Ohio SIM: Episode-based Payment Update. Webinar September 21, 2017

Transcription

1 Ohio SIM: Episode-based Payment Update Webinar September 21,

2 Ohio was awarded a federal grant to test multi-payer, value-based payment models HI WA OR NV CA ID AZ UT MT CO NM ND NE KS TX OK MN IA MO AR LA WI IL MI TN KY OH WV VT NY PA VA ME NH MA RI CT NJ DE MD State Innovation Model (SIM) Test Grant States Design Grant States Comprehensive Primary Care Plus (CPC+) Regions SOURCES: State Innovation Models, Comprehensive Primary Care Plus and Comprehensive Primary Care Initiative, Centers for Medicare & Medicaid Services CPC+ Regions that also participated in CPCi 4

3 Value-Based Alternatives to Fee-for Service Fee for Service Incentive-Based Payment Transfer Risk Ohio s State Innovation Model focuses on (1) increasing access to patient-centered medical homes and (2) implementing episode-based payments Fee for Service Pay for Patient- Centered Medical Home Episode- Based Payment Accountable Care Organization Payment for services rendered Payment based on improvements in cost or outcomes Payment encourages primary care practices to organize and deliver care that broaden access while improving care coordination, leading to better outcomes and a lower total cost of care Payment based on performance in outcomes or cost for all of the services needed by a patient, across multiple providers, for a specific treatment condition Payment goes to a local provider entity responsible for all of the health care and related expenditures for a defined population of patients

4 Ohio s State Innovation Model (SIM) progress to date Ohio received SIM test award in 2014 to implement innovative payment models Ohio is in the third year of the four-year award and well-positioned to meet goals Episode-Based Payment 31 episodes designed across 10+ clinical advisory groups (CAGs), 43 episodes to be reported on by the end of 2017 Ten payers released episode reports on select wave 1 episodes For Medicaid, completed first year of performance tied to incentives for 3 episodes and increases to 9 episodes for 2017 State delivers aggregated performance reports across Medicaid FFS and MCPs including interactive functionality on 13 episode starting in September 2017 Comprehensive Primary Care Ohio CPC practices enrolled, representing over 830K attributed Medicaid members and 111 practices ODM designated as a CPC+ participating payer; increasing the resources available to those practices to now cover both Medicaid and Medicare members Infrastructure and financial processes in place for attribution, enrollment, scoring, reporting, and payment State delivers performance and referral reports to 111 practices each quarter 4 SOURCE: Episode based payments; Patient-centered medical homes (PCMH): eligible provider; Patient centered medical homes (PCMH): payments

5 Multi-payer participation is critical to achieve the scale necessary to drive meaningful transformation

6 Ohio s episode model is retrospective, building on the current FFS infrastructure already in place Patients seek and providers deliver care as they do today Patients seek care and select providers as they do today Providers submit claims as they do today Payers reimburse for all services as they do today Calculate incentive payments based on outcomes after close of 12 month performance period 4 5 Review claims from the performance period to identify a Principal Accountable Provider (PAP) for each episode Payers calculate average risk-adjusted reimbursement per episode for each PAP Compare to predetermined commendable and acceptable levels 6 Providers may Share savings: if average costs below commendable levels and quality targets are met Pay negative incentive: if average costs are above acceptable level See no impact: if average costs are between commendable and acceptable levels

7 Retrospective thresholds reward cost-efficient, high-quality care 7 Provider cost distribution (average risk-adjusted reimbursement per provider) - Negative incentive No change No Change + Avg. risk-adjusted reimbursement per episode $ No incentive payment Eligible for positive incentive payment based on cost, but did not pass quality metrics Positive incentive Acceptable Commendable Positive incentive limit Principal Accountable Provider NOTE: Each vertical bar represents the average cost for a provider, sorted from highest to lowest average cost

8 Wave W1 Ohio s reporting and performance years by episode wave Episodes Acute PCI, Asthma exacerbation, COPD exacerbation, Non-acute PCI, Perinatal, Total joint replacement Reporting only Y1 Y2 Y3 Linked to payment 1 Y4 W2 Appendectomy, Cholecystectomy, Colonoscopy, EGD, GI bleed, URI, UTI Reporting only Y1 Y2 Y3 W3 Ankle sprain/strain, ADHD, Breast biopsy, Breast cancer surgery, Breast medical oncology, CABG, Cardiac valve, CHF exacerbation, Dental: tooth extraction, Diabetic ketoacidosis (DKA) / hyperosmolar hyperglycemic state, Headache, Hip/pelvic facture procedure, HIV, Hysterectomy, Knee arthroscopy, Knee sprain/strain, Low back pain, Neonatal (high-risk), Neonatal (low-risk), Neonatal (moderate-risk), ODD, Otitis media, Pancreatitis, Pediatric acute lower respiratory infection, Shoulder sprain/strain, Skin and soft tissue infection, Spinal decompression (without fusion), Spinal fusion, Tonsillectomy, Wrist sprain/strain Reporting only 2 Y1 1 Payment episode status only determined for W1 and W2 so far; decisions to be made in future for W3 2 Reporting for Wave 3 episodes extended to CY2018 given need to incorporate physician feedback through reactive clinical process into episode design prior to performance periods (most Wave 3 episodes designed and launched on accelerated timelines without Clinical Advisory Groups)

9 CY2016 performance: three episodes linked to payment Wave 1 Wave 2 Asthma acute exacerbation COPD acute exacerbation Perinatal Linked to payment Cholecystectomy Colonoscopy Esophagogastroduodenoscopy (EGD) GI hemorrhage (GIH) Linked to payment Acute PCI Non-acute PCI Total joint replacement Reporting only All Medicaid view Upper respiratory infection (URI) Urinary tract infection (UTI) Appendectomy Reporting only All Medicaid view

10 Episode : CY 2016 First episodes linked to performance and financial incentives asthma, COPD and perinatal; performance period is January 1, 2016 December 31, 2016 To be eligible for a positive incentive payment, a provider must have 5+ valid episodes with an average risk-adjusted episode spend below the commendable threshold, and pass specified quality metrics To be assessed a negative incentive payment, a provider must have 5+ valid episodes with an average risk-adjusted valid episode spend above the acceptable threshold Final performance reports delivered separately from FFS and each of the MCPs. FFS reports available in Medicaid MITS portal; MCPs will be delivering reports over next few weeks ODM and MCPs will process payments within 90 days of report delivery

11 Asthma CY2016 Thresholds 11

12 COPD CY2016 Thresholds 12

13 Perinatal CY2016 Thresholds 13

14 CY2017 performance: nine episodes linked to payment Wave 1 Wave 2 Asthma acute exacerbation COPD acute exacerbation Perinatal Linked to payment Cholecystectomy Colonoscopy Esophagogastroduodenoscopy (EGD) GI hemorrhage (GIH) Linked to payment Acute PCI Non-acute PCI Total joint replacement Reporting only All Medicaid view Upper respiratory infection (URI) Urinary tract infection (UTI) Appendectomy Reporting only All Medicaid view

15 Episode Reporting and : CY episode reports for performance CY2017 are now available in Medicaid MITS portal Six new episodes in performance period: URI, UTI, EGD, Colonoscopy, Cholecystectomy, GI Bleed Reports cover the first quarter: January 1, 2017 March 31, 2017 All reports will be consolidated into a single PDF reflecting all-medicaid view with an accompanying CSV file For the nine episodes in a performance period will include all-medicaid view as well as broken down by payer FFS and MCP Reports can be accessed through the Medicaid MITS portal including new interactive functionality

16 Preview: new interactive functionality on episode reports Interactive, web-based view of episode report with drill-down functionality for providers to: Filter and explore episode data without opening any PDF or CSV files Drill down to review individual claims behind a specific episode Directly go to relevant drill-downs on the portal through embedded links in PDF reports Search capabilities (e.g. episode ID) New portal functionality for consolidated reports to be reviewed in detail in a separate webinar October 19 th

17 Menu option to view Episode Reports

18 Dropdown to select report type

19 Report hyperlinks (1/2)

20 Report hyperlinks (2/2)

21 Episode Reporting and : CY 2017 Live demonstration of Medicaid MITS portal TENTATIVE Thursday, October 19, 2017 more details to come Tentative Agenda How to access reports in MITS How to assign roles to other people within organization How to use new interactive functionality in episode reports Other data accessible in MITS

22 Wave W1 Ohio s reporting and performance years by episode wave Episodes Acute PCI, Asthma exacerbation, COPD exacerbation, Non-acute PCI, Perinatal, Total joint replacement Reporting only Y1 Y2 Y3 Linked to payment 1 Y4 W2 Appendectomy, Cholecystectomy, Colonoscopy, EGD, GI bleed, URI, UTI Reporting only Y1 Y2 Y3 W3 Ankle sprain/strain, ADHD, Breast biopsy, Breast cancer surgery, Breast medical oncology, CABG, Cardiac valve, CHF exacerbation, Dental: tooth extraction, Diabetic ketoacidosis (DKA) / hyperosmolar hyperglycemic state, Headache, Hip/pelvic facture procedure, HIV, Hysterectomy, Knee arthroscopy, Knee sprain/strain, Low back pain, Neonatal (high-risk), Neonatal (low-risk), Neonatal (moderate-risk), ODD, Otitis media, Pancreatitis, Pediatric acute lower respiratory infection, Shoulder sprain/strain, Skin and soft tissue infection, Spinal decompression (without fusion), Spinal fusion, Tonsillectomy, Wrist sprain/strain Reporting only 2 Y1 1 Payment episode status only determined for W1 and W2 so far; decisions to be made in future for W3 2 Reporting for Wave 3 episodes extended to CY2018 given need to incorporate physician feedback through reactive clinical process into episode design prior to performance periods (most Wave 3 episodes designed and launched on accelerated timelines without Clinical Advisory Groups)

23 New episodes are launching this year ODM will launch 30 episodes with informational reports by the end of this year Informational reports include a year s worth of data Reports delivered in September will contain data from April 1, 2016 March 31, 2017 Reports will be launched in a staggered fashion: 18 episode reports to be released for first time next week Remaining 12 episode reports to be released in November 2017 Reports delivered in November will contain data from July 1, 2016 June 30, 2017

24 Launching 18 new episodes in September (1/2) Behavioral health Neonatology Pediatrics Neurology & pain Episode Attention deficit and hyperactivity disorder (ADHD) Oppositional defiant disorder (ODD) Neonatal, high-risk Neonatal, moderate-risk Neonatal, low-risk Otitis media Pediatric acute lower respiratory infection (LRI) Tonsillectomy Headache Low back pain (LBP) Principal accountable provider (PAP) Provider with plurality of related E&M and medication management visits when applicable Facility where the newborn is born Clinician who diagnosed the otitis media Facility where the patient first presents Surgeon who performs the tonsillectomy Physician entity diagnosing the headache or LBP

25 Launching 18 new episodes in September (2/2) Cardiology Other Episode Cardiac valve Coronary artery bypass graft (CABG) Congestive heart failure (CHF) exacerbation Diabetic ketoacidosis (DKA) / hyperosmolar hyperglycemic state (HHS) HIV Pancreatitis Skin and soft tissue infection Hysterectomy Principal accountable provider (PAP) Surgeon who performs the valve repair or replacement Surgeon who performs the CABG Facility treating the CHF exacerbation Facility where the patient first presents Physician with the most outpatient visits for HIV and HIV-related conditions Physician diagnosing the infection Facility where the patient first presents Surgeon who performs the hysterectomy

26 We are seeking provider feedback on 12 episodes Cardiology Pediatrics Neurology & pain Cardiac valve Coronary artery bypass graft (CABG) Congestive heart failure (CHF) exacerbation Otitis media Pediatric acute lower respiratory infection (LRI) Tonsillectomy Headache Low back pain (LBP) Monday, November 6 th If you are interested in participating in one of the Provider Feedback Sessions, please contact Beanca Cooper, Beanca.cooper@Medicaid. ohio.gov Other Diabetic ketoacidosis (DKA) / hyperosmolar hyperglycemic state (HHS) Pancreatitis Skin and soft tissue infection Hysterectomy Monday, November 13 th

27 Launching 12 new episodes in November Orthopedics Breast cancer Dental Knee arthroscopy Knee sprain/strain Ankle sprain/strain Shoulder sprain/strain Wrist sprain/strain Breast biopsy Breast medical oncology Breast cancer surgery Dental tooth extraction Hip/pelvic fracture procedure Spinal fusion Spinal decompression (without fusion)

28 Quarterly episode of care performance report

29 What content is available on the portal? In addition to pdf reports, there is a detailed csv file delivered to each PAP to complement provider reports How to use these files to learn more: Understand key sources of variation, for example: Breakdown of avg. risk-adjusted episode reimbursement by rendering provider Breakdown of avg. reimbursement by inpatient, outpatient, professional, & pharmacy Understand variability in quality metric performance and relationship to average episode reimbursement 29

30 How do I access my report(s) on the MITS portal? Reports for Ohio Medicaid are available on the MITS Provider Portal: ODM FFS and W1, W2 consolidated reports are located in the Portal under the Reports Section MITS administrators have access to the portal and can pull down reports to share with others in a practice For assistance accessing ODM FFS reports or identifying your MITS Portal Administrator: Contact the Medicaid Provider Hotline at: Visit the Ohio Department of Medicaid website Provider tab, and click on the blue box in the right corner for: Access the MITS Portal 30

31 Episode-based Payment: Next Steps For Asthma, COPD and perinatal episodes, final CY2016 performance reports are delivered by each of the MCPs and ODM for FFS. For questions about access to your MCP report, please contact your MCP representative as indicated on the reports For all 13 episodes CY2017 reports, consolidated interactive reports available now via the Medicaid MITS portal. Save the date for Episode Report Live Demo October 19, 2017 Launching 18 new episodes in September available via the Medicaid MITS portal in late September. Save the date for Provider Comment Sessions (select episodes) November 6 th and November 13 th Launching 12 new episodes in November via Medicaid MITS portal 31

32 Where to find episodes information on the ODM website SOURCE: Ohio Department of Medicaid website 32

33 Additional episode details can be found online The Ohio Department of Medicaid website includes links to the following documents for each episode ( vation/episodes.aspx): Concept paper: Overview of episode definition including clinical rationale for the episode, patient journey, sources of value, and episode design dimensions Detailed business requirements (DBR): Description of episode design details and technical definitions by design dimensions Code sheet: Medical, pharmacy, and other related codes needed to build the episode, to be referenced with the DBR There is also a How to read your report guide available for providers on the same site. 33