Ohio SIM: Episode-based payment updates Webinar June 29, 2017 www.healthtransformation.ohio.gov
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
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 Performance 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
Ohio s State Innovation Model (SIM) progress to date Ohio received SIM test award in 2014 to implement innovative payment models We are 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), with 12 additional episodes under development, all 43 to be reported on in 2017 Nine payers released performance reports on first wave of 6 episodes Thresholds for performance payments across Medicaid FFS and MCPs on Wave 1 and 2 episodes State released performance reports aggregated across Medicaid FFS and MCPs on second wave of 7 episodes State and federal authority approved Comprehensive Primary Care 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 released first performance reports to 92 CPC practices in May State and federal authority approved Sources: 5160-1-70 Episode based payments; 5160-1-71 Patient-centered medical homes (PCMH): eligible provider; 5160-1-72 Patient centered medical homes (PCMH): payments
Multi-payer participation is critical to achieve the scale necessary to drive meaningful transformation
Contents Update on reporting and payment Ohio CPC Overview Referral reports 6
Ohio s episode model is retrospective, building on the current FFS infrastructure already in place Patients and providers continue to deliver care as they do today Calculate incentive payments based on outcomes after close of 12 month performance period 1 Patients seek care and select providers as they do today 4 5 Review claims from the performance period to identify a Principal Accountable Provider (PAP) for each episode 2 3 Providers submit claims as they do today Payers calculate average risk-adjusted reimbursement per episode for each PAP Compare to predetermined commendable and acceptable levels 6 Payers reimburse for all services as they do today 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
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
Ohio s episode timeline 2014 2015 2016 2017 2018 2019 Wave 1 Perinatal, asthma, COPD, Acute PCI, Non-acute PCI, total joint replacement Reporting only Performance Y1 Performance Y2 Performance Y3 Wave 2 URI, UTI, cholecystectomy, appendectomy, upper GI endoscopy, colonoscopy, GI hemorrhage Reporting only Performance Y1 Performance Y2 Wave 3 Preliminary: HIV, Neonatal (3 episodes), Hysterectomy, Pancreatitis, Skin and soft tissue infection, Diabetic ketoacidosis, Lower back pain, Headache, CABG, Cardiac valve, Congestive heart failure, Breast cancer surgery, Breast medical oncology, Mastectomy, Otitis, Pediatric acute lower respiratory infection, Tonsillectomy, Shoulder non-operative injury, Wrist non-operative injury, Ankle non-operative injury, Knee non-operative injury, Femur / pelvis fracture, Knee arthroscopy, Spinal fusion, Spinal decompression w/o fusion, ADHD, Oppositional defiant disorder, dental (TBD) Reporting only Design Performance Y1 Reporting Only
EPISODES UPDATE Wave 3 episode design progress to date 2016 2017 Batch 1 Episodes Cardiac valve, CABG, CHF exacerbation, Hysterectomy Head-ache Low back pain Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Initial design Clinical input Finalization Jul Aug Sep 2 Neonatal (3 episodes), HIV, Pancreatitis, SSTI 1, Diabetic ketoacidosis Initial design Clinical input Finalization 3 Breast biopsy, Breast medical oncology, Mastectomy, Otitis, Tonsillectomy, palri 2 Initial design Clinical input Clinical input Finalization 4 Shoulder sprain, Wrist sprain, Ankle sprain, Knee spring, Hip/Pelvic fracture, Knee arthroscopy, Spinal decompression, Spinal fusion exc. cervical Initial design Initial design Clinical input Finalization 5 Dental episode (TBD) Initial design Initial design Clinical input Finalization BH ADHD and ODD Initial design Clinical input Finalization 1 Skin and soft tissue infection 2 Pediatric acute lower respiratory infection
Episode of Care Performance Report
Shift to consolidated reporting approach for Wave 1 for Medicaid as of August 2017 Reports distinct for each Medicaid plan Reports aggregated across Medicaid data for all plans Reports released by 1 Description Wave 1 Asthma exacerbation COPD exacerbation Perinatal Acute PCI Starting Q1 2017 (August) reports via ODM MITS portal One single pdf comprised of reports for each individual MCP Non-acute PCI TJR via ODM MITS portal One single pdf with one All Medicaid report Appendectomy Cholecystectomy Wave 2 Colonoscopy EGD GI hemorrhage via ODM MITS portal One single pdf comprised of reports for each individual MCP URI UTI NOTE: Reporting plan for Wave 3 episodes will be shared later in this presentation
How to Access your Episode Reports For Asthma, COPD and perinatal episode, reports are produced and delivered by each of the MCPs and ODM for FFS. For questions about access to your MCP report or questions about the report, please contact your MCP provider representative For Assistance accessing your ODM FFS reports or identifying your MITS Portal Administrator: ODM FFS reports are located in the MITS Provider Portal under the Reports Section Contact the Medicaid Provider Hotline 1-800-686-1516 Visit the Ohio Department of Medicaid website Provider tab, and click on the blue box in the right corner, Access the MITS Portal http://medicaid.ohio.gov/providers.aspx 13
How do I access my report(s)? Reports for Ohio Medicaid are available on the MITS portal MITS administrators have access to the portal and can pull down to share with others in a practice 14
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 15
Additional questions Questions Who do I reach out to if I have questions about my report? Will Wave 1 reports continue to come from different sources? What will happen for Wave 3? Response Please reach out to either Medicaid (Provider hotline 800.686.1516) or the plan from which you receive the report Contact information included in the cover letter for Wave 2 reports with plan-specific contact Wave 1 reports will be consolidated starting with Q1 2017 data (August report) Select Wave 3 reports will begin to be available in Fall 2017 16
Timing for episodes reporting over the next few months Wave 1 Wave 2 Wave 3 ~June 2017 PAPs receive report with full CY2016 performance 1 and preliminary eligibility for positive or negative payment, as well as an appended referral report 2 PAPs receive report with full CY2016 performance (informational only) No Wave 3 reports ~August 2017 PAPs receive report with data from Q1 2017 1 PAPs receive final CY2016 report indicating final positive or negative incentive amount 2 PAPs receive report with data from Q1 2017 PAPs receive report with data from Q1 2017 for 18 Wave 3 episodes Within 90 days of August reports Positive or negative incentive payments applied based on final report 2 N/A N/A 1 Applicable to all episodes in wave 2 Applicable only to Wave 1 episodes linked to payment (Asthma, COPD, Perinatal)
Contents Update on reporting and payment Ohio CPC Overview Referral reports 18
In parallel to the episodes model, Ohio launched a Comprehensive Primary Care (CPC) Program Ohio s CPC Program financially rewards primary care practices that keep people well and hold down the total cost of care There is one program in which all eligible practices participate, no matter how close to an ideal patient-centered medical home (PCMH) they are today. The program is designed to encourage practices to improve how they deliver care to their patients over time The Ohio CPC Program is designed to be inclusive: all Medicaid members are attributed or assigned to a provider The model launched with an early entry cohort in January 2017 and now has 111 Ohio CPC practices with over 836,000 Medicaid lives
High performing primary care practices engage in these activities to keep patients well and hold down the total cost of care
Ohio Comprehensive Primary Care (CPC) Program Requirements and Payment Streams Requirements Payment Streams 8 activity requirements Same-day appointments 24/7 access to care Risk stratification Population management Team-based care management Follow up after hospital discharge Tracking of follow up tests and specialist referrals Patient experience Must pass 100% 4 Efficiency measures ED visits Inpatient admissions for ambulatory sensitive conditions Generic dispensing rate of select classes Behavioral health related inpatient admits Must pass 50% 20 Clinical Measures Clinical measures aligned with CMS/AHIP core standards for PCMH Must pass 50% Total Cost of Care PMPM All required Shared Savings All required Based on selfimprovement & performance relative to peers
Ohio CPC Performance Report
Contents Update on reporting and payment Ohio CPC Overview Referral reports 23
Ohio s Price and Quality Transparency Initiative Ohio CPC Practice Report Referral Episode Performance Report Episode Specialist Referral for Primary Care xx Report
2017 Referral Report Details Who receives a report? What information is included? How is it sorted? What is the data timeframe? How often will providers receive the report? PAP referral report PAPs for perinatal, asthma, and COPD episodes By episode, all PAP names, riskadjusted cost indicator, quality indicator, and zip code, episode and quality metric summary All PAPs, alphabetical order Calendar year 2016 Annually CPC referral report Enrolled Ohio CPC practices By episode, PAP names, riskadjusted cost indicator, quality indicator, number of attributed members, and associated payers, episode and quality metric summary and CSV file Number of attributed members, and includes PAPs within radius Rolling 12 months (July report CY16) Quarterly (July, October, December)
Information will be given to PAPs before being distributed to CPC practices ILLUSTRATIVE Materials shared with PAPs will receive reports June 2017 PAP referral report (PDF file) Shows zip codes and cost / quality performance for all PAPs in the state Appended to the quarterly episode reports CPC practices will receive reports starting July 2017 CPC referral report (PDF file) Shows the number of patients receiving care from each PAP for a given CPC practice Displays PAP performance, with PAPs ordered by the current CPC practice s patient volume CPC detailed patient file (CSV file) One CPC practice-specific underlying data file to show the episodes and members that drive the patient utilization fields in the pdf report (one episode per row) Enables practices to develop their own analyses or tools 1 Member-level CSV file will be specific to each CPC practice
PAPs will receive a PDF file showing cost and quality performance against peers Description of report item This reports will be released late June 2017 ILLUSTRATIVE Episode cost is risk adjusted to enable an apples to apples comparison of PAPs ranges shown here correspond to the expected non-risk adjusted cost for the average patient, to provide insight on average impact to you and your peers have on total cost of care Risk-adjusted cost and quality metrics align with those in a PAP s episode report Individual quality metrics and targets required are shown on the context page of this report; also included is an overview of what s included in the episode The zip code is presented to allow PAPs to compare performance against peers
CPC practices will receive PDF reports showing episode performance across PAPs Description of report item ILLUSTRATIVE Starting Q2 2017, this report will be released quarterly Episode cost is risk adjusted to enable an apples-toapples comparison of PAPs ranges shown here correspond to the expected non-risk adjusted cost for the average patient, to provide insight on average impact you and your peers have on total cost of care The number of episodes over the last year from a given CPC practice is displayed in absolute and percentage terms Risk adjusted cost and quality metrics align with those in a PAP s episode report Individual quality metrics and targets required are shown on the context page of this report; also included is an overview of what s included in the episode Also included is a list of managed care plans for which this specific PAP has at least one episode
Increased transparency offered by PAP and CPC referral reports For potential future consideration Details to follow Provider performance shared with For example Today: Episode reports go to PAPs and CPC reports go to practices Starting June 2017: PAP cost and quality information shared with peer PAPs for select episodes Themselves Starting July 2017: PAP cost and quality information shared with CPC practices for select episodes Potential future application: For example, PAP performance can be used by Medicaid and other payers for network assessments Potential future application: For example, PAP performance can be shared with patients via a mobile app to aid in healthcare decision-making 1 E.g: Identifiable PAP performance shared with other PAPs 2 E.g. Identifiable episode PAP performance shared with PCMHs 3.E.g. Payer, software developers, academic researchers, etc.
Episode Based Payment: Next steps Thursday, June 29 Episode Update Webinar Friday, June 30 New episode reports available in MITS provider portal to PAPs including referral reports Post sample PAP referral report and PAP version of how to read reports on website July (TBD) Episode Based Payment Webinar August (TBD) Episode Based Payment Webinar
Where to find episodes information on the ODM website SOURCE: Ohio Department of Medicaid website 31