Advancing Care Coordination Proposed Rule Released July 25, 2016 Erin Smith, JD VP and Executive Director, PACCR Jourdan Meltzer Research Associate, PACCR August 4, 2016 1
Presentation Overview Three new mandatory Episode Payment Models (EPMs) Episode definition: AMI, CABG, & SHFFT Payment: Risk-bearing, benchmarking, quality, & overall financial arrangement Patterns of care Opportunities for savings Cardiac Rehabilitation (CR) Incentive Payment Model Incentive payment structure Changes to CJR MACRA & pathway to Advanced APM qualification Projected BPCI updates 2
Episode Payment Models paccr.org
Overview: Three New Episode-Based Payment Models (EPMs) CMS proposed three new EPMs Acute myocardial infarction (AMI) Coronary artery bypass graft (CABG) Surgical hip/femur fracture treatment excluding lower extremity joint replacement (SHFFT) Cardiac (AMI & CABG) EPMs will be mandatory in 98 randomly selected metropolitan statistical areas (MSAs TBD) SHFFT EPM will be an expansion of CJR and include the same 67 MSAs Proposed start July 1, 2017 5-year model ending December 31, 2021 Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 4
Episode Definition Initiates upon a hospital inpatient admission and extends through 90 days postdischarge AMI Episodes Acute myocardial infarction AMI admissions treated with medical management MS-DRGs 280-282 AMI admissions treated with PCI MS-DRGs 246-251 with AMI ICD-CM diagnosis code CABG Episodes Coronary artery bypass graft admissions for coronary revascularization irrespective of AMI diagnosis MS-DRGs 231-236 SHFFT Episodes Surgical hip/femur fracture treatment procedures excluding lower extremity joint replacement MS-DRGs 480-482 Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 5
Episode Payment Calculation & Risk Bearing Regular Medicare FFS payments throughout the model Retrospective payment model after episode ends the episode payment will be calculated based on Medicare claims data and reconciled against established EPM quality-adjusted target price Phased-In Risk: no downside risk PY 1 and increasing upside and downside risk PY 1 Q1 PY 2 Jul 2017 Mar 2018 Q2 4 PY 2 Apr 2018 Dec 2018 PY 3 Jan 2019 Dec 2019 PY 4 & 5 Jan 2020 Dec 2021 Upside Gains: capped at 5% Upside Gains capped at 5% Upside Gains capped at 10% Upside Gains capped at 20% Downside Losses no repayment Downside Losses capped at 5% Downside Losses capped at 10% Downside Losses capped at 20% Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 6
Target Price: Benchmarking Target prices will be based on blend of regional- and participant-specific data, with increasing proportion of regional data over time Proposal to use the 9 U.S. Census Regions PY 1 & 2 July 2017 Dec 2018 PY 3 Jan 2019 Dec 2019 PY 4 & 5 Jan 2020 Dec 2021 H R H R R Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 7
Quality Component Composite quality score to assign EPM participants to four quality categories Only EPM participants that achieve quality category of "acceptable" or higher will be eligible for a reconciliation payment AMI CABG SHFFT MORT-30-AMI: Hospital 30-Day, All- Cause, Risk-Standardized Mortality Rate Following AMI Hospitalization (NQF #0230) AMI Excess Days: Excess Days in Acute Care after Hospitalization for AMI HCAPHS Survey (NQF #0166) Voluntary Hybrid Hospital 30-Day, All- Cause, Risk-Standardized Mortality emeasure (NQF #2473) data submission MORT-30-CABG: Hospital 30-Day, All- Cause, Risk-Standardized Mortality Rate Following CABG (NQF #2558) HCAPHS Survey (NQF #0166) Same measures as CJR: Hospital-Level Risk-Standardized Complication Rate Following Elective Primary THA and/or TKA (NQF #1550) Successful Voluntary Reporting of Patient-Reported Outcomes and Limited Risk Variable data submission HCAPHS Survey (NQF #0166) Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 8
Payment Eligibility and Repayment Responsibility: Performance Year 1 & Quarter 1 of Performance Year 2 PY 1 & Q1 PY 2 Quality Category Eligible for Reconciliation Payment Effective Discount % for Reconciliation Payment Effective Discount % for Repayment Amt. Excellent Yes 1.5% N/A Good Yes 2.0% N/A Acceptable Yes 3.0% N/A Below Acceptable No 3.0% N/A Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) Downside risk/ repayment begins being phased in Q2 of PY 2 9
Payment Eligibility and Repayment Responsibility: Quarters 2-4 of Performance Year 2 & Performance Year 3 Q2-4 PY 2 & PY 3 Quality Category Eligible for Reconciliation Payment Effective Discount % for Reconciliation Payment Effective Discount % for Repayment Amt. Excellent Yes 1.5% 0.5% Good Yes 2.0% 1.0% Acceptable Yes 3.0% 2.0% Below Acceptable No 3.0% 2.0% Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) Downside risk/ repayment begins 10
Payment Eligibility and Repayment Responsibility: Performance Years 4 & 5 PYs 4 & 5 Quality Category Eligible for Reconciliation Payment Effective Discount % for Reconciliation Payment Effective Discount % for Repayment Amt. Excellent Yes 1.5% 1.5% Good Yes 2.0% 2.0% Acceptable Yes 3.0% 3.0% Below Acceptable No 3.0% 3.0% Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) Discount increases by 1% for all categories 11
Gainsharing and Risk Sharing EPM hospitals may share reconciliation payments and repayment risk with collaborators Gainsharing Eligibility Must meet the criteria set by participating hospital Physicians, NPPs, and PGPs must furnish a billable service in an episode EPM Collaborators SNF HHA LTCH IRF PGP Physician Nonphysician practitioner Provider/supplier of outpatient therapy services ACOs Hospitals CAHs Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 12
Downstream Distribution Payments Alignment Payments (-) Gainsharing Payments (+) Proposed EPM Financial Arrangements Repayment Amounts (-) CMS EPM Participants Reconciliation Payments (+) Physician or Nonphysician Practitioner ACO PGP SNF, HHA, LTCH, IRF, Hospital, CAH, Provider/ Supplier of OP Therapy Services ACO Provider/Supplier (e.g., Physician) ACO Participant: PGP ACO Participant: Other Physician or NPP (PGP Member) Physician or NPP (PGP Member) Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 13
Limits on Gainsharing and Risk Sharing Gainsharing Payments Participant hospitals may share reconciliation payments and internal cost savings Individual physicians/practitioners gainsharing payments are capped at 50% of their PFS payments for episode services PGPs may receive gainsharing payments up to 50% of their PFS payments for episode services EXAMPLE SHARING ARRANGEMENT 5% 20% Participant Hospital Alignment Payments Participant hospitals may share repayment responsibilities Hospital must retain responsibility for retaining 50% of the repayment amount A single collaborator that is not an ACO may not pay more than 25% of the repayment amount ACO collaborators may pay up to 50% of the repayment amount 25% 50% Collaborator 1 (HHA) Collaborator 2 (SNF) Collaborator 3 (PGP) Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 14
Payment Policy Waivers SNF 3-day Stay AMI only Not applicable for CABG or SHFTT episodes Allows coverage of a SNF stay following discharge from an anchor CJR hospital stay of less than 3 days SNF must have 3 star or better rating Beginning April 1, 2018 Home Visits Waives supervision requirement so that clinical staff may provide home visits under general supervision AMI up to 13 home visits in the 90 days CABG up to 9 home visits in the 90 days SHFFT up to 9 home visits in the 90 days Waive global period restrictions to allow for home visits Telehealth Waives the geographic site requirement and the originating site requirement for telehealth services Telehealth services may be provided in a CJR beneficiary s home or residence Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 15
Patterns of Care: Contrast to LEJR Episode in CJR LEJR in CJR is predominantly elective, has rare hospital readmissions, & commonly substantial post-acute care provider utilization none of which are characteristics of AMI or CABG AMI, CABG, & SHFFT EPMs all encompass chronic conditions that require both planned and unplanned care AMI model as important next step for testing EPMs for clinical conditions with variety of different approaches to treatment and management Single clinical condition with substantially different clinical care pathways: medical management and PCI Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 16
Opportunities for Savings Understanding historical spending patterns for the three high-expenditure, common episodes selected with their significant spending variation in mind AMI Model ~50% of spending on initial hospitalization Majority of post-discharge spending is for readmissions Lesser spending for SNFs, Part B professional services, & hospital outpatient CABG Model ~75% of spending on initial hospitalization. Post-discharge spending is evenly distributed among Part B professional services & hospital readmissions. Most patients are discharged to SNFs SHFFT Episodes Substantial readmissions High use of PAC services Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 17
Cardiac Rehabilitation Incentive Payment Model paccr.org
Overview: Cardiac Rehabilitation (CR) Incentive Payment Model Direct financial incentives for hospitals treating AMI or CABG beneficiaries to encourage care coordination and greater utilization of medically necessary CR/ICR services in the 90 days post-discharge. 45 MSAs from the AMI and CABG EPMs. 45 MSAs with regular Medicare payments. CR/ICR seen as underutilized way to improved long-term patient outcomes. Focus: increased utilization of CR/ICR services alone, payment NOT tied to quality and efficiency. Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 19
CR Incentive Payment Structure Determination: Number of CR/ICR services - counted on OPPS and PFS paid claims First 11 CR/ICR Services Within a single AMI or CABG model episode or AMI or CABG care period: $25 per service After 11 CR/ICR Services Within a single AMI or CABG model episode or AMI or CABG care period: $175 per service Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 20
Maximum Services Cardiac Rehabilitation (CR) Examples: exercise training, education on heart healthy living, counseling to reduce stress, etc. Two one-hour sessions/day For a total of 36 sessions total over 36 weeks Intensive Cardiac Rehabilitation (ICR) Example: similar services to CR provided more rigorously and frequently ICR program must illustrate within peer-reviewed, published research that it 1). a). positively affects the progression of coronary heart disease, b). reduces the need for CABG, or c). reduces the need for PCI, and 2). makes a statistically significant reduction in one or more of the following six measures: low density lipoprotein, triglycerides, BMI, systolic blood pressure, diastolic blood pressure, & need for cholesterol, blood pressure, and diabetes medications, in order to receive CMS approval. Six one-hour sessions/day For a total of 72 sessions total over 18 weeks 21
Limitations CR Incentive Payments cannot be included in gain-sharing arrangements. Understanding depth of impact: CR incentive model impact of Medicare program: 2017 2024 range of $27 million in spending to $32 million in savings. HUGE range dependent on change in utilization of CR/ICR services under the incentive program. Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 22
CJR Refinements paccr.org
Overview: CJR Updates Creation of two separate tracks, Track 1 and Track 2, where Track 1 would create a pathway to qualification as Advanced APM. Track 1 has CEHRT requirement. Opens possibility for similar pathway for BPCI to meet Advanced APM criteria. Technical changes for quality scoring effect on reconciliation payments. Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 24
MACRA Background: Advanced APMs under the QPP Criteria for Advanced APMs Certified EHR Use APM requires participants to use certified EHR technology. Quality Measures APM bases payment on quality measures comparable to those in the MIPS quality performance category. Financial Risk APM entities bear more than nominal financial risk for monetary losses, OR: APM is a medical home expanded under CMMI authority. In APM with Advanced APM Designation Must meet qualifying thresholds for seeing statistically significant amount of Medicare patients within the APM or receiving statistically significant payment for services through the APM. Qualify as group All eligible clinicians in Advanced APM Entity become QPs for payment year. 25
Creation of Track 1 and Track 2: CEHR Requirement Fitting in with larger contexts of MACRA and Advanced APMs. In Track 1 CJR and its participant hospitals will meet criteria for Advanced APMs as proposed in Quality Payment Program in the MACRA proposed rule. Biggest change to be consistent with qualifying standards for Advanced APMs is CEHR requirement for CJR Track 1. Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 26
Quality Alignment with Language and Directives of MACRA Stronger connection & alignment with quality scoring of other CMS programs. Reducing threshold for defining quality measure improvement from 3 deciles to 2 deciles ultimately increasing number of CJR participant hospitals eligible for quality improvement points. Awarding up to 10% of maximum measure performance score on certain measures and imposing a cap on composite quality score at 20 points. Technical term change: episode target price to quality-adjusted target price. Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 27
Looking Forward paccr.org
Projected BPCI Updates EPMs aren t just for hospitals BPCI 2.0 is planned for 2018 onwards Adapted version of BPCI? Expanded version of BPCI? Voluntary models and mandatory models can coexist not either/or 29
Takeaways Driving towards the HHS goal of tying 50% of FFS payments to Alternative Payment Models. High-level: episode payment models, ACOs, and advanced primary care. While we see similarities to CJR, don t assume that this is the new norm. Seeking new approaches to episode payments for conditions/procedures that do not fit into this model. Expanding opportunities for MACRA incentives for Advanced APMs. New options to create pathways for qualifications. Expecting a final rule on new models this fall. 30
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Appendix 1: Measures and Associated Performance Weights in Composite Quality Score Model Quality Measure Weight in Composite Quality Score Quality Domain/Weight MORT-30-AMI (NQF #0230) 50% AMI Excess Days 20% Outcome/ 80% AMI Model Hybrid AMI Mortality (NQF #2473) Voluntary Data HCAHPS Survey (NQF #0166) 20% Patient Experience/ 20% 10% CABG Model MORT-30-CABG (NQF #2558) 75% Outcome/ 75% HCAHPS Survey (NQF #0166) 25% Patient Experience/ 25% SHFFT Model Hip/Knee Complications (NQF #1550 THA/TKA voluntary PRO and limited risk variable submission 50% Outcome/ 50% 10% Patient Experience/ 50% HCAHPS Survey (NQF #0166) 40% Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 32
Appendix 2: Individual Measure Performance Scoring For Three Required AMI Quality Measures Performance Percentile MORT-30-AMI (Points) AMI Excess Days (Points) HCAHPS Survey (Points) 90 th 10.00 4.00 4.00 80 th and <90 th 9.25 3.70 3.70 70 th and <80 th 8.50 3.40 3.40 60 th and <70 th 7.75 3.10 3.10 50 th and <60 th 7.00 2.80 2.80 50 th and <50 th 6.25 2.50 2.50 30 th and <40 th 5.50 2.20 2.20 <30 th 0.00 0.00 0.00 Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 33
Appendix 3: Individual Measure Performance Scoring For Two Required CABG Quality Measures Performance Percentile MORT-30-CABG (Points) HCAHPS Survey (Points) 90 th 15.00 5.00 80 th and <90 th 13.88 4.63 70 th and <80 th 12.75 4.25 60 th and <70 th 11.63 3.88 50 th and <60 th 10.50 3.50 50 th and <50 th 9.38 3.13 30 th and <40 th 8.25 2.75 <30 th 0.00 0.00 Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 34
Appendix 4:Individual Measure Performance Scoring For Two Required SHFFT Quality Measures Performance Percentile Hip/Knee Complications (Points) HCAHPS Survey Quality Score (Points) 90 th 10.00 8.00 80 th and <90 th 9.25 7.40 70 th and <80 th 8.50 6.80 60 th and <70 th 7.75 6.20 50 th and <60 th 7.00 5.60 50 th and <50 th 6.25 5.00 30 th and <40 th 5.50 4.40 <30 th 0.00 0.00 Source: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) (CMS-5519-P) 35