Moving To Value-Based Payment: What Are The New Models In Medicaid & Medicare?

Transcription

1 Moving To Value-Based Payment: What Are The New Models In Medicaid & Medicare? #OMPerformance The 2017 OPEN MINDS Performance Management Institute Thursday, February 16, :30am 12:45am Athena Mandros, Market Intelligence Manager, OPEN MINDS James Stewart, President & CEO, Grafton Integrated Health Network & Institute Chair, OPEN MINDS York Street, Gettysburg, Pennsylvania Phone: info@openminds.com All Rights Reserved.

2 Agenda 1. What Are Alternative Payment Methodologies? 2. Medicare Alternative Payment Initiatives 3. Medicaid Alternative Payment Initiatives 4. Preparing For Alternative Payment Models 5. Questions & Discussion All Rights Reserved.

3 What Are Alternative Payment Methodologies?

4 Not All Alternative Payment Models Are Created Equal Pay-For-Performance (P4P) 1. Additional payment or penalties on top of FFS rate for: a. Performance measures (quality, costs, etc.) 2. Examples of P4P include incentive payments for meeting quality measures such as medication adherence, follow-up after hospitalization, and screening for depression. Value-Based Purchasing (VBP) 1. Links payment to: a. Cost of care b. Quality measures 2. Models include: a. Episodes of care b. Case rates c. Population health management risk d. Traditional capitation All Rights Reserved.

5 5

6 Medicare Alternative Payment Initiatives

7 What Is The Medicare APM Landscape? By 2018, the Centers for Medicare & Medicaid Services (CMS) plan to have 90% of Medicare payments in APMs and 50% in VBP arrangements How will they get there? ACOs Comprehensive Primary Care Plus Initiative Bundled Payments For Care Improvement Initiative MACRA 7

8 1. Accountable Care Organizations Groups of provider organizations form an agreement to coordinate care for a set group of consumers. ACO receive a share of the savings/losses based on costs compared to the baseline and performance on quality measures Multiple program with varying amounts of risk: Shared Savings Program (Track 1, 1.5, 2, 3) Pioneer ACOs Advanced payment/investment ACO Next Generation ACOs 8

9 Key ACO Trends More than 560 ACOs in 2017 More than 10.2 million attributed beneficiaries in 2016, 17.8% of 57.3 million Medicare beneficiaries Pioneer ACO savings total $341 million, Shared Saving ACO savings total $1.2 billion 600 Number Of ACOs FY2012 FY2013 FY2014 FY2015 FY2016 FY2017 MSSP Track One MSSP Track Two MSSP Track Three Pioneer ACO Next Generation ACO 9

10 2. Comprehensive Primary Care Plus (CPC+) Multi-payer initiative, but mainly a Medicare model Primary care practices act as comprehensive patient-centered medical homes Requirements include 24/7 access, patient assignment to provider panel, supporting quality improvement activities, developing and recording care plans, etc. Two Tracks based mainly on payment model chosen Three payments: Care Management Fee- a per member per month (PMPM) for attributed beneficiaries and risk-adjusted to provide care coordination Performance- based incentive payments- prospective PMPM for meeting quality measures and utilization measures. Reconciled against results at end of year. Comprehensive Primary Care Payment (Track 2 only)- Partial capitation and fee-forservice payments 10

11 States Participating In CPC+ OR WA Idaho ID MT Montana MT WY ND SD MN WI MI NY ME North Hudson/ Capital District Region CA NV UT AZ CO NM NE Greater Kansas City Region OK IA MO AR IL IN OH KY TN PA WV VA NC SC Greater Philadelphia Region VT MA NJ MD DC NH RI CT DE MS AL GA TX LA AK FL HI CPC+ States 11

12 3. Bundled Payments For Care Improvement (BPCI) Initiative Provider organizations must keep costs under a target for a defined set of services or an episode of care Examples of BCPI initiatives include amputation, major cardiovascular procedure, major joint replacement of the lower extremity, stroke, urinary tract infection (48 clinical episodes total) Three models under the BCPI initiative: Model 2 Model 3 `Model 4 Episode Selected DRGs; hospital Selected DRGs; post-acute Selected DRGs; hospital plus post-acute period period only plus readmissions All non-hospice Part A and All non-hospice Part A and All non-hospice Part A and Services included in the B services during the initial B services during the post-acute services during initial bundle inpatient stay, post-acute period and readmissions period and readmissions inpatient stay and readmissions Payment Retrospective Retrospective Prospective Model 2: 649 participants, Model 3: 864 participants, Model 4: 10 participants 12

13 4. MACRA Medicare Access and CHIP Reauthorization Act Goal is to move all clinical professionals to pay-for-value Implements the Quality Improvement Program Merit-Based Incentive Payment System (MIPS) Alternative Payment Model (APM) Not yet effecting behavioral health organizations, but: Opportunity for partnership May be included in the future Implementation Schedule Jan- Oct 2017: Data collection begins March First round of data due to CMS Jan First payment adjustment period begins 13

14 Quality Payment Program Characteristics Characteristics MIPS APM Eligible Clinical professionals Estimated Participants Physicians and nurses participating in the Medicare Part B Program Excludes those with low Medicare volume 687, ,000 clinical professionals Incentive Payment : Positive or negative payment adjustments 2026:.25% fee schedule adjustment each year Payment Calculations Payment adjustment determined by composite score relative to the threshold score Composite score consists of four weighted categories: quality, resource use, clinical practice improvement activities, advancing care information Physicians and nurses participating in advanced payment models defined as those taking on nominal financial risk 30,000-90,000 clinical professionals : 5% lump sum bonus 2026:.75% fee schedule adjustment each year All or nothing, if the clinician meets the criteria to participate, they receive the lump sum bonus 14

15 Quality Measure Examples NQF: 1879 Adherence to Antipsychotic medications for individuals with schizophrenia Quality ID 325: Adult major depressive disorder: Coordination of care for patients with comorbid conditions NQF 0140: Adult major depressive disorder: Suicide risk assessment NQF: 0105: Anti-depressant medication management Quality ID 367: Bipolar disorder and major depression: Appraisal for alcohol or chemical substance use Quality ID: Documentation of signed opioid treatment agreement Other measures related to: Depression, addiction treatment, dementia, and children s behavioral health 15

16 Medicaid Alternative Payment Initiatives

17 What Is The Medicaid APM Landscape? Each APM model is unique like each state s Medicaid program Patientcentered medical homes Health Homes ACOs Contractual requirements on MCOs 17

18 1. Patient-Centered Medical Homes A model of care coordination, usually at the primary care level PCMHs provide primary care services, care coordination, enhanced access to care, and care that is culturally and linguistically appropriate. i.e., extended hours, quality improvement, follow-up calls, etc. Each model varies between state, payer, and provider organization 20 states (does not include health home states) 7.4 million attributed enrollees Opportunities for colocation, integration, and possible participation 18

19 States With PCMH Programs, 2017 WA OR ID Montana MT WY ND SD MN WI MI NY ME CA NV AZ UT NM CO NE KS OK IA MO AR IL IN OH TN KY PA WV VA NC SC VT MA NJ MD DC NH RI CT DE MS AL GA TX LA AK HI FL PCMH Program 19

20 2. Health Homes Receive capitated rate to provide six health home care coordination functions Next wave of the program is moving towards value-based models Rhode Island and Tennessee 21 states and 29 programs 3 states with programs for consumers with chronic conditions and/or SMI 8 states with programs for consumers with chronic conditions only 18 states with programs for SMI, SED, and SUD 1.25 million consumers enrolled, 56% in chronic condition health homes Direct opportunity for provider organizations to participate 20

21 States With Health Homes, 2017 WA CA OR NV Idaho ID UT AZ Montana MT WY CO NM ND SD NE KS OK MN IA MO A R WI NY MI PA IL IN OH WV VA KY NC TN SC MS AL GA ME VT MA NJ MD DC NH RI CT DE TX LA AK HI FL Health Homes 21

22 3. Accountable Care Organizations Every state ACO model is different depending on the state Three major models: Traditional Shared Savings- ACOs contract with the state Medicaid program and receive shared savings/losses Risk-based model ACO acts as the MCO Health Plan Shared Savings- Health plans contract with ACOs and set the payment agreement 11 states with ACOs Three states with risk-based model, 8 states with shared savings model. At least $1.2 billion in savings Opportunity for partnership with ACOs. Medicaid programs are much further ahead than Medicare ACOs in requiring specialty provider organization participation 22

23 States With Medicaid ACOs, 2017 OR WA Idaho ID MTMontana MT WY ND SD MN WI MI NY ME CA NV AZ UT NM CO NE KS OK IA MO AR IL IN OH TN KY PA WV VA NC SC VT MA NJ MD DC NH RI CT DE MS AL GA TX LA AK HI FL Traditional ACOs Risk-based ACOs Proposed ACO Models 23

24 4. MCO APM Contractual Requirements 38 states have managed care contracts 13 allow P4P or VBP arrangements between MCOs and provider organizations 5 allow VBP only 4 more states planning to implement in future States That Require P4P or VBP In MCO Contract 1. Arizona 2. Hawaii 3. Michigan 4. Minnesota 5. Missouri 6. New Hampshire 7. New Mexico 8. Ohio 9. Oregon 10. South Carolina 11. Virginia 12. Washington 13. Delaware States That Require VBP 1. Iowa 2. Nebraska 3. New York 4. Rhode Island 5. Tennessee 24

25 Should Your Organization Factor APMs Into Your Strategy? You should start preparing for APMs if You have contracts with Medicaid MCOs You have contracts with Medicare Your state has health homes, ACOs, PCMHs Your state places APM requirements on the Medicaid health plans Your state has APM requirements for Primary/acute care 25

26 Preparing For Alternative Payment Models

27 Adoption Of Value-Based Care Is Uneven Different surveys show different rates of value-based payments across the industry: OPEN MINDS 2016 survey found that 15% of health and human service provider organizations reported having some payment through pay-for-value arrangements Modern Healthcare s annual Hospital Systems Survey reported that two-thirds of hospitals report that 0% or 1% of their net patient revenue was generated from risk-based contacts ORC International reports that among hospitals surveyed, half of their business was via value-based reimbursement, up from 46% in

28 How Do You Prepare Your Organization For APM? 1. Define value in your organization 2. Determine how to measure that value MUST BE CONCRETE! 3. Your Work Flows must support acquisition of the data 4. Have the proper technical systems in place to measure value 5. Onboard your staff to why this is important 6. Demonstrate your value to payers All Rights Reserved.

29 Determine How Your State Defines Value Analyze your current market to determine which Medicaid APM are in place and how major payers for your services are defining value. In many states, Medicaid programs are moving forward with alternative payment models and establishing clear performance metrics with new value-based reimbursement models How your state is (or is planning to) define value is how your organization should be defining value. If your state is not using APM, its up to you to define and demonstrate your own value 29

30 1. Define Value In Your Organization We operate in a system where there is no consensus on the definition of value. Successful outcomes are defined differently across the board from state to state and payer to payer, making it difficult to compare provider organizations to each other. So what constitutes a successful result in treating a complex consumer who has behavioral health issues? The consumer can live a somewhat independent and productive life with longterm care and supervision The consumer isn t readmitted to the hospital or clinic within a month? What specifically represents the desired outcome? 30

31 Grafton Definition Of Value We have chosen to define Value using the views of our Customers A Customer is : Who We serve and their families: What Benefit do they gain from our services Who regulates our services: Do we ethically achieve desired results Who pays for our services: What is the merit of our services for their payment Grafton Value Deliver agreed upon outcome For Agreed upon Reimbursement In a Trauma Directed and informed manner 31

32 2. Determine How To Measure Value Determine the metrics your organization will utilize to demonstrate your organization s financial and clinical outcomes Consider the metrics that best demonstrate improvements in the life of consumers and meet the needs of payers 32

33 Grafton s Measurement Of Value 1. Physical aggression towards others 2. Physical aggression towards self 3. Elopement (Bolting) 4. Lack of safety awareness (possibly to include PICA) 5. Lack of communication skills 6. Lack of minimal skills for self-care 7. Extreme inattention/impulsiveness 8. Extreme oppositional or conduct disordered behavior (possibly to include property destruction) 9. Sexual acting out 10. Suicidality All Rights Reserved.

34 3. Have The Proper Technical Systems In Place To Measure Value Value-based reimbursement and true population health management responsibilities dramatically increase the requirements that information systems must support in near real-time Beyond an EHR, your organization needs access to data across its multiple platforms : A Data Warehouse allows you to congregate Cost data from payroll and fiscal systems Clinical outcomes data from multiple sources Data-driven decision support platform Data without definition is just a wasteland Must know how you will use the data better and better decisions 34

35 Grafton s Performance Measurement System We use an internal Goal Mastery Process We develop and define expected progress Minimum Growth Line defines required slope Data Points Drive Clinical Decision Support REBOOT- Reliable Evidence Based Outcome Optimization Technology We track goals and objectives and port Goal Data to Data Warehouse 35

36 Goal Mastery Progress data are graphed and monitored using a Minimum Growth Line (MGL) an anticipated trajectory of progress to ensure goals are mastered by the anticipated mastery date. When progress is off track, we consider modifications to instruction or interventions. Example below is for a new skill being taught. Goal met MGL /20/09 11/13/09 11/6/09 10/30/09 10/23/09 10/16/09 10/9/09 10/2/09 9/25/09 9/18/09 9/11/09 9/4/09 8/28/09 8/21/09 8/14/09 8/7/09 7/31/09 7/24/09 7/17/09 7/10/09 7/3/09 6/26/09 6/19/09 6/12/09 6/5/09 5/29/09 5/22/09 5/15/09 5/8/09 5/1/09 4/24/09 4/17/09 4/10/09 4/3/09 3/27/09 3/20/09 3/13/09 3/6/09 2/27/09 2/20/09 2/13/09 2/6/09 1/30/09 1/23/09 1/16/09 1/9/09 1/2/09 12/26/08 12/19/08 12/12/08 12/5/08 11/28/

37 Setting the Example for Minimization of Restraints Closed April 1,

38 Setting the Example for Minimization of Restraints Explain that Restratints were D/C in Winc in FY15 and are not used in the ABA or EI programs The use of physical restraint for behavior management was discontinued in the Winchester program January 1,

39 4. Build A Culture Based On Performance To prepare your organization to succeed in a value-based market, you need to build a performance-driven culture Ask these six questions to determine is your organization is prepared for performance: Is it clear what specific team member is accountable for each critical performance metric revenue, program profitability, etc.? Are your C-Suite incessantly monitoring customer performance data both payer and consumer? Does customer experience drive your executive decisionmaking? Does performance measures change staffing qualitatively and quantitatively? Are team members terminated because they don t perform? Are team members rewarded because they have superior performance? 39

40 Grafton s Performance-Based Culture Grafton Key Performance Indicators Constant Measurement Internal Ukeru assessments No delivering our models to entities in 16 states We hold ourselves to the same standards 40

41 5. Demonstrate Your Value To Payers Start making contacts with payers and finding ways to demonstrate your value based on payer needs Meet with payers to identify problems and concerns and develop services and programs that address those payer problems Payers are looking for three things in a value-based market: 41 Increased transparency of performance Increase pressure for improvement Facilitate consumer-directed care Reimbursement linked to desired performance Improved access to care Increase care integration and coordination Person-centered planning and recovery focus Focusing on controlling costs of care Financial incentives to help consumers become and remain healthy for longer periods of time Increase lower-cost interventions for not yet seriously ill population Reduce unnecessary use of highcost services

42 Grafton Demonstrating Value To Payers First the payers have to want value. Virginia is Behind other states. We believe that tying goal achievement to functional improvement demonstrates our value and leverages our future worth Two Current White Papers Child ABA n=22 study Community Supports Waiver results program 42

43 Questions & Discussion

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