MEDICARE UPDATES: VBP, SNF QRP, BUNDLING PRESENTED BY: ROBIN L. HILLIER, CPA, STNA, LNHA, RAC-MT ROBIN@RLH-CONSULTING.COM (330)807-2850 MEDICARE VALUE BASED PURCHASING 1
PROTECTING ACCESS TO MEDICARE ACT OF 2014 (PAMA) IMPLEMENTS A VALUE BASED PURCHASING PROGRAM (SNF VBP) 2% WITHHOLD TO PART A PAYMENTS THAT CAN BE PARTIALLY EARNED BACK BASED ON REHOSPITALIZATION RATE AND LEVEL OF IMPROVEMENT PASSED IN 2014, RATES NOT IMPACTED UNTIL FY 2019 (OCTOBER 1, 2018); DETAILS TO BE DEVELOPED BY CMS RULEMAKING PAMA VBP IMPLEMENTATION TIMELINE FY 2016 MEASURE DEVELOPMENT, DATA COLLECTION FY 2017 SNF PREVIEW OF DATA FY 2018 PUBLIC REPORTING OF DATA FY 2019 (OCTOBER 1, 2018) WITHHOLD IMPLEMENTED 2
FY 2016 PPS UPDATE RULE CMS SELECTED THE SKILLED NURSING FACILITY 30-DAY ALL-CAUSE READMISSION MEASURE RISK ADJUSTED REHOSPITALIZATION MEASURE (SNFRM NQF #2510) WILL MOVE TO POTENTIALLY PREVENTABLE REHOSPITALIZATION MEASURE SNFRM BACKGROUND HOSPITAL READMISSIONS OF MEDICARE VBENEFICIARIES DISCHARGED FROM A SNF ARE COMMON, STUDIES SUGGEST A LARGE PROPORTION ARE PREVENTABLE HOSPITAL READMISSIONS ALSO PUT BENEFICIARIES AT RISK FOR COMPLICATIONS THE INTENT OF THE SNFRM IS TO ENCOURAGE SNF PROVIDERS TO MONITOR AND REDUCE HOSPITAL READMISSIONS, THEREBY REDUCING COSTS AND IMPROVING THE QUALITY OF CARE MEDICARE BENEFICIARIES RECEIVE DURING THEIR SNF STAY 3
SNFRM MEASURE OVERVIEW SNFRM ESTIMATED THE RISK-STANDARDIZED RATE OF ALL-CAUSE, UNPLANNED HOSPITAL READMISSIONS FOR SNF BENEFICIARIES WITHIN 30 DAYS OF DISCHARGE FROM THEIR PRIOR PROXIMAL SHORT-STAY ACUTE HOSPITAL DISCHARGE SNF ADMISSION MUST HAVE OCCURRED WITHIN 1 DAY AFTER DISCHARGE FROM THE PROXIMAL HOSPITAL STAY MEASURE BASED ON DATA FOR 12 MONTHS OF SNF ADMISSIONS BENEFICIARIES WITH MORE THAN ONE ELIGIBLE ADMISSION MAY BE INCLUDED IN THE MEASURE MULTIPLE TIMES WITHIN A GIVEN YEAR SNFRM MEASURE OVERVIEW - EXCLUSIONS SNFRM EXCLUDES CERTAIN STAYS: STAYS FOR WHICH PATIENT HAD INTERVENING PAC ADMISSION BETWEEN HOSPITAL STAY AND SNF OR AFTER SNF DISCHARGE PATIENTS WHO DID NOT HAVE FFS PART A ENROLLMENT BEFORE PROXIMAL HOSPITAL DISCHARGE PATIENTS WHO DID NOT HAVE FFS PART A ENROLLMENT FOR ENTIRE 30 DAY RISK WINDOW PATIENTS WHOSE HOSPITALIZATION WAS FOR THE MEDICAL (NONSURGICAL) TREATMENT OF CANCER OR RECEIVING REHABILITATION CARE OR PROSTHESIS FITTING 4
SNFRM MEASURE OVERVIEW SNF RM PRODUCES A RISK-ADJUSTED READMISSION RATE FOR EACH FACILITY, EXCLUDING PLANNED READMISSION FROM THE SNF MEASURE IS COMPUTED BY CALCULATING THE STANDARDIZED RISK RATIO (SRR): THE PREDICTED NUMBER OF READMISSIONS AT THE FACILITY DIVIDED BY THE EXPECTED NUMBER OF READMISSIONS FOR THE SAME PATIENTS IF THESE SAME PATIENTS HAD BEEN TREATED BY THE AVERAGE SNF SRR IS THEN MULTIPLIED BY THE MEAN RATE OF READMISSION IN THE POPULATION TO GENERATE THE FACILITY-LEVEL STANDARDIZED READMISSION RATE, REFERRED TO AS THE RISK- STANDARDIZED READMISSION RATE OR RSRR SNFRM MEASURE OVERVIEW MEASURE IS DESIGNED TO CAPTURE THE OUTCOME OF UNPLANNED ALL-CAUSE HOSPITAL READMISSIONS OCCURRING WITHIN 30 DAYS OF DISCHARGE FROM THE PATIENTS PRIOR PROXIMAL ACUTE HOSPITALIZATION HOSPITAL OBSERVATION STAYS DO NOT COUNT AS A READMISSION READMISSIONS IDENTIFIED AS BEING PLANNED USING THE CMS PLANNED READMISSION ALGORITHM ARE EXCLUDED SNFRM IS EVALUATED ON A 1-YEAR CYCLE 5
SNFRM PLANNED READMISSION PLANNED READMISSION IS DEFINED AS ANT NON-ACUTE READMISSION IN WHICH ONE OF A SET OF TYPICALLY PLANNED PROCEDURES OR DIAGNOSES OCCURRED IF ANY OF THE PROCEDURES DENOTED AS PLANNED OCCUR IN CONJUNCTION WITH A DIAGNOSIS THAT DISQUALIFIES A READMISSION FROM BEING CONSIDERED PLANNED, THE READMISSION WILL BE CONSIDERED TO BE UNPLANNED SNFRM PLANNED READMISSION PLANNED READMISSION PROCEDURES: ONE OF A PRE-SPECIFIED LIST OF PROCEDURES TOOK PLACE, OR READMISSION FOR BONE MARROW, KIDNEY OR OTHER TRANSPLANT PLANNED READMISSION DIAGNOSES: MAINTENANCE CHEMOTHERAPY AND REHABILITATION READMISSIONS TO PSYCHIATRIC HOSPITALS OR UNITS ADMISSIONS FOR ACUTE ILLNESS OR FOR COMPLICATIONS OF CARE ARE NOT CLASSIFIED AS PLANNED, EVEN IF A TYPICALLY PLANNED PROCEDURE IS PERFORMED DURING THE STAY PRINCIPAL DIAGNOSIS AND ALL PROCEDURE CODES FROM THE READMISSION ARE UTILIZED TO IDENTIFY PLANNED READMISSIONS 6
SNFRM RISK ADJUSTMENT COVARIATES USED IN THE MEASURE: AGE, GENDER PROXIMAL HOSPITALIZATION LOS TIME IN ICU? ESRD # ACUTE CARE HOSPITALIZATIONS IN 365 DAYS BEFORE PROXIMAL HOSPITALIZATION PRINCIPAL DIAGNOSIS SYSTEM-SPECIFIC SURGICAL INDICATORS KIDNEY, CARDIAC, VASCULAR PATIENTS WITH SURGICAL INDICATORS ARE HIGHER RISK ORTHO WITH SURGICAL INDICATOR ARE LOWER RISK INDIVIDUAL COMORBIDITIES ESRD, DIABETES, HEART FAILURE, PRESSURE ULCERS MULTIPLE COMORBIDITIES CHARLSON COMORBIDITY INDEX IS CALCULATED USING BOTH THE NUMBER AND SERIOUSNESS OF COMORBIDITIES FY 2017 PPS UPDATE RULE FY 2016 PPS UPDATE RULE SPECIFIED THE USE OF THE SNF REHOSPITALIZATION MEASURE (SNF RM) FOR VALUE BASED PURCHASING RATE ADJUSTMENTS EFFECTIVE OCTOBER 1, 2018 FY 2017 UPDATE RULE ANNOUNCES TRANSITION TO A POTENTIALLY PREVENTABLE REHOSPITALIZATION MEASURE ( SNFPPRM ) AT SOME POINT 30 DAY MEASURE SIMILAR TO THE SNF RM, BUT ONLY COUNTS REHOSPITALIZATIONS WITH A DIAGNOSIS ON HOSPITAL CLAIM THAT IS CONSIDERED POTENTIALLY PREVENTABLE (I.E., COPD, CHF) THIS IS A SPECIFIC LIST OF DIAGNOSES, COVERS MOST ADMISSIONS RLH Consulting 14 7
FY 2017 PPS UPDATE RULE PERFORMANCE PERIOD JANUARY 1, 2017 TO DECEMBER 31, 2017 IMPROVEMENT PERIOD IMPROVEMENT TO BE CALCULATED OVER RATE FROM TWO YEARS BEFORE PERFORMANCE PERIOD CY 2017 IMPROVEMENT OVER CY 2015 CMS ANNOUNCED PLANS TO TRANSITION FROM A CALENDAR YEAR MEASUREMENT PERIOD TO A FISCAL YEAR MEASUREMENT PERIOD BEGINNING OCTOBER 2017, SO THE QUARTER FROM OCTOBER 1 THROUGH DECEMBER 31, 2017 WILL COUNT IN TWO DIFFERENT RATE YEAR ADJUSTMENTS RLH Consulting 15 FY 2017 PPS UPDATE RULE REHOSPITALIZATION SCORE USED TO CALCULATE PAYMENT RATE CAN RANGE FROM 0 TO 100 POINTS IT WILL BE THE HIGHER OF THE FACILITY ACHIEVEMENT SCORE OR IMPROVEMENT SCORE FACILITIES WILL BE RANKED BASED ON REHOSPITALIZATION SCORE TO DETERMINE PAYMENT ADJUSTMENT RLH Consulting 16 8
FY 2017 PPS UPDATE RULE ACHIEVEMENT SCORE OF 0 TO 100 IS AWARDED BASED ON RANKING OF THE REHOSPITALIZATION RATE IN THE PERFORMANCE PERIOD SNFS IN LOWEST 25% RECEIVE 0 POINTS SNFS IN TOP 5% RECEIVE 100 POINTS FORMULA PROPOSED FOR ALLOCATING POINTS TO REMAINING SNFS RLH Consulting 17 FY 2017 PPS UPDATE RULE IMPROVEMENT SCORE OF 0 TO 90 POINTS AWARDED BASED ON IMPROVEMENT OVER A TWO- YEAR PERIOD A UNIQUE IMPROVEMENT RANGE IS ESTABLISHED FOR EACH SNF THAT DEFINES THE DIFFERENCE BETWEEN THEIR BASELINE PERIOD SCORE AND THE NATIONAL BENCHMARK ESTABLISHED RLH Consulting 18 9
FY 2017 PPS UPDATE RULE IMPROVEMENT SCORE, CONTINUED IF PERFORMANCE PERIOD SCORE IS EQUAL TO OR LOWER THAN IMPROVEMENT THRESHOLD, 0 POINTS AWARDED IF PERFORMANCE PERIOD SCORE IS EQUAL TO OR HIGHER THAN THE BENCHMARK, 90 POINTS AWARDED IF PERIOD SCORE IS GREATER THAN IMPROVEMENT SCORE, BUT LESS THAN THE BENCHMARK, BETWEEN 0 AND 90 POINTS WILL BE AWARDED USING A PROPOSED FORMULA RLH Consulting 19 FY 2017 PPS UPDATE RULE SNF PART A PAYMENT ADJUSTMENT WILL BE BASED ON REHOSPITALIZATION SCORE RANKING FACILITIES WILL BE TOLD THE PAYMENT ADJUSTMENT AT LEAST 60 DAYS PRIOR TO RATE EFFECTIVE DATE REMEMBER, FIRST PAYMENT ADJUSTMENTS EFFECTIVE OCTOBER 1, 2018 RLH Consulting 20 10
UPCOMING SNF VBP COMPONENTS CMS IS NOW PROVIDING QUARTERLY CONFIDENTIAL FEEDBACK REPORTS SO THAT FACILITIES CAN MONITOR THEIR PERFORMANCE CMS HAS POSTED A FILE WITH EVERY SNF 2015 BASELINE (2015) RISK STANDARDIZED READMISSION RATE THE FY2018 PPS UPDATE RULE WILL PROVIDE ADDITIONAL INFORMATION RELATED TO THE PAYMENT SPECIFICS IMPACT ACT 11
IMPACT ACT THE IMPACT ACT (2014) REQUIRED CMS TO SPECIFY STANDARD ASSESSMENT TOOLS ACROSS PAC PROVIDERS (HH, SNF, IRF, LTCH) ALONG WITH CROSS-SETTING QMS BY OCTOBER 2015 IN FOUR DOMAINS: FUNCTIONAL STATUS COGNITIVE FUNCTION AND CHANGES IN COGNITION SKIN INTEGRITY AND CHANGES IN SKIN INTEGRITY INCIDENCE OF MAJOR FALLS SNF QUALITY REPORTING PROGRAM (QRP) COLLECTION AND SUBMISSION OF DATA REQUIRED WITHIN TWO YEARS OF FINAL MEASURE SPECIFICATION (OCTOBER 2017) PROPOSED MEASURES REQUIRE TWELVE MONTHS OF DATA, SO DATA SUBMISSION REQUIRED BEGINNING OCTOBER 2016 2% PENALTY FOR FAILURE TO REPORT REQUIRED DATA (IMPLICATION OF DASHES ON MDS) FUTURE IMPLICATIONS FOR VBP 12
SNF PART A DISCHARGE ASSESSMENT THE MEASURES SPECIFIED FOR SNFQR REQUIRES AN ASSESSMENT BE COMPLETED AT THE END OF EACH PART A STAY TO CAPTURE QUALITY MEASURE ITEMS. DISCHARGE ASSESSMENTS ARE COMPLETED FOR PART A BENEFICIARIES WHO GO HOME AT THE END OF THE EPISODE OF CARE, BUT THERE IS CURRENTLY NOT AN END OF CARE ASSESSMENT REQUIRED FOR THOSE WHO WILL REMAIN IN THE FACILITY AT THE END OF PART A COVERAGE EFFECTIVE OCTOBER 1, 2016 A NEW SNF PART A PPS DISCHARGE ASSESSMENT IS REQUIRED IN THESE CIRCUMSTANCES SNF PART A DISCHARGE ASSESSMENT THE MEASURES SPECIFIED FOR SNFQR REQUIRES AN ASSESSMENT BE COMPLETED AT THE END OF EACH PART A STAY TO CAPTURE QUALITY MEASURE ITEMS. DISCHARGE ASSESSMENTS ARE COMPLETED FOR PART A BENEFICIARIES WHO GO HOME AT THE END OF THE EPISODE OF CARE, BUT THERE IS CURRENTLY NOT AN END OF CARE ASSESSMENT REQUIRED FOR THOSE WHO WILL REMAIN IN THE FACILITY AT THE END OF PART A COVERAGE EFFECTIVE OCTOBER 1, 2016 A NEW SNF PART A PPS DISCHARGE ASSESSMENT IS REQUIRED IN THESE CIRCUMSTANCES 13
SNF PART A DISCHARGE ASSESSMENT REVIEW CODING INSTRUCTIONS FOR A2400C AS WELL AS RETURN ANTICIPATED VS. RETURN NOT ANTICIPATED FOR A MEDICARE PART A DISCHARGE WHERE THE BENEFICIARY LEAVES THE FACILITY, THIS ASSESSMENT WILL BE COMBINED WITH THE OBRA DISCHARGE ASSESSMENT FOR A RESIDENT WHO WILL REMAIN IN THE FACILITY AFTER BEING DISCHARGED FROM MEDICARE, THIS WILL BE A STAND ALONE ASSESSMENT SNF QRP ASSESSMENT-BASED QUALITY MEASURES NQF #0674: APPLICATION OF PERCENT OF RESIDENTS EXPERIENCING ONE OF MORE FALLS WITH A MAJOR INJURY NQF #0678: PERCENT OF PATIENTS OR RESIDENTS WITH PRESSURE ULCERS THAT ARE NEW OR WORSENED NQF #2631 APPLICATION OF PERCENT OF LONG-TERMCARE HOSPITAL ADMISSIONS WITH AN ADMISSION AND DISCHARGE FUNCTIONAL ASSESSMENT AND A CARE PLAN THAT ADDRESSES FUNCTION 14
SNF QRP CLAIMS-BASED MEASURES DISCHARGE TO COMMUNITY POST ACUTE CARE (PAC) SKILLED NURSING FACILITY QUALITY REPORTING PROGRAM (QRP) POTENTIALLY PREVENTABLE 30-DAYS POST-DISCHARGE READMISSION MEASURE FOR SKILLED NURSING FACILITY QUALITY REPORTING PROGRAM MEDICARE SPENDING PER BENEFICIARY POST ACUTE CARE (PAC) SKILLED NURSING FACILITY MEASURE SNF QRP MEASURES CMS HAS POSTED SEVERAL RESOURCES: TABLE OF MDS ITEMS USED TO GENERATE SNF QRP MEASURES SNF QRP QUALITY MEASURES USER S MANUAL REVIEW AND CORRECT REPORTS 15
BUNDLING UPDATE MAJOR BUNDLING INITIATIVES Bundled Payments for Care Improvement (BPCI) Comprehensive Care for Joint Replacement (CJR) Episode Payment Models (EPMs) April 2013 Voluntary for all Medicare acute and PAC providers 4 models: acute, PAC, and acute+pac Providers can select from 48 clinical episodes to test within a specific timeframe (ranging from inpatient acute care to 30, 60, or 90 days after discharge) April 2016 5-year demo Mandatory bundles in 67 markets for Medicare beneficiaries who receive hip and knee replacements (also called lower extremity joint replacements or LEJR) Hospital is risk-bearer, impacts ~800 hospitals 90-day episodes January 1, 2018? 5-year demo? Mandatory bundles in 98 markets for heart attack, bypass surgery Mandatory surgical hip/femur fracture treatment episode added to 67 CJR markets Proposed in 2016, subsequently delayed twice (current start date is January 2018) Hospital is risk-bearer 90-day episodes 16
CMS SCALES BACK MANDATORY BUNDLING DEMOS 1. Completely withdraw proposed AMI, CABG, and SHFFT episodes 2. Reduce mandatory CJR markets from 67 to 34 (remaining 33 become voluntary) 3. No longer mandatory for rural and low-volume hospitals August 17, 2017 Proposed Rule Source: https://www.gpo.gov/fdsys/pkg/fr-2017-08-17/pdf/2017-17446.pdf HALF OF CJR MARKETS WOULD GO VOLUNTARY 17
IS SCALE-BACK A GOOD THING? SCALING BACK OF MANDATORY BUNDLING PROGRAMS COULD EASE THE PRESSURE ON SNFS, PARTICULARLY IN REFORM-HEAVY MARKETS WITH MANY COMPETING OVERLAPPING VALUE-BASED INITIATIVES SNF OPPORTUNITY TO SHARE RISK IN HOSPITAL-CONTROLLED, MANDATORY PROGRAMS IS LIMITED CONCERNS OVER UNINTENDED CONSEQUENCES ON PATIENT ACCESS TO SNF SERVICES DOESN T MEAN BUNDLING GOES AWAY CMS TO EXPAND VOLUNTARY OPTIONS WE EXPECT TO CONTINUE TO OFFER OPPORTUNITIES FOR PROVIDERS TO PARTICIPATE IN VOLUNTARY INITIATIVES, INCLUDING EPISODE PAYMENT MODELS. BUILDING ON THE BPCI INITIATIVE, CMMI EXPECTS TO DEVELOP NEW VOLUNTARY BUNDLED PAYMENT MODEL(S) DURING CY 2018 THAT WOULD BE AN ADVANCED APM. 18
ADVANCED BPCI: DETAILS STARTING TO EMERGE MODELS 1 AND 4 OF BPCI NOT LIKELY TO BE CONTINUED LOOKING TO BUILD OFF EXISTING BPCI RISK-BEARING ARCHITECTURE LIKELY TO CONTINUE TO USE CONVENER AND EPISODE INITIATORS STRUCTURE TWEAKS UNDER CONSIDERATION BY CMS INNOVATION CENTER: ALLOWING NEW PARTICIPANTS NEWLY DEFINED EPISODES LONGER PERFORMANCE PERIODS TARGET PRICE CALCULATION ENSURING THAT THE NEW MODEL QUALIFIES AS MACRA ADVANCED APM ADVANCED BPCI: WHAT WE RE WATCHING FOR DOES IT MAINTAIN A MODEL 3-LIKE OPTION FOR PAC PROVIDERS TO DIRECTLY BEAR RISK FOR A PAC-ONLY EPISODE OF CARE? WILL EPISODE OPTIONS BE MAINTAINED? WILL THERE BE NEW EPISODE OPTIONS? (E.G., CHRONIC CARE EPISODE) WILL THERE BE BETTER RISK ADJUSTMENT AND RISK MITIGATION? WHAT TYPE OF DATA AND HOW FREQUENTLY WILL CMS PROVIDE TO APPLICANTS/PARTICIPANTS? WHAT WILL THE TECHNOLOGY REQUIREMENTS BE? 19
WHY ENGAGE IN VOLUNTARY BUNDLES? Learn by doing; force culture change Understand markets through data Improve quality through care redesign Earn positive margins Master skills for gainsharing in other arenas Immediate Consider participating in Advanced BPCI ACTION STEPS Understand who in your market is bearing downside risk Find out if referral hospitals are staying in CJR could impact BPCI If you are serious about participating in Advanced BPCI Evaluate potential convener relationship Identify clinical/ episode focus areas Systematically reach out with your (quality & cost) value proposition 20