data-driven strategy for new payment models data-driven strategy for new payment models mark sharp,...
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Data-Driven Strategy for New Payment Models
Mark Sharp, CPAPartner
Objectives
• Understand new payment model reforms and bundling arrangements
• Learn how these new payment models can impact your agencies
• Consider strategies that can help you succeed within the new payment models
ACO Accountable Care Organization
APM Advanced Payment Models
BPCI Bundled Payment for Care Improvement
CJR Comprehensive Care for Joint Replacement
CMMI Center for Medicare & Medicaid Innovation
DRG Diagnosis Related Group
FFS Fee for Service
HHA Home Health Agency
HHVBP Home Health Value Based Purchasing
IRF Inpatient Rehabilitation Facility
MSA Metropolitan Statistical Area
PFS Physician Fee Schedule
PGP Physician Group Practice
SNF Skilled Nursing Facility
Common Acronyms
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2011 2015 2016 2018
HHS goal of 30% of traditional FFS Medicare payments through Advanced Payment Models by the end of 2016 and 50% by the end of 2018
%
Medicare
Payments FFS
APM
Future of Medicare Payments
AccountableCare
BPCIPrimary Care
TransitionMedicaid and
CHIPAcceleration
ModelsSpeed Adoptionof Best Practices
ACOs Model 1Advanced Primary
Care InitiativeReduce Avoidable Hospitalizations
State Innovation Models
Beneficiary Engagement Model
Advanced PaymentACOs
Model 2Comprehensive
Primary Care Initiative
Financial Alignment Incentive for
Medicare and Medicaid
Frontier Community Health
Integration
Community BasedCare Transitions
ACO Investment Model
Model 3FQHC Advanced
Primary Care Practice
Strong Start forMothers and
Newborns
Health Care Innovation Rounds
Health Care Actionand Learning
Network
Next Generation ACO
Model 4Graduate Nurse
Education
MedicaidPrevention of
Chronic Diseases
Health PlanInnovation Initiative
Innovative Advisors Program
Pioneer ACOTransforming
Clinical Practice
Medicaid Emergency Psychiatric
Demonstration
Million HeartsCJR
CMMI Advanced Payment Models
Bundled Payment Popularity
Source: CMMI Website
0
100
200
300
400
500
600
700
800
900
1000
Participants in CMMI Payment Models
Bundled Payment Popularity
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Collaborative relationships and gainsharing with physicians and
post-acute providers
Financial accountability for two of the most common DRGs: 469 & 470
Target prices derived from historical claims data
Episodes lasting 90 days post-discharge
2 Quality Measures + Voluntary PRO
CJR Model
67MSAs
MSAs in CJR Model
• Medicare shared savings program
• Bundled Payments
Hospitals bear financial accountability
All providers continue to be paid under current methodologies
• DRG
• Per diem
• Episodes
Retrospective reconciliation against target prices
CJR Financial Accountability
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• Bundled payments
Inpatient vs post-acute payments
Risk and variability is often highest in post-acute setting
• Pressure towards vertical integration
Ownership vs partnership
Financial Accountability in Bundles
• From 67 MSAs to ALL MSAs
• From hips and knees to:• Cardiac procedures
• COPD
• CHF
• AMI
• Pneumonia
What’s Next?
• Pilot for home health only
• Per CMS, pilot will– Incentivize Medicare agencies to provide higher
quality and more efficient care
– Test whether a payment incentive of up to 8% significantly improves provider performance
– Test the use of new quality measures in the home health setting
– Enhance the current public reporting process
HHVBP Pilot
12 // 2015 AHHC Home Health Intensive Conference
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• All Medicare-certified agencies in nine states
HHVBP Pilot States
• Financial bonus pool funded by payment reductions to others– Performance and outcome standards are
established to determine which providers receive bonus payments
– Those that do not meet the standards are left with lower payment rates
– Those that out perform the standards receive financial rewards
• Current congressional consideration for nation-wide VBP for all post-acute providers
HHVBP Pilot Overview
• Performance scores based on the following measures– 9 outcomes measures
– 5 patient satisfaction measures
– 3 process measures
– Ranked within common sized cohorts
– Scores for achievement and/or improvement
HHVBP Performance Scoring
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• Starting in 2016– Baseline year of 2015
– Payment adjustments made to the final Medicare claims paid during the payment adjustment year
HHVBP Pilot Years
Performance YearPayment
Adjustment YearMax Pay Adjust
(up or down)
2016 2018 3%
2017 2019 5%
2018 2020 6%
2019 2021 7%
2020 2022 8%
17 // 2015 AHHC Home Health Intensive Conference
Success Today and Tomorrow
18 // 2015 AHHC Home Health Intensive Conference
Success Today and Tomorrow
Increase efficiency
in providing care
Improve outcomes
TRIPLE AIM
Improve the patient experience
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Success in APMs
• It’s not a sprint…it’s a marathon
• Understand current state
• Develop a strategy
• Don’t need to go it alone
• Data access and horsepower
• Leadership buy-in
• Challenge traditional thinking
Success in APMs
• Identify and manage the high risk patients
• Ongoing patient monitoring
• Effective care transitions care and triage practices
• Excellent communication and coordination
• Define and communicate the value proposition
• Physician involvement can be key
What’s Going
To Happen?
What Should We
Do About It?
What Are The
Implications?
Strategic Management Model
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Road to APM Success
Direction from Leadership
• Define and communicate the vision
• Develop culture of change
• Establish the behavior and performance expectations
• Ensure access to necessary resources
• Identify known barriers and manage resistance
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Patients
Physicians
Post-Acute Providers
1 2
Ris
k S
trati
ficati
on
Data Analytics
9
Patients in the Population
Average CJR Episode Payments
CJR Episode Outliers
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Post-Acute Care Providers
Longitudinal View
Physician Analysis
11
Competitor Analysis
A B C D E F G H I J
A B C D E F G H I J
COLLABORATORS, GAINSHARING AND QUALITY
1 2 3
Physicians Skilled Nursing Home Health
Collaborators, Gainsharing & Quality
Development of Collaborators
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Collaborators and Gainsharing
1 2 3 4
• Leverage data to perform a gap analysis and identify best practices
• Establish baseline: value stream mapping
• Coordinate with current orthopedic programs
• Present findings to Steering Committee
• Develop work groups and provide targeted training
• “Prehab”
• Acute Care
• Care Transitions/PAC
• IT
• Finance
• Discharge selection tool
• PAC Provider Scorecards
Care Redesign
1 2 3 4 5
Monthly progress reports
Key metrics dashboard
Data Custodian
Target price calculation
Reconciliation
Monitoring Progress
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Assessing Opportunities
Assess Current State
• SWOT analysis
Market Analysis
• Creating Value Proposition
Financial
Analysis• Financially feasible?
Business
Plan• The road map
• Market Analysis Discharges by DRG Post-acute utilization by DRG Value: Quality : Cost ratio DRG 470 averages
• $2,400 Home Health• $10,000 SNF• $15,000 IRF
Benchmarking performance• HHA competition• SNF competition
Creating a Value Proposition
• Preferred partners
CJR and other bundles allow collaborators to recommend “preferred providers”
Are you a preferred provider?
How do I become a preferred provider?
Creating a Value Proposition
