Hospital Rate Setting Rate Year 2016 Division of Health Care Access and Accountability Bureau of Fiscal Management March 31, 2015 1 Agenda 1. Introduction and Welcome 2. SFY 2015 Q2 Financial Dashboard 3. SFY 2014 Assessment Reconciliation Report 4. MY 2016 Hospital P4P Guide 5. RY 2016 Policy Requests 6. 7. Public Comment 8. Adjournment 2 1
SFY 2015 Q2 Financial Dashboard DHS uses a methodology for determining the hospital spending target based on actual data from the previous state fiscal year For RY 2016, actual Medicaid payments with DOP SFY 2015 will be used to determine the inpatient and outpatient hospital spending target DHS will provide quarterly updates to the financial dashboard leading up to the presentation of the completed spending target in August 2015 Review Handout 1: SFY 2015 Q2 Hospital Financial Dashboard 3 SFY 2015 Q2 Financial Dashboard DHS has provided an additional comparison summary of access payments to more appropriately compare the actual access payments paid for SFY 2015 and SFY 2014 Comparing access payment spending year-over-year is not meaningful because the access payment funding allocated to FFS varies from assessment model to assessment model Access payments paid in SFY 2015 with DOS in SFY 2015 as a percentage of the SFY 2015 Assessment Model total is now compared to access payments paid in SFY 2014 with DOS in SFY 2014 as a percentage of the SFY 2014 Assessment Model total for a better comparison As of the end of Q2, SFY 2015 access payments are outpacing SFY 2014 access payments, so the outlook is optimistic for avoiding another retroactive rate adjustment process Q2 SFY 2015 Q2 SFY 2014 Total SFY 2014 before Retroactive Adjustment FFS Inpatient 40.32% 37.98% 95.31% FFS Outpatient 45.11% 36.22% 88.84% Review Handout 2: SFY 2015 Q2 Access Payment Comparison 4 2
SFY 2014 Assessment Reconciliation Report DHS finalized the SFY 2014 Hospital and Critical Access Hospital Assessment Reconciliation Reports for the Legislature in December 2014 Retroactive FFS rate adjustments were made for hospitals in January Reconciliation payments were made to the HMOs at the end of January Acute Care and Rehab Hospitals Critical Access Hospitals HMO Reconciliation Payment $33,845,653 $763,461 FFS Retroactive Rate Increase $25,151,122 $411,452 Provider Tax Refunded $0 $0 Final Assessment Reconciliation Payment $58,996,775 $1,174,913 Review Handouts 3 & 4: Final Assessment Reconciliation Reports 5 MY 2016 Hospital P4P Guide DHS conducted a meeting with hospital quality contacts on March 11, 2015 to discuss updates to the Assessment and Withhold Hospital P4P programs for MY 2016 (April 1, 2015 March 31, 2016) The resulting MY 2016 Hospital P4P Guide is available on the ForwardHealth Portal at https://www.forwardhealth.wi.gov/wiportal/tab/42/icscontent/pro vider/medicaid/hospital/resources_01.htm.spage under the title April 1, 2015 MY 2015 payouts will occur by December 31, 2015 6 3
MY 2016 Hospital P4P Guide Withhold o Both inpatient and outpatient o 1.5% of payment withheld from FFS claims o Equal weight for each applicable measure (e.g. 4 measures 25% of withhold each) o Individual measures can yield 0%, 50%, 75%, or 100% earn-back o Leftover money distributed among hospitals as bonus payments o o So hospitals can earn-back more or less than was withheld from them CAHs and UW can only receive bonus payments up to their withheld amount Payment made by December 31 following measurement year Assessment o Inpatient only o No critical access or psychiatric hospitals o $5 million assessment funds split over three measures o Payout for each measure is total dollars / number of satisfactory hospitals o Payment made by December 31 following measurement year 7 MY 2016 Hospital P4P Guide Assessment P4P: no changes to measures or methodology Withhold P4P: no changes to methodology o 8 Pay-for-Performance measures (MY2015 had 6) o 2 Pay-for-Reporting measures (MY2015 had 2) o Changes from MY 2015: Moved Early Elective Induced Delivery and CAUTI to P4P from P4R Addition of SSI-Colon Surgery and SSI-Abdominal Hysterectomy to P4P Addition of CDI and MRSA measures to P4R Removal of SCIP and PN-6 8 4
RY 2016 Policy Requests DHS recorded the following RY 2016 policy requests at the December 2014 MHRAG meeting Rural/urban outlier trimpoints Provider-based billing (if not redefining outpatient hospital, at least using UB form) Billing therapies on the UB form Additional requests should be made at this time or in the next few days to allow DHS sufficient time to research, model, etc. for June Other requests at this time? 9 Biennial Budget Status DHS request from 9/2014 and Governor s Budget from 2/2015 used same underlying intensity increases for hospital services: 4.53% for inpatient hospital and 4.40% for outpatient hospital The hospital rate setting process is not tied to the biennial budget; rather, it derives from the financial dashboard (presented earlier) Governor s Budget includes a renewal of the $36 million/year supplemental DSH funding; formula streamlined but not expected to materially alter the distribution of the funds across hospitals If this provision of the budget is passed, DHS may need to reach out to hospitals for additional data in order to ensure compliance with CMS DSH audit requirements 10 5
$100K DSH Program Auditor procured for FY 2012 and FY 2013 Myers & Stauffer again, this time they ll be requesting data directly from hospitals These audits will apply to supplemental DSH as well starting in FY 2014 11 Inappropriate Inpatient Admission RAC Audits Per policy, if an audit determines that an inpatient service should have been outpatient, DHS recoups the difference between IP and OP reimbursement Under EAPGs, DHS cannot calculate what OP reimbursement would have been without data not supplied via the IP claim (e.g. HCPCS/CPT codes) DHS s intent is to provide the OP reimbursement, so if your hospital is contacted by the RAC auditor requesting this kind of data, DHS encourages you to supply it For hospitals unable to provide this kind of data, DHS can make other arrangements If DHS cannot obtain this data, or a hospital does not respond to a request for data, DHS must assume that OP reimbursement would have been $0 Hospital could rebill OP, but timely filing is likely to be an issue in most cases For questions, please contact Randy McElhose (608-267-7127 or randy.mcelhose@wisconsin.gov) 12 6
Settlements Letters for most FY 2008 2010 OP & Lab settlements have been mailed Some hospitals did not yet have audited cost reports for these years These settlements will continue for a few more years (until EAPG implementation) Letters for most FY 2009 FY 2010 CAH settlements coming soon Some hospitals did not yet have audited cost reports for these years FY 2010 is the last year for these settlements For questions, please contact Randy McElhose (608-267-7127 or randy.mcelhose@wisconsin.gov 13 Project Updates DHS is continuing to work on collecting the necessary data to model the effect of adding access payments for childless adults DHS is continuing to work on collecting the necessary data to model the provider-based billing requests New reporting tool for HMO access payments almost complete 14 7
Changes in Hospital Section Jonathan Thayil-Blanchard s last day was March 20, 2015 Brittany Rosales s first day was March 23, 2015 Joining Peter Pavich as a Hospital Budget and Policy Analyst M.A. in Political Science, Certificate in Health IT Formerly worked at Children s Hospital, strong background in WI hospitals David Hoffert s last day will be April 20, 2015 15 Request for Public Comment 16 8
Questions Chad Lillethun, Deputy Director Bureau of Fiscal Management Division of Health Care Access and Accountability Phone: (608) 267-7168 Chad.Lillethun@wisconsin.gov Krista Willing, Director Bureau of Fiscal Management Division of Health Care Access and Accountability Phone: (608) 266-2469 KristaE.Willing@wisconsin.gov All Questions can be sent by EMAIL to: DHSDHCAABFM@dhs.wisconsin.gov 17 9