Maryland’s Medicare Waiver
What is it? How do we fit?
Gayle Olano HurtApril 21, 2015
CMSA of the Chesapeake Annual Conference
Objectives• Understand the frame work for Maryland's
Medicare waiver.• Identify the key pay for performance components
of the waiver proposal• Visualize how case management can play a role
in successful achievement of the wavier proposals goals
Setting the Stage• Medicare Waiver (1977)• Exempt from Inpatient and Outpatient
Prospective Payment Systems (IPPS & OPPS)• Meet specific criteria (e.g., cost containment)
o Payment per admission• Flexibility to set our own model & rates
o All payer modelo Health Services Cost Review Commission
(HSCRC)• Maryland - only state remaining
Challenges• Challenges in this new Era of payment reform• Meeting the waiver test
o Rising hospital costs• Value
o Cost containment o What about quality of care?
• Integration and care coordinationo $ Incentive on admissions not integration
CMS P4R and P4P
HHCAHPSHHQR
IQR,OQR, IPFQRVBP/HCAHPS (P4P)Readmissions (P4P)HACs (P4P)Meaningful Use
ACUTE CARE HOSPITALS (7%+)
MEDICAL GROUPS (6+%)Meaningful Use
PQRS / CGCAHPSPhysician VM (P4P)
HOME HEALTH (2%)
OQR
HOSPITAL OUTPATIENT (2%)
ICHCAHPSESRD-QIP (P4P)
DIALYSIS CENTERS (2%)
Hospice CAHPSHQR
HOSPICE (2%)
LTCHQR
NHCAHPSSNFQR (2019)
SKILLED NURSING (2%)
IRFQR
LONG-TERM CARE (2%)
REHAB HOSPITALS (2%)
IPFQRINPATIENT PSYCHIATRIC FACILITY
(2%)Performance EvaluationQBRARR (& PAU)PPCs
Performance Evaluation
Beyond CMS
Reimbursement Model?
• Value and the reimbursement model• Value based payments• FFS Integrated
o Accountable Care Organizationso Patient Centered Medical Homeso Bundled paymentso Shared savings
• Fit within context of Maryland Medicare Waiver?
Value
COST
QUALITY + OUTCOMES
New Waiver• 5 year demonstration
Federal Triple Aim• Better Care• Healthy People/Communities• Affordable Care
Framework
Key Components• Quality Based Revenue (2017)
• Healthcare Acquired Conditions (MHAC/PPC)
25%
5%
45%
25%
Fed
45%
5%
50%
MdClinical ProcessHCAHPSOutcomesEfficiency
Key Components• Quality Based Revenue (2017)
• Healthcare Acquired Conditions (MHAC/PPC)
25%
5%
45%
25%
Fed
45%
5%
50%
MdClinical ProcessHCAHPSOutcomesEfficiency
Key Components• Admission-Readmission Reduction (ARR)
o 30 day all cause < national by end of 2018o One example calculation
• New Concept: Potentially Avoidable Utilizationo 30 day all causeo Revisits include inpatient, *observation, & *ER
Case Management• What are the goals and purposes?• Improve quality • Control costs• Coordination & Care Access
• Case Management functions*• Assess• Enable • Facilitate• Evaluate /Monitor
*(Abbreviated from Moore 1990 model)
Case Management• Case Management functions• Assess• Enable • Facilitate• Evaluate /Monitor
(Abbreviated from Moore 1990 model)
Case Management• Impact on payment based reimbursement?• Outcomes measures• Efficiency measures• Readmission reduction • Potentially avoidable utilization
Discussion / Q&A