Alternative Payment Mdels: Payment Mdel Innvatins in Lng-Term and Pst-Acute Care September 26, 2017 Alternative Payment Mdel An Alternative Payment Mdel (APM) is a payment apprach that gives added incentive payments t prvide high-quality and cst-efficient care. APMs can apply t a specific clinical cnditin, a care episde, r a ppulatin. Surce: CMS Quality Payment Prgram 1
Learning Objectives Develp an understanding f new payment mdels such as Medicare ACOs and pst-acute bundled payment prgrams Identify the key reasns t cnsider participatin in APMs Understand the primary pprtunities fr lng-term and pstacute rganizatins Evaluate yur rganizatin s readiness t participate Overview Why are (APMs) Imprtant? APMs that are active tday What t expect if yu wish t participate in APMs 2
Understanding the Current State: Overall Health Care Industry Quality and Value Based Purchasing DHHS prpsed 50% Medicare fees tied t quality r Value Based Purchasing by 2018 MedPac Better quality care while incentivizing prviders t cnstrain cst and cntrl spending Reduce rates CMMI Center fr Medicare & Medicaid Innvatin (the Innvatin Center) Grwth utside f gvernment payrs Medicare Advantage plans are implementing r establishing gals fr value-based payments CMS is wrking with plans n multi-payr initiatives t align FFS and managed care value-based payment gals Where Innvatin Mdels Are Being Run r Tested Natinally Surce: https://innvatin.cms.gv/initiatives/map/index 3
Where Innvatin Mdels Are Being Run r Tested in Pennsylvania Surce: https://innvatin.cms.gv/initiatives/map/index Medicare Mney Linked t APMs 4
Current State: Hme Health and Skilled Nursing Industries Cntinued changes and price pressure frm traditinal payment surces Rebasing Pre-claim review Increased Medicare Advantage enrllment Hme Health Value Based Purchasing; SNF Value Based Purchasing (2019) New Medicare hme health payment mdel n hrizn Emphasis n utcmes Shift Frm Fee Fr Service t Value Payments Lwer Risk --------------------------------------------------- Higher Risk FFS Episdic Perfrmance Based Bundled Shared Savings/ Shared Risk Capitatin 5
Why Engage with APMs? Hme Health and SNF Partnership Opprtunity Alternative surces f revenue share in risk/reward Shw value Increase market share Speed at which APMs are made available has been increasing Strategic partners are requesting it Future benefits that may be utside f the APM (data) Accuntable Care Organizatins (ACOs) Intrduced in 2011 as part f the ACA Cmpsed f service prviders and suppliers that are assigned a ppulatin f Medicare beneficiaries with the gal f imprving quality and experience f care while reducing the rate f grwth in health care spending Beneficiaries cntinue t have the right t chse prviders ACOs are assessed fr quality and financial perfrmance 6
ACO Details Payments Prviders cntinue t receive FFS reimbursement Financial benchmarks are assigned based n histrical expenditures fr assigned beneficiaries Quality perfrmance standards must be met t receive shared savings payments Types f ACOs Pineer ACO Medicare Shared Savings Prgram Next Generatin ACO Shared Savings Prgram -2016 Figures 433 ACOs Cver 7.7 Millin Beneficiaries Prgram Savings $429 millin 84% verall imprvement in quality measures frm 2014 t 2015 119 ACO earned shared savings and met quality standards 2012 42% Savings 2013 37% Savings 2014 22% Savings 2015 21% Savings 7
Pineer ACO Medicare Pineer ACO 32 health rganizatins in 2012 8 in 2016 Initial incentive fr data submissin Fllwing years shared savings and lss mdel 2016 results 12 Pineer ACO ttal mdel savings $37 millin 4 Pineer ACO generated lsses Next Generatin ACO Mdel Began January 2016 45 participating ACOs Higher levels f financial risk and reward Testing Ppulatin Health mdels driven by capitated payment Waivers fr: Expanded use f telehealth Skilled nursing hme 3 day rule Pst-Discharge Hme Visits Encuraging crss cntinuum care 8
Hme Health and SNF ACO Opprtunity Preferred Prvider Agreements with ACOs with a fcus n: Care Crdinatin/Transitins Increased Efficiency fr Seeing Patients Timely Imprving Quality f Care Sharing Data CMS Apprval Prcess Review f Quality Scres Emphasis n Hme Health and SNF Partnerships Bundled Payment Care Initiative (BPCI) Mdels BPCI vs ACO BPCI nly apply t mdel descriptins vs ACO applies t grup f beneficiaries Mdel 1 Retrspective Acute Care Inpatient Stay Mdel 2 Retrspective against Target Price Inpatient stay initiates Episde Episde runs 30, 60 r 90 days 9
Bundled Payment Care Initiative (BPCI) Mdels Cnt d Mdel 3 Retrspective with actual expenditures against target price Episde triggered with hspital stay Episde STARTS with pst acute services within 30 days f discharge acute care Ends 30, 60 r 90 days Mdel 4 Bundled payment cvering hspital, physicians, practitiners Episde begins with hspital stay N claims submitted t MC Related 30 day readmissins part f bundle Cmprehensive Care fr Jint Replacement (CJR) Mdel Initiated 2016 fr select 67 gegraphic areas Hip and knee replacement surgeries MS DRG 469 and 470 Episde f care starts at admissin and ends 90 days pst discharge Prviders and suppliers paid per usual FFS End f year expenditures cmpared t Medicare target episde pricing Pst acute cllabratrs encuraged t cllabrate with care redesign Pst acute cllabratrs can include risk sharing and rewards 2017 new DRG fr hip and femur fractures added t CJR mdel 10
Cardiac Care Bundled Payment Recently delayed and nw effective n Octber 1, 2017 Episde starts with admissin t hspital with MI r CABG surgery Inpatient stay and 90 days pst discharge FFS payment cntinues End f year spending cmpared t Medicare quality adjusted target episde pricing Pst acute prviders encuraged t cllabrate Pst acute prviders can participate in risk r shared savings Dwnside risk des nt start until perfrmance year 3 Medicare Access and CHIP Reauthrizatin Act (MACRA) Replaced the Physician s Sustainable Grwth Rate Frmula Physician payments nw cnnected t quality and cst f care prvided Physician can chse tw prgrams: Merit-Based Incentive Payment System (MIPS) Advanced Alternative Payment Mdel (Advanced APM) 11
MACRA Cnt d Payment Adjustments MIPS Payment adjustments are weighted fr scre quality, resurce use, meaningful use and practice imprvement 2019 +/- 4%, 2020 5%, 2021 7%, 2022 9% 2019 t 2024 Exceptinal perfrmers may have additinal adjustments 2026-0.25% annual baseline payment update Advanced APM 2019 2024 includes a 5% annual lump sum bnus Transitin int payment with mre risk 2026 and beynd 0.75% annual baseline payment update MACRA Cnt d Physicians must reprt data thrugh PQRS r 2% reductin HH Agencies and SNFs can help with PQRS reprting by prviding data frm OASIS and SOC and MDS and admissin data Flu Vaccinatin Pneumcccal Vaccinatin Weight Assessments and cunseling Tbacc use and cessatin Fall Risk Assessment Fall Plan f Care 12
Medicare Care Chice Mdel 141 participants in the mdel Mdel is designed t: Increase access t supprtive care services prvided by hspice Imprve quality f life and patient/family satisfactin Imprve new prspective payment systems fr the Medicare and Medicaid prgrams Been difficult fr hspices t identify eligible patients with mst participating hspices having less than 15 participants Reimbursement is $200 t $400 per patient per mnth Value Based Purchasing- Hme Health CMS mandated in 9 states Episde begins with admissin t Hme Health and ends with episde Based n OASIS Outcmes, HHCAHPS, claims data, and ther measures Cmpete against ther prviders in yur state Benchmark, Achievement Threshld, and Imprvement scring n each utcme Starting in 2018, episdic reimbursement will be based n TPS scre with +/- 3% and increasing t +/- 8% in 2022 13
Value Based Purchasing- What t Expect with SNF Prgram t start in fiscal year 2019 Payment will be based n quality f care, nt just quantity f services Based n established measures Skilled Nursing Facility 30-Day All-Cause Readmissin Measure (SNFRM) Estimates the risk f unexpected readmissins fr FFS Medicare patients at PPS, Critical Access r Psychiatric Hspitals r any cause r cnditin Skilled Nursing Facility 30-Day Ptentially Preventable Readmissin Measure (SNFPPR) Estimates the risk f preventable readmissins fr FFS Medicare patients at PPS, Critical Access r Psychiatric Hspitals r any cause r cnditin APM Expectatins in the Hme Health and SNF Setting 14
What t Expect Get paid less t d mre Expect t see higher acuity patients Easy CJR, AMI, and CABG patients may skip right ver hme care t the utpatient setting Increase in LUPA claims and shrt SNF LOS and lw therapy utlizatin Agencies need t imprve service delivery time Be cgnizant f impact t quality f care Discharge planning Need fr true partnerships acrss a variety f prvider types t impact/change culture Ex - CJR patient educatin n pst acute care prir t surgery Strategic Partnerships Dn t assume that health system APM participants are utilizing their wn prviders Be patient and persistent! Typically takes 12-18 mnths t g thrugh this prcess Develp prgrams that health systems view as valuable Preventing ER visits Discharging patients t hme frm ER SNF bypassing and/r earlier SNF discharge Health system hiring f care crdinatrs/navigatrs vs. hme health Des the APM incentives align with the HHA r SNF? 15
Value Prpsitin Share Yur Organizatin s Stry!!! Ability t Manage Readmissins Patient Outcmes Relative t Peers Episdic Management Capabilities Knwledge f Care Planning Fcus n Patient Centered Care Scpe f Service Lines and Outcmes Data Sharing with Partners Create yur wn playbk with the gal f hw t eliminate the need fr hspitalizatin What t d next? Market Analysis Review CMS map t determine what APMs are happening in yur market Are yu getting referrals frm these APM participants? What des yur data shw fr these referrals surces? Organizatinal Analysis Review CMS map t determine what APMs are happening in yur market Are yu getting referrals frm these APM participants? What des yur data shw fr these referrals surces? Outcmes Analysis D yur utcmes shw value t yur ptential partner? 16
QUESTIONS? Cntact Infrmatin: www.blacktreehealthcarecnsulting.cm Diane Link RN, MHA Directr, Clinical Services DianeLink@blacktreehealthcare.cm Vicki Freedman, MBA Assciate VickiFreedman@blacktreehealthcare.cm 17
Thank yu! 18