Technical Overview of HCIP/CCIP Using Care Redesign to Align Provider Incentives Presentation to HFMA, Maryland Chapter HSCRC Care Redesign Summit August 18, 2017
Facilitators Nicole Stallings Vice President, Policy & Data Analytics Maryland Hospital Association
Learning Objectives At the end of this session, you will understand: The authority provided under the newly-approved Care Redesign Amendment The details of the two initial care redesign programs: Hospital Care Improvement Program (HCIP) and Complex and Chronic Care Improvement Program (CCIP) The next steps for care redesign initiatives and some of the challenges that lie ahead
Maryland's All-Payer Model The boldest proposal in the United States in the last half century to grab the problem of cost growth by the horns. Uwe Reinhardt Princeton University health care economist IHI Triple Aim
Journey from Volume to Value Source: Adapted from Ian Morrison, 2011 5
Physician Alignment Strategies Non-compensatory Shared infrastructure, analytics, other resources Better quality and cost reporting Investment to support practice delivery (i.e. care management support) Compensatory Pay for performance Gainsharing Shared Savings Episodic payments, bundles Population-based models Some of these strategies face legal barriers that would first need to be addressed including State and federal Stark laws, the Anti-Kickback Statute, the False Claims Act, the Civil Monetary Penalty Act, antitrust limitations, IRS limitations on charitable hospitals, and State insurance law restrictions. --Final Report of the HSCRC Physician Alignment & Engagement Workgroup. June 2014 6
Care Redesign Amendment: Background Approved May 2017 Allows hospitals to implement Maryland-designed Care Redesign Program (CRP) with hospital-based and community-based care partners Aimed at supporting: Effective care management and population health activities Improvement in care for high and rising risk populations Efforts to provide high quality, efficient, well-coordinated episodes of care Hospitals and their care partners in monitoring and moderating the growth in Medicare beneficiaries Total Cost of Care (TCOC) Next steps toward delivery system transformation 7
Care Redesign Amendment: Initial Programs Starting July 2017 Voluntary participation Two initial CRP Tracks approved to align hospitals and other providers However, also focused on ability to add tracks or modify programs based on stakeholder need and input Hospital Care Improvement Program (HCIP) Designed for hospitals and Care Partners practicing at hospitals Hospitals improve care and save money through more efficient episodes of care Physicians may share in those gains Goal: Facilitate improvements in hospital care that result in care improvements and efficiency Complex and Chronic Care Improvement Program (CCIP) Designed for hospitals and communitybased Care Partners Hospitals and Care Partners collaborate on care of complex and chronic patients Hospitals provide resources to practices that should improve quality and reduce costs Goal: Enhance care management and care coordination 8
CRP Tools Amendment provides hospitals and their hospitalbased and non-hospital care partners the following tools: Access to comprehensive Medicare data Opportunity for hospitals to share resources and pay incentives to their care partners Support for providers under MACRA (requested) Flexibility to add/modify/delete care redesign programs, and accelerate transformation for Phase 2 of All-Payer Model 9
Total Cost of Care (TCOC) Guardrail For hospitals to be make incentive payments, the first hurdle is to meet the TCOC Guardrail All hospitals meet the TCOC Guardrail test for the first two performance periods Relied on our statewide TCOC success to set a TCOC Trend Factor that all hospitals satisfied Episodic costs not used Geographic costs based on hospital PSAs 10
Timeline Performance Period 1: July 1 Dec. 31, 2017 16 hospitals participating Performance Period 2: Jan. 1 Dec. 31, 2018 For Performance Period 1: CRP Committee established Participating hospitals working to enroll approved Care Partners Preparing for submission of CRP Reports to HSCRC and CMS User Groups convened to support implementation and inform modifications for Performance Period 2 11
HCIP Participants Performance Period 1 Atlantic General Hospital Doctors Community Hospital Frederick Memorial Hospital Holy Cross Hospital Holy Cross Hospital - Germantown Mercy Medical Center Meritus Medical Center Shady Grove Medical Center Washington Adventist Hospital Western Maryland Health System 12
CCIP Participants Performance Period 1 Carroll Hospital Garrett Regional Medical Center Greater Baltimore Medical Center Northwest Hospital Sinai Hospital St. Agnes Hospital 13
Hospital Care Improvement Program
Purpose Allows hospitals to incentivize hospital-based physicians to reduce inpatient hospital use, readmissions and other potentially avoidable utilization and improve care by performing care redesign activities Intended to improve the delivery of healthcare services during the inpatient stay by focusing on efficient use of resources Drives improvement in priority areas and creates important linkage to other hospital efforts (e.g. ACOs, clinical integration, population health) to provide care more efficiently and effectively 15
HCIP: Modeled After NJ Demonstration $112,692,977 cumulative savings, $822 per admission or 8.5% NOTE: Savings analysis is a comparison of actual cost to base year cost adjusted for inflation, case-mix and SOI (i.e. expected cost). Source: Agency for Healthcare Research and Quality. (2014, July 16). Hospital Gain-Sharing Program Offers Incentives to Physicians Based on Their Efficiency, Producing Significant Cost Savings Without Decline in Quality. Innovations Exchange. Rockville, MD, USA. 16
Program Overview Incentives are based on individual performance. Physicians are not required to join a group to participate; not paid per capita. Methodology provides a direct linkage to measurable results. Methodology incorporates adjustments to emphasize Improvement and/or Performance. CRP Committee, composed of at least 50% physicians, conditions incentive payments based on specific quality and care redesign initiatives. Methodology can be extended to consultants and ancillary physicians at the decision of the institution. 17
Design Principles Purpose: Recognize the important role of physicians in contributing to efficient hospital operations 18 Rewards achieved levels of performance, incent improved performance Safeguards to ensure patient protections, maintain quality of care Measurement: Performance is rewarded based on regionally derived Best Practice Norms 25th percentile of lowest patient costs in MD hospitals Responsible Physician/Physician of Record eligible for incentive Ability to add specialists, consultants and ancillary physicians 18
Securing Physician Buy-In Voluntary participation for private physicians; Employed physician participation determined by hospital No change in physician professional payment Incentive only; No risk or penalties Emphasizes Quality: Links quality metrics to incentive payment, including institution-specific objectives Severity of Illness: Utilizes severity adjusted, physician-specific data to identify savings opportunities, determine incentive payments Comprehensive: Includes all DRGs (except psych, deliveries and newborns) 19
Care Redesign Interventions Care redesign interventions are activities the hospital will develop for implementation in hospital based care. Hospitals may select one, multiple or all of the care redesign interventions. Standard Measures Required Other Measures determined by Hospital Steering Committee and consistent with other hospital initiatives 20
Care Redesign Interventions (Continued) Category of Allowable Activity Care Coordination Discharge Planning Clinical Care Patient Safety Patient & Caregiver Experience Population Health Efficiency and Cost Reduction 21
Integrating HCIP into a Global Model Specific APR DRGs, severity levels and outpatient clinical categories Identify broad clinical categories that should not be treated in a hospital setting Payment to specific physicians could be conditioned based on potentially avoidable admission rates related to specific APR DRG and / or severity levels Incentives / penalties could be linked to the departments or specialties that play a role in the clinical categories identified by the Commission Length of Stay (LOS) specific objectives can be established utilizing payer specific data (i.e. Medicare) or total LOS to align with the Waiver tests 22
Maximum HCIP Incentive Payment Pool by Hospital Maximum Pool totals $17 million across all hospitals for Performance Period One Whether or not an individual hospital s HCIP includes care partner incentives is at the discretion of the hospital If electing to pay incentives under HCIP, a hospital must pay in accordance with the approved HCIP Track Implementation Protocol and may set a maximum that is lower than the HCIP Incentive Payment Pool amount shown in the attachment All incentives are subject to the review and approval of the hospital s CRP Committee 23
Complex and Chronic Care Improvement Program
Purpose A complex and chronic care improvement program for the most seriously ill and those on the cusp of being the most seriously ill. An opportunity for hospitals to provide care management staff and care resources to help community providers care for patients. An innovative way to reduce medical expenses and improve health A program aligned with CMS s CCM fee requirements 25
Eligible Care Partners Community physicians and practitioners include all types of providers that are defined as eligible for the Chronic Care Management Fee (CCM). Family practice, general or specialist physician, clinical nurse specialists and nurse practitioners Must be designated by the patient as the primary provider of care Must agree to manage all the patient s care Only one provider may be selected by the patient as the manager of that patient s care. For purposes of this program, the eligible provider selected by the patient will be called the Patient Designated Provider (PDP). 26
How Does the CCIP relate to the CCM fee? Program requirements are designed to meet the billing requirements for CCM Patient requirements - Two or more chronic conditions Comprehensive care plan Care plans established, implemented and revised Continuous care management Patient agreement Structured reporting Access to care Hospital provided care management staff enables the process 27
Hospital Identifies the Patients The program is open to all Medicare FFS and Dual Eligible patients who are classified as high risk or rising risk patients. The hospital may use their own risk stratification tool of their choice. Hospitals must include high risk and rising risk patients in the program. A hospital may: Use a standard definition of high risk which is patients with 3 or more admissions or observations within 12 months and two or more chronic conditions, one of which is one of the following conditions: Diabetes, COPD, Heart Failure or Hypertension. Rising risk is composed of at least 2 chronic conditions, with one of them being same conditions above and at least 2 admissions or observations and 2 ED visits in the last 12 months. A hospital may also submit their own definition 28
Hospitals Partner with PDPs Hospitals will identify the PDP through patient selection in the hospital admission process, CRISP data, Medicare data or other methods. Hospitals will invite the PDP to participate. PDPs will be required to sign a state approved Care Partner Agreement. Hospitals will organize care management resources to assist the PDP s execution of care management activities. 29
The Role of the PDP PDPs must agree to: Provide direction to the care management team Deploy processes to invite patient participation Upload CCIP participating patient panels into CRISP including additions and deletions Use certified electronic health record technology. Agree to a structured recording of patient health information development and up keep of patient health care management plan. Complete the care redesign activities. They include ensuring the care plan is completed, reviewing the care plan before each office visit, ensuring medication reconciliation occur as appropriate, and a physician visit occurs within 7 days after a hospitalization PDPs may bill CCM fee when appropriate 30
CCIP Incentive Funding and Payouts Hospitals may elect to provide financial incentives to PDPs beginning in 2018. Three interacting goals must be accomplished for financial incentives to be paid: 1. PDPs complete a set of activities known to reduce the need for hospitalizations for each patient in the CCIP: Completion of a Care Plan- including a Health Risk Assessment (HRA) Medication management Post-discharge management including visit to physician within 7 days of discharge 2. The incentive pool from which PDPs are paid is funded by actual reductions in avoidable utilization. 3. Total Cost of Care (TCOC) Guardrails are met in order for incentives to be paid. 31
Next Steps for Care Redesign
Preparing for Performance Period 2 Modifications to Implementation Protocols and Participation Agreements Recruit new hospitals and care partners Pay out incentives from Performance Period 1 (HCIP) and prepare for ability to offer incentives for CCIP Explore expansion of programs beyond Medicare 33
Revising Maryland Patient Referral Law (MPRL) MPRL is broader than federal law (Stark) as it applies to all payers, all providers and all health care services Issue: (c)(1) Compensation arrangement means any agreement or system involving any remuneration between a health care practitioner or the immediate family member of the health care practitioner and a health care entity. 19 carve-outs from Maryland self-referral law, including: Compensation arrangements with academic medical centers Compensation arrangements between health care entities and employed health care practitioners 34
2017 Legislative Session Objective: Provide certainty in statute that protects value-based compensation arrangements (federal and commercial) from liability under Maryland s self-referral law SB 369/HB 403 was signed into law on April 18, 2017 Exempts a health care practitioner who has a specified compensation arrangement with a health care entity from the prohibition against self-referral Narrow exception to Maryland law; future changes may be necessary to promote alignment and innovation 35
Work Ahead Continue to improve and expand HCIP and CCIP Explore development of additional CRP Tracks Linkages to Maryland Primary Care Model Opportunities to align with post-acute care Specialty-specific tracks Oncology Cardiac Other? 36
Technical Overview of HCIP/CCIP Using Care Redesign to Align Provider Incentives Presentation to HFMA, Maryland Chapter HSCRC Care Redesign Summit August 18, 2017