NewPayment Models: What DoesThisMeanfor Cardiology · PDF file · 2016-11-18Key...

New Payment Models:What DoesThisMean for Cardiology

Paul N. Casale, MD, MPH, FACCExecutive Director, NewYork Quality CareNew York-Presbyterian • Columbia • Weill Cornell

Alternative Payment Models

Quality Payment Program

Alternative Payment Models

• An Alte rna tive PaymentModel (APM) is a paymentapproach that provides addedincentives to clinicians toprovide high-qua lity and cos t-e fficient care .

• APMs can apply to

- Care episode (PCMH)

- Specific clinica l condition(episode /bundled payment)

- Popula tion (ACO)

Advanced APMs are a Subs e t of

APMs

APMs

Advanced

APMs

Fragmenta tion Of Care

Specia lty Care

PrimaryCare

In-patient &Out-patient

Hospita l

HomeHealth

HospicePost-acute

Care

Adverse DrugEvents

Hospita lReadmiss ion

DiagnosticErrors

Lack of Communicationand Appropria te

Follow-up

▪Established by HHS–

◦ to accelerate the health care system’s transition to alternative payment models

◦ capture best practices, disseminate information, and apply lessons learned

7

HealthierPeople

Requires theparticipation of theentire health care

community.

SmarterSpending

Shift payment structureto pay for quality of

care rather thanindividual services.

Better CareMove from current fee-for-service payment to amodel that paysclinicians

for quality care andimproved health.

Nationa l Quality S tra tegy

8

Better Care, Smarter Spending, Healthier People

Adoption of Alternative PaymentModels(APMs)

At least 50%of U.S.health care paymentsare so linked.

2018

50%

At least 30%of U.S. healthcare paymentsare linkedto quality and valuethrough APMs.

2016

30%

Goals for U.S. Health Care

9

Category 1

Fee for Se rvice –No Link to

Qua lity & Value

Ca tegory 2

Fee for Se rvice –Link to

Qua lity & Value

Ca tegory 3

APMs Built onFee -for-Se rvice Architecture

Category 4

Popula tion-BasedPayment

A

Foundational Payments forInfrastructure & Operations

B

Pay for Reporting

C

Rewards for Performance

D

Rewards and Penaltiesfor Performance

A

APMs withUpside Gainsharing

B

APMs with UpsideGainsharing/Downside Risk

A

Condition-SpecificPopula tion-Based Payment

B

ComprehensivePopula tion-Based

Payment

Population-Based Accountability

APM Framework

10

For Payment ReformAPM Goals

CMS Charting a Pa th Toward Grea te r Ris k

Cardiac EPM, MSSP Track 3, and Next-Gen ACO Filling Out the Continuum

Continuum of Medicare Ris k Models

BundledPayments

SharedSavings

SharedRis k

FullRis k

• Merit-BasedIncentive PaymentSystem

• MSSP Track 1(50% sharing)

• MSSP Track 2(60% sharing)

• MSSP Track 3(up to 75% sharing)

• Next Genera tionACO Model(80-85% sharedsavings option)

• Next Genera tionACO Model(full risk option)

• Medica reAdvantage(provide r-sponsored)

Pay-fo r-Performance

• Bundled Paymentsfor CareImprovementInitia tive (BPCI)

• Comprehens iveCare for JointReplacement(CJR) Model

• Card iac Epis odePayment Models

©2016 Advisory Board • All RightsReserved • advisory.com

CMS Charting a Path Toward Greater Risk

12

ACOs by Contract Type in the US

14

15

Bundled PaymentsSavingsPotential16

BPCI Cardiac Episodes

• Acute MyocardialInfarction

• Percutaneous CoronaryIntervention

• Coronary Artery BypassGraft

• Cardiac Arrhythmia

• Cardiac Defibrillator

• Cardiac Valve

• Congestive Heart Failure

• Chest pain

• Major CardiovascularProcedure

• Pacemaker

• Pacemaker devicereplacement or revision

• AICD generator or leadrevision

17

Bundled Payment for Care Improvement (BPCI) Model

Medicare , Medica id, Commercia l, and Employer Participants

Where Are Bundled Payments Happening?

Medicare BundledPayments for CareImprovement (“BPCI”)

Medicaid Bundled PaymentPrograms

ArkansasOhioTennessee

Employer Bundled PaymentPrograms

Commercial Bundled PaymentPrograms


Advanced APMsin 2017

Oncology Care Model(Two-sided Risk Arrangement)

Comprehensive Primary Care Plus (CPC+)

Next Generation ACOModelShared Savings Program Track 2 and 3 ACO

Comprehensive Care for Joint Replacement(CJR) Payment Model

Future Advanced APM Opportunities

Advancing Care Coordination throughEpisode Payment Models

Acute Myocardial Infarction (AMI)

Coronary Artery Bypass Surgery(CABG)

New Voluntary Bundled Payment Model

ACOTrack 1+

Comprehensive ESRDCare Model

How Did We Get Here?

CMS Has Been Building to Mandatory Cardiac Bundles for Years

Medicare Partic ipa ting HeartBypas s Demo

Acute Care Epis ode (ACE) Demo

Bund led Payment for CareImprovement (BPCI)

1991-1996• Seven hospita ls• Tes ted bundled Part A and B payments

for two CABG DRGs

2013 – ongoing• 4 Models , includes medica l and surgica l

cardiac episodes1

2

3

CMS Evolution to Card iac Bundling

2009-2012• 3-years , 5 participants• Bundled Part A and B payments for

nine cardiac DRGs

Card iovas cu lar a Familia r Targe t fo rQuality Meas u res

• Readmissions Reduction Programincludes AMI, HF, CABG

• Hospita l-based VBP includes AMI,HF 30-day morta lity ra tes

• AMI, HF 30-Day payment reporting

• AMI, HF excess days metric


How Did We Get Here?

Cardiac EPM Checklis t

Unders tanding Key Components of the New Cardiac EPM Proposa l

Composition of the cardiac EPM episode

Trans fer rules

Retrospective payment mode l mechanics

Quality requirements

Regula tory waive rs

Ga insharing opportunities


Cardiac Episode Payment Models

Centra l Elements of Cardiac EPM Bundles

Composition of the ca rdiac EPM episode

Episode ofCare

Target Price

Reconcilia tionProcess

Quality

All care (Part A & B) re la ted to anchor hospita liza tion(AMI & CABG) and 90 days pos t-discharge

Episode ta rget - up to a 3% discount off ofhis torica l/regiona l spending performance

Calcula te diffe rence between episode spend andta rge t price

Specific measures tha t CMS has defined as importantindica tors of qua lity for ca rdiac EPMs


Central Elements of Cardiac EPM Bundles

Partic ipa ting Markets Would Be Selec ted Randomly

Eligibility Crite ria Based on AMI Volumes

Key Elements of Cardiac EPM Market Se lec tion

• 98 marke ts would be chosenrandomly from 284 eligibleMetropolitan S ta tis tica lAreas(MSAs)

• Eligible MSAs:

• >75 AMIs per year

• The AMI and CABG episodeswould be implemented toge therin selected marke ts


Participating Markets Randomly Selected

Taking a Long View of Pa tient Care

EPMs Would Track Cos ts , Outcomes Up to 90 Days Pos t-Discharge

AnchorHospitalization

Episode Trigger Episode Ends

EPM Propos ed Epis ode and Inc luded Services

90 DaysPost-Discharge


Taking a Long View of Patient Care

CMS Would Use Retrospective Reconcilia tion to Adjus t Hospita l PaymentsPropos ed Hos pita l Payment Proces s Under Cardiac EPM

1 32Fee-fo r-Service Billing Payment Reconcilia tionComparis on to Targe t

Hospita l bills FFS ,ece ive payment assua l; CMS tracks

claims

Tota l cos tsmpared toge t price based

on his toric cla ims

If over ta rge t hospita lays CMS; ifer, rece ives

reconcilia tion

Phas es in Ups ide andDowns ide Financia l Ris k

Incorporates Blend of Regional and FacilityHis toric Claims Data

• Target price based on 3 years of his toric cla ims

• Hospita l & regional cla ims define targe t price

• In 2020 and 2021, only regional data used

• Partia l ups ide risk in year 1Phased to 20% by year 4

• Partia l downs ide risk in year 2 & 3Full risk (20%) in years 4 & 5


No Immediate Change in Billing

Two Factors Would Dete rmine Whether You Pay CMS, or CMS Pays You

1 2Medicare Paymen tBelow Targe t

Meet Quality S tandards

EPM episode paymentsmust be below CMS ’ta rge t

Hospita l performance on EPMquality compos ite determinesdiscount ta rget and reconcilia tionpayment eligibility

Reconcilia tion paymen t e lig ib ility dependenton min imum quality s tandard

If hospita l comes in below target price but doesnot achieve a t leas t “Acceptable ” ra ting, they willnot be e ligible for reconcilia tion payment.


Reconciliation to be Based on Payment and Quality

Individua l Performance Would be Phased Out from Target Price by Year 5

20162015 2017 2018 2019

ModelYears1-2

ModelYears3-4

20142013

ModelYear5

1/3 Individual CY2015-2017

2/3 Regional CY2015-2017

2/3 Individual CY2013-2015

1/3 Regional CY2013-2015

3/3 RegionalCY2017-2019

Hospita ls will rece ive updated targe t prices twice per year (January and October)to account ra te updates across various payment sys tems

Target Price Updates


Target Price Base on Historical, Regional Blend

QualityMeas ure

Defin itionWeight inCompos ite

Co llec tion

30-DayMorta lity

30-day, a ll cause , risk-s tandardized morta lity ra tefollowing a hospita liza tion for AMI

50% Claims -based perInpa tient QualityReporting (IQR)(NQF #0230)

AMI Exces sDays

Excess days in acute care (ER,observa tion, and readmis s ion daysfollowing a hospita liza tion for AMI

20% Cla ims -based perIQR

HCAHPSSurvey

Patient experience (not specific toDRGs).Communica tion, painmanagement, cleanliness ,quie tness etc.

20% Patient Survey(NQF #0166)

Hybrid AMIMorta lityVoluntaryData

30-day, risk-s tandardized AMImorta lity ra te , us ing a combina tionof cla ims data and EHR datasubmitted by hospita ls

10% Volunta rysubmis sion(NQF #2473)


AMI Quality Measures

A Potentia l Replacement for the Current 30-Day Morta lity Measure

30-Day AMI Morta lityMeasure (NQF #0230)

• Same measure cohortand outcome

Claims Data EHR Data

Five core clinical data elements :

• Age

• Heart ra te

• Sys tolic blood pressure

• Troponin

• Creatinine

Hybrid AMI Morta lity Meas u re


Hybrid AMI Mortality to Measure Clinical Status

Gainsharing opportunitie s

Ris k-Sharing Res tric tions

Hospita l may only share funds from in te rna ls avings or fina l reconc ilia tion /repayment

Maximum phys ic ian ga ins ha re is 50% ofPart B phys ic ian fee s chedule

Gainsharing payments must be partly bas edon qua lity metrics s e t by the hos pita l (notre fe rra ls /pa tient volumes)

If sharing downs ide risk, the hos p ita l mus tre ta in 50% of repayment ris k.

Maximum repayment amount for onepartner is 25%


CMS Proposes Options for Gainsharing

Waiver of “Inc ident To”Direc t Supervis ion Requirement fo rpos t d is charge home vis its

Non-phys ician and clinica l s ta ff can provide home vis its (phys iciandoesn’t have to be present) - for pa tients not e ligible for homehealth services . 13 vis its for AMI and 9 vis its for CABG EPM.

Telehealth Services

Waive the geographic s ite requirement for te lehea lth, a llowingpa tients to receive te lehea lth services no matte r where they areloca ted. Also would waive the originating s ite requirement.

Skilled Nurs ing Fac ility Three -Day Rule

CMS will waive the SNF 3-day rule only for the AMI EPM ifa pa tient is dis charged to a SNF with a t leas t a three s tarquality ra ting (s tarting in performance year 2)


Proposed Cardiac EPM Program Waivers

Unders tanding the Issues , Defining the Terms

Trans fe r rules

Before Going Further, DefineYour Terms

• Partic ipant: Hospita l in se lectedMSA for EPMs

• Nonpartic ipant: Hospita l not inselected MSA for EPMs

• Inpa tien t to inpa tien t trans fe r:Patient admitted at initia l hospita l,then trans fe rred to differenthospita l

• Outpa tien t to inpa tien t trans fer:Patient not admitted a t initia lhospita l then trans ferred todifferent hospita l (e .g., s een in ERand immediate ly trans fe rred),

Key Ques tions Regard ing Trans fe rs

If an AMI patient s ta rts a tone hospita l and then issent e ls ewhere for care ,who is financia llyrespons ible?

If the DRG at the initia lhospita l is diffe rent thanthe DRG at the trans fe rhospita l (e .g., if AMI patienthad a CABG), how is theepisode ta rget price set?


Hospital Transfers a Concern

CMS Proposes Rules for AMI, CABG Episode Attribution

Situa tion In itia tion , Attribu tion Takeaway

1Inpatien t toInpa tien t Trans fe r:Nonparticipant toParticipant

Initia te episode based on DRG attrans fer (i.e ., rece iving) hospita l

Attribute episode to trans fer

hospita l

Trans fer hospita ldete rmines DRG

Trans fer hospita lfinancia llyrespons ible forepisode

2Inpatien t toInpa tien t Trans fe r:

Participant toParticipant orNonparticipant

Initia te episode based on DRG atinitia l hospita l

Attribute episode to in itia l hospita l

Initia l hospita lde termines DRG

Initia l hospita lfinancia llyrespons ible forepisode

Inpa tien t to Inpa tien t Trans fe rs


AMyriad of Circumstances Seems Daunting

CMS Proposes Rules for AMI, CABG Episode Attribution

Situa tion In itia tion , Attribution Takeaway

3

Outpa tien t toInpa tien t Trans fer:

Nonparticipant orparticipant toParticipant

Initia te episode based on DRG attrans fe r (i.e ., receiving) hospita l

Attribute episode to trans fer

hospita l

Trans fe r hospita lde termines DRG

Trans fe r hospita lfinancia llyrespons ible forepisode

4Outpa tien t toInpa tien t Trans fe r:

Participant toNonparticipant

No AMI or CABG model initia ted No episode initia ted

Outpa tien t to Inpa tient Trans fe rs


AMyriad of Circumstances Seems Daunting (Cont.)

Responding to the Proposed Rule for Cardiac EPMs

1 Unders tand the s ources of cos ts in epis odes ; identifyhigh areas of episodic cos t and eva lua te inte rna l e fficienciesand loca l PAC provider outcomes .

2 Patien t engagement; eva luate care management program,access to care , communica tion tools including EMR patientporta l.

3 Phys ic ian leaders hip ; engage and educa te cardiovascula rspecia lis ts and team members on the ca rdiac EPM program,deve lop coherent s tra tegy and organiza tiona l s tructure .

Even if not chosen for participa tion, ca rdiologis ts shouldcons ider this proposa l to be a s igna l tha t future bundling orepisodic payment re form is like ly to occur


Preparing for Cardiac Episode Payment Models

Unders tanding Costs a Crucia l Step to Deve loping an EPM Stra tegy

Percen tage of To ta l Cos ts Attribu ted to Each Setting

Medicare, 2014


Assessing Costs At 90 Days After Admission

ACCKey Comment Areas:Proposed Rule for Cardiac EPMs

• Clinical homogeneity in the AMI model

• AMI model quality measures

• Advanced APMs

• Special policies for hospital transfers ofbeneficiaries with AMI

• Risk sharing and financial arrangements underEPMs

• Additional care coordination considerations

Clinical Homogeneity

CMS proposes to include beneficiaries who aredischarged under AMI (MS-DRGs 280-282) and PCI(MS-DRGs 246-251) with an AMI ICD-10 CMdiagnosis code in the principal or secondarydiagnosis position.

ACC strongly recommends limiting the AMI model toSTEMI patients discharged with AMI code only in theprincipal diagnosis position.

39

Proposed AMI Quality Measures

4 measures: 3 required, 1 voluntary

Measure Weight

• MORT-30-AMI (NQF #0230) 50%

• AMI Excess Days 20%

• HCAHPS Survey (NQF #0166) 20%

• Hybrid AMI Mortality (NQF #2473) 10%

Voluntary Data

40

AMI Quality Measures and Role of NCDR

• The ACC recommends reducing the weighting forthe MORT-30-AMI measure to no more than 30%ofthe composite quality performance score

• The ACC recommends reallocating the remaining20%of the weight to the Core Quality MeasureCollaborative (CQMC) cardiovascular measures setand measures reported through NCDR.

Transfer Policy

• The ACC strongly recommends attributing patientsto the hospital where revascularization proceduresare performed rather than the anchor hospital

• The admitting hospital that transfers the patientfor treatment has little or no control over the rest ofthe episode and thus should not be heldaccountable.

42

Other Positions

Risk Sharing and Financial Arrangements underEPMs

• The ACC recommends including both Part AandPart B services in gainsharing arrangements toachieve truly meaningful risk sharing.

Additional Care Coordination Considerations

• The ACC urges CMS to make resources for carecoordination strategies available to supportadvancing care coordination.

43

Bundled Payment Model: Opportunities

• Representscontinued movement towardsa value-based payment system that focuseson improvedquality and value – key elementsof ACC’sstrategicplan.

• ReflectsCMS’ continued efforts to find new waysforspecialists to be rewarded for deliveringquality care

• May qualify asan Advanced Alternative PaymentModel (APM) under MACRA.

• Opportunity to extend the value of NCDR(ACTION,Cath-PCI) and ACCquality programs.

Bundled Payment Model: Challenges

• Different from previousCMSbundlespayment models:

– Higher-risk patients

– Surgeriesare not elective (Physicianshave lesscontrol overtiming/planning)

• Those without experience with bundles will have littletime to adapt or plan in advance.

• Changes in payment structuresmust be driven byclinical practices that improve patient outcomes.

• Potential for unintended consequences

Program Would Sta rt J uly 1, 2017

2016 2017 2018 2019 2020 2021

6 Months 12 Months 12 Months 12 Months 12 Months

Card iac EPM Performance Periods

Downside riskcommences on

April 1, 2018


Program Would Start July 1, 2017


• MACRA established the Phys ician-Focused Payment Model

Technica l Advisory Committee (PTAC) to review and assess

Phys ician-Focused Payment Models based on proposa ls

submitted by s takeholde rs to the committee .

• The PTAC is a federa l advisory committee tha t provides

independent advice to the Secre ta ry. The PTAC is supported

by HHS Office of the Ass is tant Secre ta ry for P lanning and

Evalua tion.

• This committee provides a unique opportunity for s takeholde rs

to pa rticipa te in the deve lopment of new models and to he lp

de te rmine priorities for the phys ician community

Physician-Focused Payment Model TechnicalAdvisory Committee


PFPM =Phys ic ian -Focus ed Payment

Model

Goal to encourage new APM options forMedicare clinicians

PFPM Technical Advisory Committee (PTAC)

Submiss ion ofmode l

proposa ls byStakeholders 11 appointed care

delivery experts tha treview proposals , submitrecommenda tions to HHS

Secre tary

Secre tarycomments onCMS webs ite ,

CMScons iders

tes tingproposedmode ls

Mode ls withfavorable

response go toCMS

InnovationCenter

49

Date post:	20-Mar-2018
Category:	Documents
Upload:	hoangtruc
View:	215 times
Download:	2 times

NewPayment Models: What DoesThisMeanfor Cardiology · PDF file · 2016-11-18Key...

Documents