health system transformation and care coordination: cms ......nov 12, 2015 · health system...
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Health System Transformation and Care Coordination: CMS Policies addressing the Hospital and Post-Acute Population
Ashby Wolfe, MD, MPP, MPHChief Medical Officer, Region IX
Centers for Medicare and Medicaid Services
Presentation to the National Readmissions Prevention CollaborativeNovember 12, 2015
Los Angeles, CA
This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services.
This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. Medicare policy changes frequently, and links to the source documents have been provided within the document for your reference
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide.
Disclaimer
• Quality of Care: demands for transparency & accountability– Continuous quality improvement to address patient safety– Key CMS priorities in transformation– Shifting from Volume to Value-Based payments
• Value-Based Care– Hospital Readmissions Reduction Program– Care Transitions – Review of the current ACO programs and new models forthcoming
• Next steps in health system reform: pertinent legislation & rules– Updates regarding “Meaningful Use”– Review of the IMPACT Act 2014– Review of the Medicare Access and CHIP Reauthorization Act (MACRA) 2015
Objectives
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Size and Scope of CMS Responsibilities
• CMS is the largest purchaser of health care in the world
• Combined, Medicare and Medicaid pay approximately one-third of national health expenditures (approx $800B)
• CMS programs currently provide health care coverage to roughly 105 million beneficiaries in Medicare, Medicaid and CHIP; or roughly 1 in every 3 Americans.
• The Medicare program alone pays out over $1.5 billion in benefit payments per day.
• Through various contractors, CMS processes over 1.2 billion fee-for-service claims and answers about 75 million inquiries annually.
• Millions of consumers will receive health care coverage through new health insurance exchanges authorized in the Affordable Care Act.
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Better. Smarter. Healthier.So we will continue to work across sectors and across the aisle for the goals we share: better care, smarter spending, and healthier people.
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Encourage the integration and coordination of services Improve population health Promote patient engagement through shared decision
making
Incentives
Create transparency on cost and quality information Bring electronic health information to the point of care for
meaningful use
Focus Areas Description
Care Delivery
Information
Promote value-based payment systems – Test new alternative payment models– Increase linkage of Medicaid, Medicare FFS, and other
payments to value Bring proven payment models to scale
Better Care, Smarter Spending, Healthier People
Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.
CMS support of health care Delivery System Reform
Key characteristics Producer-centered Incentives for volume Unsustainable Fragmented Care
Systems and Policies Fee-For-Service Payment
Systems
Key characteristics Patient-centered Incentives for outcomes Sustainable Coordinated care
Systems and Policies Value-based purchasing Accountable Care Organizations Episode-based payments Medical Homes Quality/cost transparency
Public and Private sectors
Evolving future stateHistorical state
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Improving the way providers are incentivized, the way care is delivered, and the way information is distributed will help provide better care at lower cost across the health
care system.
Delivery System Reform requires focusing on the way we pay providers, deliver care, and distribute information
Source: Burwell SM. Setting Value-Based Payment Goals ─ HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.
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PayProviders
Deliver Care
DistributeInformation
FOCUS AREAS
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Framework for Progression of Payment to Clinicians and Organizations in Payment Reform
Category 1: Fee for Service – No Link to Quality
Category 2: Fee for Service – Link to Quality
Category 3: Alternative Payment Models on Fee-for Service Architecture
Category 4: Population-BasedPayment
Description Payments are based on volume of services and not linked to quality or efficiency
At least a portion of payments vary based on the quality or efficiency of health care delivery
• Some payment is linked to the effective management of a population or an episode of care
• Payments still triggered by delivery of services, but, opportunities for shared savings or 2-sided risk
• Payment is not directly triggered by service delivery so volume is not linked to payment
• Clinicians and organizations are paid and responsible for the care of a beneficiary for a long period (eg, >1 yr)
Examples
Medicare • Limited in Medicare fee-for-service
• Majority of Medicare payments now are linked to quality
• Hospital value-based purchasing
• Physician Value-Based Modifier
• Readmissions/Hospital Acquired Condition Reduction Program
• Accountable Care Organizations
• Medical Homes• Bundled Payments
• Eligible Pioneer accountable care organizations in years 3 – 5
• Some Medicare Advantage plan payments to clinicians and organizations
• Some Medicare-Medicaid (duals) plan payments to clinicians and organizations
Medicaid Varies by state • Primary Care Case Management
• Some managed care models
• Integrated care models under fee for service
• Managed fee-for-service models for Medicare-Medicaid beneficiaries
• Medicaid Health Homes• Medicaid shared savings
models
• Some Medicaid managed care plan payments to clinicians and organizations
• Some Medicare-Medicaid (duals) plan payments to clinicians and organizations
Rajkumar R, Conway PH, Tavenner M. The CMS—Engaging Multiple Payers in Risk-Sharing Models. JAMA. Doi:10.1001/jama.2014.3703
The Six Goals of the National Quality Strategy
Make care safer by reducing harm caused in the delivery of care
Strengthen person and family engagement as partners in their care
Promote effective communication and coordination of care
Promote effective prevention and treatment of chronic disease
Work with communities to promote healthy living
Make care affordable
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Tools aligning with the Strategy
• Performance measurement and feedback– PQRS, Value Modifier, EHR Incentive program
– Hospital Readmission Reduction Program
– Transitional Care Management, Comprehensive Primary Care
• New payment models tested under CMMI
– ACOs and Bundled Payments, CCJR
– Alternate Payment Models under the Medicare Access and CHIP Reauthorization Act
• Public reporting of performance – ”Transparency”– Physician Compare, Hospital Compare, Nursing Home Compare
• National and local coverage policy decisions– Payment adjustments (i.e., no payment for certain hospital acquired conditions)
• Conditions of participation
– Survey & Certification evaluating INFECTION CONTROL12
Hospital Readmission Reduction
• What’s the problem?
• High re-admission rates could indicate breakdowns in care delivery systems.– Payment systems incentivized fragmentation.– More complicated cases = more “hands in the pot.”– Expectation of patients to self-manage is great
• Medicare patients said they were more dissatisfied with their preparation for discharge than any other patient satisfaction measure.– 80% received discharge information.– 59% received medication information.
What’s all of this costing us?• Re-admissions cost Medicare $17.4 billion in 2004.1
– 30-day re-admission rate: 19.6%.– Of them, 50.2% didn’t see a doctor before re-hospitalization– Re-hospitalized patients stayed 0.6 days longer on average.
• We could have saved $12 billion if we prevented 30-day “potentially preventable” readmissions in 2005.2
– “Potentially preventable” per MedPAC estimates.– 13.3% of all hospitalizations or 3 out of 4 re-admissions!
• First NEJM article published November 1984.3
– Rate was 22% after 60 days.– Re-admissions comprised 25¢ of every inpatient claim dollar.
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Readmission Reduction Program
• Required by Section 3025 of the 2010 Affordable Care Act
• Requires Secretary to establish a Hospital Readmissions Reduction Program which– Reduces Inpatient Prospective Payment System (IPPS)
payments to hospitals for excess readmissions– For discharges on or after October 1, 2012 (Fiscal Year [FY]
2013)
• Required initial adoption of the National Quality Forum-endorsed 30-day Risk-Standardized Readmission measures:– acute myocardial infarction (AMI), – heart failure (HF), – pneumonia
Why are patients readmitted?
Reporting of Readmission Measures
• Measures reported yearly based on 3 years of data
• Reported on Hospital Compare as:– Better than the U.S. national rate;– Worse than the U.S. national rate;– No different than the U.S. national rate; or – Difference is uncertain
• Will not classify performance for hospitals with <25 cases in 3 year period
• Are risk-adjusted, and a relative measure of hospital performance
• Allows comparison of hospital’s performance given its case-mix to average hospital’s performance with same case-mix
CMS Transparency EffortsHOSPITAL COMPARE
Number of SessionsHospital CompareTotal sessions: (3,872,191)112,237 sessions for July 2015
Number of Page viewsHospital CompareTotal sessions: (18,001,685)682,465 page views for July 2015
New and Returning SessionsUser Type SessionsNew Visitor 60,597Returning Visitor 51,640
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Goals for Readmission Measures
Promote broadest possible efforts to lower readmission rates:
• Assume all patients are at risk of readmission and their risk can be lowered
• Opportunity to focus efforts on patients most at risk of readmission
• CMS is targeting funding support to hospitals and communities with greatest need for improvement
• Goal is not zero readmissions, but to lower readmission rates overall
Medicare all-cause, 30-day hospital readmission rate is declining
Legend: CL: control limit; UCL: upper control limit; LCL: lower control limit
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miss
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Care Transitions
• Created by Section 3026 of the Affordable Care Act– Community Based Care Transitions program tests care
delivery models for improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries
• Goals of the Program– To improve transitions of beneficiaries from the inpatient
hospital setting to other care settings– To improve quality of care– To reduce readmissions for high risk Medicare
beneficiaries– To document measurable savings to the Medicare program
Transitional Care ManagementService Requirements
• Services are required during the beneficiary’s transition to the community setting following particular kinds of discharges;
• The health care professional accepts care of the beneficiary post-discharge from the facility setting without a gap;
• The health care professional takes responsibility for the beneficiary’s care; and
• The beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making.
• The 30-day TCM period begins on the date the beneficiary is discharged from the inpatient hospital setting and continues for the next 29 days.
Community-based Care Transitions Program
72 organizations currently participating
Goals:• To improve transitions of beneficiaries from the
inpatient hospital setting to other care settings• To improve quality of care• To reduce readmissions for high risk Medicare
beneficiaries• To document measurable savings to the Medicare
program
Where partnerships are in action
CCTP Evaluationby Econometrica, Inc. , May 30, 2014
Challenges and Lessons Learned: - hiring personnel with appropriate skills and experience- identifying at-risk patients- developing systems to manage information- learning about the qualities needed to be an effective coach through experience- revising hiring criteria to include personal qualities, such as ability to work at a fast pace that were
effective in reaching and motivating patients- having direct access to the hospitals’ electronic health record (EHR) system and case management
data to support the identification of at-risk patients
Planned Changes Going Forward: - adding new hospital partners- expanding eligibility criteria for patients- expanding reach and footprint to have a greater impact on readmission rates- broadening eligibility criteria may help achieve higher enrollment numbers, but increasing client pool
could make lower readmission rates more difficult to achieve since it would require serving more beneficiaries
- adding new hospitals as partners may still be a worthwhile goal, but it may not have the impact of increasing a CBO’s footprint
- changing services offered and strategies used to meet the needs of beneficiaries26
ACO Continuum
Global CapitationFee-for-Service
Traditional FFS
MSSP
Track 2 Track 3
Next Generation
Medicare Advantage
FFS ACOs
Pioneer
Track 1
Achieving the Goals
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• Accountable Care Organization (ACO) Models– Medicare Shared Savings Program – 3 Tracks– Pioneer ACO Model– Next Generation ACO Model– ESRD ACO Initiative– Advance Payment Model– ACO Investment Model
• Medicare Advantage also supporting ACOs
Alternative Payment Model Impact
Accountable Care Models• Providers have shared responsibility for
managing total cost and quality for a population of patients.
• Opportunity to earn shared savings payments when spending is reduced with high quality care
• Newer ACO models with population-based payments
Bundled Payments• Payment or target price for all services
associated with an episode of care• Over 2,000 hospitals, physician groups,
and post acute care providers accepting financial risk and focused on improved quality
ACOs - Participation is Growing Rapidly
• More than 400 ACOs participating in the Medicare Shared Savings Program
• Almost 8 million assigned beneficiaries in 49 states, plus D.C. and Puerto Rico
• MSSP rule seeks to build on this momentum.
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ACO Participation
ACO-Assigned Beneficiaries by County
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MSSP Early Results
• Medicare’s main ACO program• Rapid growth
– 89 new provider organizations this year– > 400 MSSP ACOs– 1/6 of Medicare FFS beneficiaries
• Data from 220 early MSSP ACOs:– Generated > $700 million savings (1%)– Significant variation in financial performance– Significant improvement in quality scores
• 30/33 measures• Higher CAHPs scores than Medicare FFS
– No correlation between financial performance and quality
Lessons Learned: MSSP
• Demographics vary …– Urban/rural, large/small, HIT, populations served
• ... But culture similar– Focus on value before started ACO– Emphasis on strengthening primary care
(e.g. built on integrated medical home)
– History of coordination across sites of care(e.g. leveraged pre-existing relationships/focus on transitions)
– Strong physician leadership / engagement– Familiarity with data
MSSP Policy Changes
• Goals:– Improve willingness to move along risk continuum
90% currently in Track 1 (shared savings)– Improve retention
2 of 5 in Track 2 (2-sided risk) dropped out
• Reduce administrative burden – Streamlines renewal process– Modification of assignment algorithm– Data sharing (reduced opt-out burden)
• Financial Methodology– Allow renewal in same track– More choice in shared savings/loss for Track 2
• Up to 60% MSR/MLR in 0.5% increments– New Track 3
• Waiver of 3-day SNF rule (same as Pioneers)
Pioneer ACOS were designed for organizations with experience in coordinated care and ACO-like contracts
Pioneer ACOs showed improved quality outcomesQuality outperformed published benchmarks in 15/15 clinical quality measures and 4/4 patient experience measures in year 1 and improved in year 2Mean quality score of 85.2% in 2013 compared to 71.8% in 2012Average performance score improved in 28 of 33 (85%) quality measures
Pioneer ACOs generated savings for 2nd year in a row $400M in program savings combined for two years† (Office of Actuary Certified
expansion likely to reduce program expenditures) Average savings per ACO increased from $2.7 million in PY1 to $4.2 million in PY2‡
Pioneer ACOs provided higher quality and lower cost care to Medicare beneficiaries in their first two performance years
19 ACOs operating in 12 states (AZ, CA, IA, IL, MA, ME, MI, MN, NH, NY, VT, WI) reaching over 600,000 Medicare fee-for-service beneficiaries
Duration of model test: January 2012 – December 2014; 19 ACOs extended for 2 additional years
Model certified by Actuary as likely to reduce expenditures and model improved quality
† Results from regression based analysis‡ Results from actuarial analysis
Pioneer Evaluation Results
• 32 ACOs; two performance years
• Saved $384 million – $279.7 million Year 1; $35.62 PBPM– $104.5 million Year 2; $11.18 PBPM– 10 ACOs had significant savings in both years– 10 ACOs had significant savings in one year
(2 had significant losses in the other year)– 12 ACOs had no distinguishable savings or losses– Cost savings result of decreases in acute inpatient stays
• Improved mean quality scores by 19 % and increased performance on 28 of 33 measures between Year 1 and Year 2.
• Independent Office of the Actuary certified this model to meet the stringent criteria for expansion to a larger population of Medicare beneficiaries.
ACO Continuum
Global CapitationFee-for-Service
Traditional FFS
MSSP
Track 2 Track 3
Next Generation
Medicare Advantage
FFS ACOs
Pioneer
Track 1
• Authorized under Section 1115A of the Social Security Act (added by Section 3201 of the ACA), establishing CMMI
• A new opportunity in accountable care– More predictable financial targets– Greater opportunities to coordinate care– High quality standards consistent with other
Medicare programs and models– Beneficiaries can select their ACO
Next Generation ACO Model
• Prospective attribution• Protect Medicare FFS beneficiaries’ freedom of choice;• Create a financial model with long-term sustainability;• Rewards quality; • Offer benefit enhancements that directly improve the
patient experience and support coordinated care;• Allow beneficiaries a choice in their alignment with the
ACO• Smooth ACO cash flow and improve investment
capabilities through alternative payment mechanisms.
Next Generation ACO Model Principles
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• Medicare payment rule waivers designed to improve care coordination and cost saving capabilities:– Telehealth expansion– Post-discharge home visits– 3-Day SNF Rule Waiver
• ACO may decide which, if any, to implement• For each, ACOs must submit an implementation
plan describing how the ACO will utilize, monitor, and report on the benefit enhancement
Benefit Enhancements
• Eliminate the requirement of a 3-day inpatient stay prior to SNF admission
• Similar to the Pioneer Model– Available to aligned beneficiaries admitted by Next
Generation Providers/Suppliers or Preferred Providers to eligible and CMS-approved SNF Affiliates
– Clinical criteria for admission, e.g. beneficiary must be medically stable with confirmed diagnosis of skilled nursing/rehab need
SNF 3-day Rule Waiver
• 15 to 20 ACOs• Representation from a variety of provider
organization types and geographic regions• Minimum aligned beneficiaries: 10,000
– 7,500 for rural ACOs
• Two opportunities to apply:– Final application due June 2015 for January 2016 start date– Second application due June 1, 2016 for January 2017 start
date
Model Scope
The bundled payment model targets 48 conditions with a single payment for an episode of care Incentivizes providers to take
accountability for both cost and quality of care
Four Models - Model 1: Retrospective acute care
hospital stay only- Model 2: Retrospective acute care
hospital stay plus post-acute care- Model 3: Retrospective post-acute
care only- Model 4: Acute care hospital stay
only 102 Awardees and 167 episode initiators in
phase 2 as of January 2015 85 new awardees and 373 new episode
initiators entered phase 2 in April 2015 187 new awardees and 1,575 new episode
initiators entered Phase 2 on July 1, 2015
Bundled Payments for Care Improvement is also growing rapidly
* Current as of January 2015
What is the Comprehensive Care Joint Replacement model?
• The model would test bundled payments for lower extremity joint replacement (LEJR) across a broad cross-section of hospitals.
• The payment model would apply to most Medicare LEJR procedures within select geographic areas with few exceptions.
• The payment model would be implemented through rule making, and the performance period proposed to begin on January 1, 2016.
CCJR Participants
• Participants include Inpatient Prospective Payment System (IPPS) Hospitals in select Metropolitan Statistical Areas (MSA) not participating in phase II of the Bundled Payment for Care Improvement (BPCI) model for the lower extremity joint replacement clinical episode.– BPCI Model 2 and Model 3 LEJR episodes initiated by
participating physician group practices or post-acute care facilities would take precedence over Comprehensive Care Joint Replacement model episodes.
• 75 MSAs were selected in a two-step randomizationprocess.MSA were placed into five groups based on their historic LEJR
episode payment and their population size. Fifteen MSAs were then randomly selected within each group.
SMARTER SPENDING: Health care costs consume a significant portion of state, federal, family, and business budgets, and we can find ways to spend those dollars more wisely.
HEALTHIER PEOPLE: Giving providers the opportunity to focus on patient-centered care and to be accountable for quality and cost means keeping people healthier for longer.
BETTER CARE: We have an opportunity to realign the practice of medicine with the ideals of the profession—keeping the focus on patient health and the best care possible.
Delivery System Transformation
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Key Concepts for the EHR Incentive Programs in 2015 through 2017
(Modified Stage 2)
• Restructured Stage 1 and Stage 2 objectives & measures to align with Stage 3
• Starting in 2015 the EHR reporting period aligns with the calendar year for all providers
• Changed the EHR reporting period in 2015 to 90 days to accommodate modifications in meaningful use
• Modified Stage 2 patient engagement objectives that require “patient action”
• Streamlined the program by removing redundant, duplicative and topped-out measures
• CQM reporting for both EPs and eligible hospitals/CAHs remains as previously finalized
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Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014
Why Post-Acute Care?
• Important part of the health system• 42% of Medicare fee for service beneficiaries
discharged from hospitals go to PAC Sicker and quicker discharges
• Large numbers of Medicare enrollees served in these settings (over 5.5 million beneficiaries)
• Recovery, support and rehabilitation Transition to lowest safe level of care
Effect of a Standardized Approach
• Currently: 4 different settings, 4 different assessments
– Skilled nursing Facilities (SNF)Minimum Data Set
– Home Health Agencies (HHA) OASIS
– Inpatient Rehabilitation Facilities (IRF) IRF-PAI
– Long Term Care Hospitals (LTCH) LTCH CARE Data Set
• Assessments lack common standards & definitions
IMPACT Act Identifies Domains for Quality Measures that Use
Standardized Assessment Data
Quality measures on which PAC providers must submit standardized patient assessment data:
• Functional status, cognitive function, and changes in function and cognitive function.
• Skin integrity and changes in skin integrity.• Medication reconciliation.• Incidence of major falls.• Communicating and providing for the transfer of health
information and care preferences of an individual when the individual transitions.
Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) Overview• Passed House 3/26/2015- Senate 4/14/2015• Signed into Law 4/16/2015
• Repeals 1997 Sustainable Growth Rate Physician Fee Schedule (PFS) Update
• Changes Medicare PFS Payment– Merit-Based Incentive Payment System (MIPS)– Incentives for participation in Alternate Payment
Model (APM)52
Physician Fee Schedule Updates
• PFS 0.5% update 7/1/15-12/31/15• PFS 0.5% update CY2016 - CY2019• PFS 0.0% update CY 2020-2025
• MIPS & APMs will drive payment 2019 onward
• Beginning with CY 2026 - 0.75% APM update• Beginning with CY 2026 - 0.25% update for other
PFS services53
Measure Development Plan(Sec. 102):
• September 2015 – Request for Information (RFI) posted: https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-24906.pdf
• October 2015 – RFI Webinars (Announcements forthcoming)
• March 2016 (anticipated) – CMS to publish proposed rule
• October 2016 (anticipated) – MIPS and APMs final regulation published
• The plan shall: – Address how measures used by private payers & integrated
delivery systems could be incorporated– Take into account how clinical best practices & guidelines should
be used in measure development 55
Request for Information:We need your input!
• Monday 9/28, CMS released a request for information for the first stage of MACRA planning– Specifically requesting input from clinicians on the
development of MIPS and APM quality metrics
• Link to the RFI: https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-24906.pdf
• Comments are due 30 days after publication = October 28th
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• Health Care Payment Learning and Action Networkhttp://innovationgov.force.com/hcplan
• Inpatient Quality Reporting Programhttps://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalRHQDAPU.html
• Meaningful Use resourceshttp://www.cms.gov/EHRIncentivePrograms
• HR 2- Medicare Access and CHIP Reauthorization Act of 2015https://www.govtrack.us/congress/bills/114/hr2
• RFI for MACRA, MIPS and APMshttps://s3.amazonaws.com/public-inspection.federalregister.gov/2015-24906.pdf
References & Further Reading
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Ashby Wolfe, MD, MPP, MPHChief Medical Officer, Region IX
Centers for Medicare and Medicaid Services90 Seventh Street, Suite 5-300
San Francisco, CA 94103(Ph) 415.744.3631
Questions?
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