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