Download Episode-Based Care Model Overview

PRELIMINARY DRAFT
Episode-Based Care Model Overview
Tutorial
November 2012
PRELIMINARY WORKING DRAFT; SUBJECT TO CHANGE
Contents
▪
Introduction
▪
Description of Episode Based Payment
▪
How Incentive Payments are Calculated
▪
Reviewing an Example Episode: Upper
Respiratory Infection
▪
Tools for Providers
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Today, we face major health care challenges in Arkansas
▪
The health status of Arkansans is poor, the
state is ranked at or near the bottom of all states
on national health indicators, such as heart
disease and diabetes
▪
The health care system is hard for patients to
navigate, and it does not reward providers who
work as a team to coordinate care for patients
▪
Health care spending is growing
unsustainably:
– Insurance premiums doubled for employers
and families in past 10 years (adding to
uninsured population)
– Large projected budget shortfalls for Medicaid
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In the face of these realities, Arkansas aims to create a sustainable
Focus of presentation
patient-centered health system
Objective
Care
delivery
strategies
Enabling
initiatives
Accountability for the Triple Aim
▪ Improving the health of the population
▪ Enhancing the patient experience of care
▪ Reducing or controlling the cost of care
Population-based care delivery
▪ Risk stratified, tailored care delivery
▪ Enhanced access
▪ Evidence-based, shared decision
making
▪ Team-based care coordination
▪ Performance transparency
Episode-based care delivery
▪ Common definition of the patient
journey
▪ Evidence-based, shared
decision making
▪ Team-based care coordination
▪ Performance transparency
Payment improvement initiative
Health care workforce development
Consumer engagement and personal responsibility
Health information technology adoption
SOURCE: State Innovation Plan
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This presentation will give an overview of the payment
improvement initiative
Focus of presentation
Examples
1
Medical
homes
2
Health homes
Populationbased care
delivery
3a
Retrospective
episodes
Episode-based
care delivery
Assessment
3b based
episodes
▪
▪
▪
URI
ADHD
Perinatal
▪
▪
LTSS
DD
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Contents
▪
Introduction
▪
Description of Episode Based Payment
▪
How Incentive Payments are Calculated
▪
Reviewing an Example Episode: Upper
Respiratory Infection
▪
Tools for Providers
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The episode-based model is designed to reward coordinated, team-based,
high-quality care for specific conditions or procedures
DETAILS TO FOLLOW
The goal
Accountability
Incentives
Coordinated, team-based care for all services
related to a specific condition, procedure, or
disability (e.g., pregnancy episode includes all care
prenatal through delivery)
A provider ‘quarterback’, or Principal Accountable
Provider (PAP) is designated as accountable for all
pre-specified services across the episode (PAP is
provider in best position to influence quality and
cost of care)
High-quality, cost-efficient care is rewarded
beyond current reimbursement, based on the PAP’s
average cost and total quality of care across each
episode
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The model rewards a Principal Accountable Provider (PAP) for leading and
coordinating services and ensuring quality of care across providers
PAP role
Core provider
for episode
Episode
‘Quarterback’
Performance
management
What it means…
▪
Physician, practice, hospital, or other
provider in the best position to influence
overall quality, cost of care for episode
▪
Leads and coordinates the team of care
providers
▪
Helps drive improvement across system
(e.g., through care coordination, early
intervention, patient education, etc.)
▪
Rewarded for leading high-quality, costeffective care
▪
Receives performance reports and data
to support decision-making
PAP selection:
▪
Payers review
claims to see
which providers
patients chose for
episode related
care
▪
Payers select PAP
based on physician
with the main
responsibility for
the patient’s care
NOTE: Episode and health home model for adult DD population in development. Model will utilize lead provider and health home to drive coordination
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Ensuring high quality care for every Arkansan is at the heart of this
initiative, and is a requirement to receive performance incentives
Two types of quality
metrics for providers
1 Quality metric(s) “to
pass” are linked to
payment
2 Quality metric(s) “to
track” are not linked to
payment
Description

Core measures indicating basic standard of care
was met

Quality requirements set for these metrics, a
provider must meet required level to be eligible for
incentive payments

In select instances, quality metrics must be
entered in portal (heart failure, ADHD)

Key to understand overall quality of care and
quality improvement opportunities

Shared with providers but not linked to payment
1 There are 5 or fewer per episode
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How episodes work for patients and providers (1/2)
1
Patients and
providers
deliver care
as today
(performance
period)
Patients seek
care and select
providers as they
do today
2
3
Providers submit
claims as they do
today
Payers reimburse
for all services as
they do today
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How episodes work for patients and providers (2/2)
4
Calculate
incentive
payments
based
on outcomes
after
performance
period,
typically 12
months long
Review claims from
the performance
period to identify a
‘Principal
Accountable
Provider’ (PAP) for
each episode
5 Payers calculate
average cost per
episode for each PAP1
Compare average
costs to
predetermined
‘’commendable’ and
‘acceptable’ levels2
6 Based on results,
providers will:
▪
Share savings: if
average costs below
commendable levels
and quality targets
are met
▪
Pay part of excess
cost: if average
costs are above
acceptable level
▪
See no change in
pay: if average costs
are between
commendable and
acceptable levels
1 Outliers removed and adjusted for risk and hospital per diems
2 Appropriate cost and quality metrics based on latest and best clinical evidence, nationally recognized clinical guidelines and local considerations
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Contents
▪
Introduction
▪
Description of Episode Based Payment
▪
How Incentive Payments are Calculated
▪
Reviewing an Example Episode: Upper
Respiratory Infection
▪
Tools for Providers
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Guiding principles that payers use to determine cost levels (e.g.,
‘commendable’ and ‘acceptable’ thresholds) and incentive payments
1. Reward high quality, efficient delivery of clinical
care
2. Promote fairness by considering patient access,
provider economics, and changes required for
improvement
3. Acknowledge that poor performance is a reality
and should not be rewarded
4. Protect quality and access by setting a gain
sharing limit at a reasonable, achievable level
5. Sustain thresholds for reasonable period to
allow for adjustment and learning
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Here’s how the payment system works
In addition to your normal payments…
There will be a commendable threshold
▪ If your average costs are below the commendable
threshold and quality standards are met, you share
in the savings
There will be an acceptable threshold
▪ If your average costs are above this threshold, you
will have to share the additional costs
There will be a gain sharing limit
▪ If your average costs are below the gain sharing limit
and quality standards are met you will receive a
share of the savings up to this limit
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What does this mean for you as a provider?
There can be many winners
▪ Aim is to have as many providers
receive rewards as possible
▪ Risk/reward levels are set so as to
make this a reality
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Each payer assesses historic provider average costs for an episode…
Year 1:
Preparatory period
Year 1: Distribution of provider costs
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… then selects thresholds to promote high quality, guideline-based and
cost effective care
Year 1:
Preparatory period
Year 1: Distribution of provider costs
High
Acceptable
Commendable
Gain
sharing limit
Low
Individual providers, in order from
highest to lowest average cost
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Selected thresholds applied to provider performance in the following
year… even though we expect that cost effectiveness will have improved
Year 2:
Performance period
Year 1: Distribution of provider costs
Year 2: Distribution of provider costs
High
Acceptable
Commendable
Gain
sharing limit
Low
Individual providers, in order from
highest to lowest average cost
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Providers that meet quality standards and have average costs between
commendable and the gain sharing limit share in the savings
Shared savings
Year 2 performance
High
Acceptable
Average
cost per
episode
for each
provider
Commendable
Gain
sharing limit
Low
Individual providers, in order from
highest to lowest average cost
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Providers with average costs between commendable and acceptable
Shared savings
receive neither risk-share nor gain-share
Year 2 performance
High
Acceptable
Average
cost per
episode
for each
provider
Commendable
Gain
sharing limit
Low
Individual providers, in order from
highest to lowest average cost
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Providers with average costs above the acceptable limit will have to share
Shared savings
in these costs
Year 2 performance
Shared costs
High
Acceptable
Average
cost per
episode
for each
provider
Commendable
Gain
sharing limit
Low
Individual providers, in order from
highest to lowest average cost
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Providers meeting quality standards that have average costs below the
gain sharing limit will share in the savings up to a limit to protect quality of
Shared savings
care
Year 2 performance
Shared costs
High
Acceptable
Average
cost per
episode
for each
provider
Commendable
Gain
sharing
limit
Low
Individual providers, in order from
highest to lowest average cost
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What does this mean for you as a provider?
Average costs are what count
▪ Extraordinary cases that exceed cost
outlier thresholds are excluded
▪ Other extraordinary cases removed based
on clinical exclusion criteria
▪ Where appropriate, remaining cases riskadjusted based on age, co-morbidities,
and other factors
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Let’s take a look at an individual provider and see how we establish his or
her performance level
Year 2 performance
Year 2 performance
High
Acceptable
Average
cost per
episode
for each
provider
Individual
provider
Commendable
Gain
sharing limit
Low
Individual providers, in order from
highest to lowest average cost
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For each Principal Account Provider, actual costs for each episode will
vary according to patient needs and the cost effectiveness of delivery
Unadjusted
Year 2
performance
Gain
sharing limit
Commendable
Acceptable
Number of
episodes
Low
Cost per episode for an individual Principal
Accountable Provider (unadjusted)
High
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At the end of the period, the payor performs a risk-adjustment to account
for patient-specific factors…
Unadjusted
Year 2
performance
Risk adjusted
Gain
sharing limit
Commendable
Acceptable
Number of
episodes
Low
Cost per episode for an individual Principal
Accountable Provider (adjusted)
High
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…and outliers are removed
Outliers removed
Year 2
performance
Gain
sharing limit
Commendable
Acceptable
Number of
episodes
Low
Cost per episode for an individual Principal
Accountable Provider (adjusted)
High
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A Principal Accountable Provider’s performance is assessed based on his
or her adjusted cost averaged across all non-outlier episodes
Outliers removed
Gain
sharing limit
Commendable
Acceptable
Number of
episodes
Average
adjusted
episode cost
Low
Cost per episode for an individual Principal
Accountable Provider (adjusted)
High
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Contents
▪
Introduction
▪
Description of Episode Based Payment
▪
How Incentive Payments are Calculated
▪
Reviewing an Example Episode: Upper
Respiratory Infection
▪
Tools for Providers
28
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Upper Respiratory Infection (URI) example: Patient care journey
URI1
General
(colds) and
Sinusitis
Patient
experiences
symptoms
Patient contacts 1
doctor
Patient visits doctor
2
3
Work-up
Pharyngitis
(sore throat)
Patient
experiences
symptoms
Patient contacts 1
doctor
Antibiotics
Patient visits doctor
3
2
Strep test
Antibiotics
Opportunities along patient journey
1 Cost-effective use of care settings and providers
2 Appropriate use of diagnostics
3 Appropriate use of prescriptions
1 Non-specific URI
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URI example: Clinical opportunity to improve antibiotic prescription rates
National guidelines
Arkansas prevalence
Antibiotic prescription rate, Arkansas Medicaid, SFY2010
% of general URI1 episodes resulting in filled antibiotic prescription
Each extra prescription puts an
Arkansan at risk and adds
unnecessary costs to system
Clinical evidence tells us: In
95% of cases, Antibiotics are
not indicated for general URI
49%
< 5%
National Guidelines
Arkansas Medicaid, SFY 20102
1 Non-specific URI; 2 For adults, age ≥ 18
SOURCE: Arkansas Medicaid claims, SFY2010
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URI example: Distribution of provider average costs for general
URI in SFY2010
Provider average costs for general URI episodes
Average episode cost per principal accountable provider1
Average cost / episode
Dollars ($)
150
125
100
75
50
25
0
Principal Accountable Providers
1 Each vertical bar represents the average cost and prescription rate for a group of 10 providers, sorted from highest to lowest average cost
SOURCE: Arkansas Medicaid claims paid, SFY10
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URI Example: Episode design specifics (1/2)
▪ A URI episode starts with patient’s first office, clinic or emergency department (ED)
What is included in
the episode?
visit resulting in a primary diagnosis of acute ambulatory URI (Non-specific,
Pharyngitis, or Sinusitis)
▪ Episode lasts for 21 days starting on the day of diagnosis
▪ Episode includes all services related to URI treatment delivered within the 21 day
episode, in any setting, including
– Initial visit(s)
– Follow-up visits for cough
– Labs, imaging, and other outpatient claims
– Antibiotics, antivirals and corticosteroids commonly used for URI, filled during
the episode
▪ Episode excludes
– Non-prescription medications (e.g., over the counter)
– Immunizations used for preventative care
– Surgical procedures or transport
▪ The first provider to diagnose1 the URI is the Principal Accountable Provider
Who is the PAP?
(PAP)2,3, even if additional providers are seen during the episode duration
1 Primary diagnosis only ; 2 Medicaid enrolled clinician
3 Based on objective criteria; final PAP determination to be made by each payer independently
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URI Example: Episode design specifics (2/2)
How are we
ensuring quality is
at the core of the
episode design?
Which episodes
are excluded when
calculating PAP
performance?
▪ Episode performance evaluation includes quality metrics1
– Directly related to payment
▫ Frequency of antibiotic use for patients with acute pharyngitis who do not
receive a strep test
– For reporting only
▫ Frequency of antibiotic usage
▫ Average number of visits
▫ Frequency of multiple courses of antibiotics during one episode
▪ To ensure the PAP’s results are clinically relevant and fair, we exclude episodes of
care for select patients
– Infants less than 1 year old
– Patients without continuous coverage throughout episode
– Inpatient stays or hospital monitoring during the episode
– URI related surgical procedures (tonsillectomy, adenoidectomy)
– Select comorbidities diagnosed at least twice within prior year (asthma, cancer,
chronic URI, end-stage renal disease, HIV and immunocompromised conditions, post-transplant, pulmonary disorders, rare genetic diseases, sickle cell)
– Select comorbidities diagnosed in episode (croup, epiglottitis, URI with
obstruction, pneumonia, influenza, otitis media)
1 For quality metrics “directly related to payment,” PAPs must meet specified quality requirements to be eligible for gain sharing. “Reporting only”
indicates quality measure included in PAP reports but not tied directly to payment.
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URI example: Over time, if providers improve performance more will share
in savings
Illustrative provider average costs for general URI episodes
Average episode cost per principal accountable provider1
ILLUSTRATIVE
Year 3 average cost / episode
Dollars ($)
150
125
100
-
Pay portion of
excess costs
No change in
payment to providers
+
Receive additional payment as
share as savings
75
50
25
0
“Acceptable”
“Commendable”
Gain share limit
PAPs
1 Each vertical bar represents the average cost for a group of 10 providers, sorted from highest to lowest average cost
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Contents
▪
Introduction
▪
Description of Episode Based Payment
▪
How Incentive Payments are Calculated
▪
Reviewing an Example Episode: Upper
Respiratory Infection
▪
Tools for Providers
35
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PAPs will be provided new tools to help measure and improve patient care
▪
▪
Overview of cost effectiveness
(how a PAP is doing relative to
cost thresholds and relative to
other providers)
Overview of utilization and drivers
of a PAP’s average episode cost
Medicaid
Little Rock Clinic
123456789
July 2012
Performance summary (Informational)
Upper Respiratory Infection –
Pharyngitis
Upper Respiratory Infection –
Sinusitis
Quality of service
requirements: Not met
Quality of service
requirements: N/A
Average episode cost:
Acceptable
Average episode cost:
Commendable
Your gain/risk share
You are not eligible
for gain sharing
Your gain/risk share
Medicaid
$0
Little Rock Clinic
123456789
$x
You will receive gain
sharing
July 2012
Summary – Pharyngitis
Overview
Upper Respiratory Infection –
Perinatal
Total episodes:
262
Non-specific URI
Your gain/risk share
< $70
to $100 cost:
Average $70
episode
Acceptable
Gain/Risk share
$0
You
> $100
All provider
average
You are not eligible for gain sharing
 Quality requirements: Not met
Average
episode
cost:Clinic
Acceptable
Little
Rock
Medicaid
Your gain/risk share
Cost summary
$x Quality summary
$0
You will not receive
Quality and utilization
detail
gain
or the
risk
sharing
You did
not meet
minimum
quality requirements
Your average cost is acceptable
You
Quality metrics – linked to gain sharing
Attention Deficit/
Hyperactivity Disorder (ADHD)
Quality of service
requirements: N/A
Average episode cost:
Acceptable
% episodes with
strep test when
antibiotic filled
$0
% episodes with 6%
multiple courses
of antibiotics filled
July 2012
Metric with a minimum quality requirement
Your total cost overview, $
Minimum quality requirement
Average cost overview, $
81
20,150
Percentile
You 25th 50th 75th
Metric
66% % of episodes
You (nonYou
that hadYou
a strep
30% 5%
adjusted)
test when an
anti-biotic(adjusted)
was filled
% episodes with
at least one
antibiotic filled
123456789
– Pharyngitis
Quality metrics:
Performance compared
to provider distribution
25,480
84
48%
Quality metrics – not linked to gain sharing
Your gain/risk share
You will not receive
gain or risk sharing
Total episodes excluded: 29
Quality of service
requirements:
Met Not acceptable
Commendable
Acceptable
Average episode cost:
Not acceptable
You are subject to
risk sharing
Total episodes included: 233
Cost of care compared to other providers
Quality of service
requirements: N/A
64%
0
99%
-
% of episodes
with at cost
leastdistribution
one
Your episode
64%
antibiotic filled
44% 60%
75%
-
% of episodes
50 with
23
15multiple
courses of antibiotics filled
3%
80
100
$40
58%
All providers
10%
$40$55
29
$55–
$70
6%
$70–
$85
45
23
10%
$85$100
Percentile
50
25
81%
Medicaid
123456789
Total episodes included = 233
You
Utilization80
metrics: Performance compared to provider distribution
# and % of episodes
60 3
Percentile
Percentile
with claims in
care
Care
Metric
You 25th 50th 75th
0
25
50
40
category
category
Average number of visits per
episode
All providers
You
July 2012
– Pharyngitis
You did not meet the Cost
minimum detail
acceptable quality
requirements
Distribution of provider average episode cost
Does not meet minimum quality requirements
Minimum quality requirement
100
Little Rock Clinic
-
18
20%
75
$100- >$115
$115
Cost, $
▪
Overview of quality across a
PAP’s episodes
Example of provider reports
# episodes
Reports provide performance
information for PAP’s episode(s):
Commendable
1.7
1.1
Acceptable
1.3
2.3
Percentile
Outpatient
Not acceptable
professional
89
75
Average cost per
episode when care
100
category utilized, $
49%
500
51%
600
All providers
Total cost in care
category, $
10,625
9,492
Key utilization metrics
Avg number of visits per episode
% episodes with antibiotics
You
48%
77
AllEmergency
providers
department
1.7
1.1
64%
3,000
52%
30%
221
Pharmacy
4
2,500
59
1,237
97%
51
1,307
Outpatient
radiology /
procedures
184
Outpatient
lab
21
9%
194
11%
179
Outpatient
surgery
16
7%
Other
79%
81
1,321
77%
81
944
2,260
1,251
1,400
5%
12
3,865
3,409
95%
1,062
5%
62
3%
69
5
1,400
1,062
433
643
6
NOTE: Episode and health home model for adult DD population in development. Tools and reports still to be defined.
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PAP performance reports have summary results and detailed analysis of
episode costs, quality and utilization
Details on the reports
▪
First time PAPs receive detailed analysis on
costs and quality for their patients increasing
performance transparency
▪
Guide to Reading Your Reports available
online and at this event
– Valuable to both PAPs and non-PAPs to
understand the reports
▪
Reports issued quarterly starting July 2012
– July 2012 report is informational only
– Gain/risk sharing results reflect claims
data from Jan – Dec 2011
▪
Reports will be available online via the
provider portal
NOTE: Episode and health home model for adult DD population in development. Tools and reports still to be defined.
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The provider portal is a multi-payer tool that allows providers to enter
quality metrics for certain episodes and access their PAP reports
Details on the provider portal
Login to portal from
payment initiative website
▪
Accessible to all PAPs
– Login with existing username/ password
– New users follow enrollment process
detailed online
▪
Key components of the portal are to provide
a way for providers to
– Enter additional quality metrics for select
episodes (Hip, Knee, CHF and ADHD with
potential for other episodes in the future)
– Access current and past performance
reports for all payers where designated
the PAP
NOTE: Episode and health home model for adult DD population in development. Tools and reports still to be defined.
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