voluntary/Mandatory Voluntary Mandatory Diagnoses Covered Up to 48 Choices of Episodes: Currently over 14,000 live Single Episode: Hips/Knees Time Frame 3 years with extension 5 years Price Determination Historical Spending Blend: Historical and Regional What’s next? On July 25, 2016 CMS issued proposed rules for two cardiac bundles and an expansion of the CJR bundle. This is proposed to start on July 1, 2017. Let’s Do the Math $40,000 $35,000 $3,500 $30,000 $3,000 $25,000 $2,000 $20,000 $3,000 $1,000 $4,000 $1,000 $500 $3,000 $4,000 $5,000 $15,000 $8,000 $10,000 $3,000 $1,800 $12,000 $5,000 $8,000 $0 Episode 1 Acute Physician Episode 2 SNF HH IRF OP LTACH Readmission What if the target price is $25,000 for Episode 1 and $30,000 for Episode 2? 27 New Cardiac & Expanded CJR Bundles/EPMs • New Acronym: Episode Payment Model= EPM • Proposed Rules issued July 25, 2016 with comment period open for 60 days. • Cardiac: AMI (DRGs 280-282 and PCI DRGs 246251) & CABG (DRGs 231-236 • Orthopedic: SHFFT: Surgical hip/femur fracture treatment excluding LEJR (DRGs 480-482) • 90 day episodes and 5 year program with first performance year truncated starting 7/1/17 through 12/31/17 EPMs continued… • No downside risk the first performance year (7/1/1712/31/17) – Downside risk starts in the 2Q in the second performance year • Settlement is retrospective and performed annually • Discounts determined similarly to CJR starting at 3% for unacceptable and acceptable quality down to 2% and 1.5% for good and excellent ratings respectively AMI CABG SHFFT • Quality metrics and weights: Mort-30 50% Excess Days 20% HCAHPS 20% Complications Voluntary 75% 25% 40% 50% 10% 10% EPMs Continued… • Who is mandated for these EPMs? – SHFFT: to expand in the 67 MSAs for CJR – AMI and CABG: will be mandated 98 in MSAs out of 294 eligible MSAs (total n= 384) • Hospitals are the episode initiators (at risk) • 3 years historical information like BPCI and CJR • Pricing will phase to regional like CJR: • Regions= 9 US Census Divisions Specialty Models Oncology Care Model • 6 month episode • Oncology practice based • Part A,B and some D • 21 participants: April 2016 • 2nd class planned • Shared savings model with target prices based on historical spend by type of cancer Comprehensive ESRD Care Model • Annual spend • Two types: large dialysis and non large dialysis organizations • 2nd class applications due 7/15/16 • Shared savings model based on 3 year historical spend Independence At Home • Objective is to test effectiveness of delivering comprehensive primary care services at home specifically to patients with multiple chronic conditions • Currently 14 sites involved for 3 year program • Tracked spending and quality measures • 2nd year results announced 8/9/16 32 Year 2 Results 6 of the Practices Year 2 Target Year 2 Expenditures Incentive Payment Boston Medical Center $4,148 $4,236 $- Christiana Care Health System $3,911 $4,450 $- Cleveland Clinic Home Care $3,619 $3,565 $- Housecall Providers $3,233 $2,393 $1,107,295 Mid Atlantic Consortium $4,076 $3,576 $866,865 Northwell HealthCare $3,276 $2,708 $874,151 All sites improved quality from first performance year. An average of $1,010 per beneficiary for the 10,484 beneficiaries was saved. 33 Post Acute Networks • Formalizing preferred providers by post acute provider type • Hold preferred providers accountable based on quality metrics/outcomes • Share data on routine basis • Partner on streamlined protocols • Gain share or put dollars at risk 34