medicare updates: vbp, snf qrp, bundling - ohca - r hillier.pdf · medicare updates: vbp, snf qrp,...

9/29/2017

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MEDICARE UPDATES: VBP, SNF QRP, BUNDLING

PRESENTED BY:

ROBIN L. HILLIER, CPA, STNA, LNHA, RAC-MT

[email protected] (330)807-2850

MEDICARE VALUE BASED PURCHASING

mailto:[email protected]

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PROTECTING ACCESS TO MEDICARE ACT OF 2014 (PAMA)

• IMPLEMENTS A VALUE BASED PURCHASING PROGRAM (SNF VBP)

• 2% WITHHOLD TO PART A PAYMENTS THAT CAN BE PARTIALLY EARNED BACK BASED ON

REHOSPITALIZATION RATE AND LEVEL OF IMPROVEMENT

• PASSED IN 2014, RATES NOT IMPACTED UNTIL FY 2019 (OCTOBER 1, 2018); DETAILS TO BE

DEVELOPED BY CMS RULEMAKING

PAMA VBP IMPLEMENTATION TIMELINE

• FY 2016 – MEASURE DEVELOPMENT, DATA COLLECTION

• FY 2017 – SNF PREVIEW OF DATA

• FY 2018 – PUBLIC REPORTING OF DATA

• FY 2019 – (OCTOBER 1, 2018) WITHHOLD IMPLEMENTED

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FY 2016 PPS UPDATE RULE

• CMS SELECTED THE SKILLED NURSING FACILITY 30-DAY ALL-CAUSE READMISSION MEASURE RISK

ADJUSTED REHOSPITALIZATION MEASURE (SNFRM NQF #2510)

• WILL MOVE TO “POTENTIALLY PREVENTABLE REHOSPITALIZATION MEASURE”

SNFRM BACKGROUND

• HOSPITAL READMISSIONS OF MEDICARE VBENEFICIARIES DISCHARGED FROM A SNF ARE

COMMON, STUDIES SUGGEST A LARGE PROPORTION ARE PREVENTABLE

• HOSPITAL READMISSIONS ALSO PUT BENEFICIARIES AT RISK FOR COMPLICATIONS

• THE INTENT OF THE SNFRM IS TO ENCOURAGE SNF PROVIDERS TO MONITOR AND REDUCE

HOSPITAL READMISSIONS, THEREBY REDUCING COSTS AND IMPROVING THE QUALITY OF CARE

MEDICARE BENEFICIARIES RECEIVE DURING THEIR SNF STAY

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SNFRM MEASURE OVERVIEW

• SNFRM ESTIMATED THE RISK-STANDARDIZED RATE OF ALL-CAUSE, UNPLANNED HOSPITAL

READMISSIONS FOR SNF BENEFICIARIES WITHIN 30 DAYS OF DISCHARGE FROM THEIR PRIOR

PROXIMAL SHORT-STAY ACUTE HOSPITAL DISCHARGE

• SNF ADMISSION MUST HAVE OCCURRED WITHIN 1 DAY AFTER DISCHARGE FROM THE PROXIMAL

HOSPITAL STAY

• MEASURE BASED ON DATA FOR 12 MONTHS OF SNF ADMISSIONS

• BENEFICIARIES WITH MORE THAN ONE ELIGIBLE ADMISSION MAY BE INCLUDED IN THE MEASURE

MULTIPLE TIMES WITHIN A GIVEN YEAR

SNFRM MEASURE OVERVIEW - EXCLUSIONS

• SNFRM EXCLUDES CERTAIN STAYS:

• STAYS FOR WHICH PATIENT HAD INTERVENING PAC ADMISSION BETWEEN HOSPITAL STAY AND SNF

OR AFTER SNF DISCHARGE

• PATIENTS WHO DID NOT HAVE FFS PART A ENROLLMENT BEFORE PROXIMAL HOSPITAL DISCHARGE

• PATIENTS WHO DID NOT HAVE FFS PART A ENROLLMENT FOR ENTIRE 30 DAY RISK WINDOW

• PATIENTS WHOSE HOSPITALIZATION WAS FOR THE MEDICAL (NONSURGICAL) TREATMENT OF CANCER

OR RECEIVING REHABILITATION CARE OR PROSTHESIS FITTING

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• SNF RM PRODUCES A RISK-ADJUSTED READMISSION RATE FOR EACH FACILITY, EXCLUDING

PLANNED READMISSION FROM THE SNF

• MEASURE IS COMPUTED BY CALCULATING THE STANDARDIZED RISK RATIO (SRR): THE PREDICTED

NUMBER OF READMISSIONS AT THE FACILITY DIVIDED BY THE EXPECTED NUMBER OF

READMISSIONS FOR THE SAME PATIENTS IF THESE SAME PATIENTS HAD BEEN TREATED BY THE

AVERAGE SNF

• SRR IS THEN MULTIPLIED BY THE MEAN RATE OF READMISSION IN THE POPULATION TO

GENERATE THE FACILITY-LEVEL STANDARDIZED READMISSION RATE, REFERRED TO AS THE RISK-

STANDARDIZED READMISSION RATE OR RSRR


• MEASURE IS DESIGNED TO CAPTURE THE OUTCOME OF UNPLANNED ALL-CAUSE HOSPITAL

READMISSIONS OCCURRING WITHIN 30 DAYS OF DISCHARGE FROM THE PATIENTS PRIOR

PROXIMAL ACUTE HOSPITALIZATION

• HOSPITAL OBSERVATION STAYS DO NOT COUNT AS A READMISSION

• READMISSIONS IDENTIFIED AS BEING PLANNED USING THE CMS PLANNED READMISSION

ALGORITHM ARE EXCLUDED

• SNFRM IS EVALUATED ON A 1-YEAR CYCLE

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SNFRM – PLANNED READMISSION

• PLANNED READMISSION IS DEFINED AS ANT NON-ACUTE READMISSION IN WHICH ONE OF A

SET OF TYPICALLY PLANNED PROCEDURES OR DIAGNOSES OCCURRED

• IF ANY OF THE PROCEDURES DENOTED AS PLANNED OCCUR IN CONJUNCTION WITH A

DIAGNOSIS THAT DISQUALIFIES A READMISSION FROM BEING CONSIDERED PLANNED, THE

READMISSION WILL BE CONSIDERED TO BE UNPLANNED

SNFRM – PLANNED READMISSION• PLANNED READMISSION PROCEDURES:

• ONE OF A PRE-SPECIFIED LIST OF PROCEDURES TOOK PLACE, OR

• READMISSION FOR BONE MARROW, KIDNEY OR OTHER TRANSPLANT

• PLANNED READMISSION DIAGNOSES:

• MAINTENANCE CHEMOTHERAPY AND REHABILITATION

• READMISSIONS TO PSYCHIATRIC HOSPITALS OR UNITS

• ADMISSIONS FOR ACUTE ILLNESS OR FOR COMPLICATIONS OF CARE ARE NOT

CLASSIFIED AS “PLANNED,” EVEN IF A TYPICALLY PLANNED PROCEDURE IS

PERFORMED DURING THE STAY

• PRINCIPAL DIAGNOSIS AND ALL PROCEDURE CODES FROM THE READMISSION ARE

UTILIZED TO IDENTIFY PLANNED READMISSIONS

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SNFRM RISK ADJUSTMENT

• COVARIATES USED IN THE MEASURE:

• AGE, GENDER

• PROXIMAL HOSPITALIZATION LOS

• TIME IN ICU?

• ESRD

• # ACUTE CARE HOSPITALIZATIONS IN 365

DAYS BEFORE PROXIMAL HOSPITALIZATION

• PRINCIPAL DIAGNOSIS

• SYSTEM-SPECIFIC SURGICAL INDICATORS

• KIDNEY, CARDIAC, VASCULAR PATIENTS WITH

SURGICAL INDICATORS ARE HIGHER RISK

• ORTHO WITH SURGICAL INDICATOR ARE LOWER

RISK

• INDIVIDUAL COMORBIDITIES

• ESRD, DIABETES, HEART FAILURE, PRESSURE

ULCERS

• MULTIPLE COMORBIDITIES

• CHARLSON COMORBIDITY INDEX IS CALCULATED

USING BOTH THE NUMBER AND SERIOUSNESS

OF COMORBIDITIES


• FY 2016 PPS UPDATE RULE SPECIFIED THE USE OF THE SNF REHOSPITALIZATION MEASURE (SNF

RM) FOR VALUE BASED PURCHASING RATE ADJUSTMENTS EFFECTIVE OCTOBER 1, 2018

• FY 2017 UPDATE RULE ANNOUNCES TRANSITION TO A POTENTIALLY PREVENTABLE

REHOSPITALIZATION MEASURE (“SNFPPRM”) “AT SOME POINT”

• 30 DAY MEASURE SIMILAR TO THE SNF RM, BUT ONLY COUNTS REHOSPITALIZATIONS WITH A

DIAGNOSIS ON HOSPITAL CLAIM THAT IS CONSIDERED POTENTIALLY PREVENTABLE (I.E., COPD, CHF)

• THIS IS A SPECIFIC LIST OF DIAGNOSES, COVERS MOST ADMISSIONS

RLH Consulting 14

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• PERFORMANCE PERIOD

• JANUARY 1, 2017 TO DECEMBER 31, 2017

• IMPROVEMENT PERIOD

• IMPROVEMENT TO BE CALCULATED OVER RATE FROM TWO YEARS BEFORE PERFORMANCE PERIOD

• CY 2017 IMPROVEMENT OVER CY 2015

• CMS ANNOUNCED PLANS TO TRANSITION FROM A CALENDAR YEAR MEASUREMENT PERIOD TO

A FISCAL YEAR MEASUREMENT PERIOD BEGINNING OCTOBER 2017, SO THE QUARTER FROM

OCTOBER 1 THROUGH DECEMBER 31, 2017 WILL COUNT IN TWO DIFFERENT RATE YEAR

ADJUSTMENTS

RLH Consulting 15


• REHOSPITALIZATION SCORE USED TO CALCULATE PAYMENT RATE CAN RANGE FROM 0 TO 100

POINTS

• IT WILL BE THE HIGHER OF THE FACILITY “ACHIEVEMENT” SCORE OR “IMPROVEMENT” SCORE

• FACILITIES WILL BE RANKED BASED ON REHOSPITALIZATION SCORE TO DETERMINE PAYMENT

ADJUSTMENT

RLH Consulting 16

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• ACHIEVEMENT SCORE OF 0 TO 100 IS AWARDED BASED ON RANKING OF THE

REHOSPITALIZATION RATE IN THE PERFORMANCE PERIOD

• SNFS IN LOWEST 25% RECEIVE 0 POINTS

• SNFS IN TOP 5% RECEIVE 100 POINTS

• FORMULA PROPOSED FOR ALLOCATING POINTS TO REMAINING SNFS

RLH Consulting 17


• IMPROVEMENT SCORE OF 0 TO 90 POINTS AWARDED BASED ON IMPROVEMENT OVER A TWO-

YEAR PERIOD

• A UNIQUE IMPROVEMENT RANGE IS ESTABLISHED FOR EACH SNF THAT DEFINES THE DIFFERENCE

BETWEEN THEIR BASELINE PERIOD SCORE AND THE NATIONAL BENCHMARK ESTABLISHED

RLH Consulting 18

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• IMPROVEMENT SCORE, CONTINUED

• IF PERFORMANCE PERIOD SCORE IS EQUAL TO OR LOWER THAN IMPROVEMENT THRESHOLD, 0

POINTS AWARDED

• IF PERFORMANCE PERIOD SCORE IS EQUAL TO OR HIGHER THAN THE BENCHMARK, 90 POINTS

AWARDED

• IF PERIOD SCORE IS GREATER THAN IMPROVEMENT SCORE, BUT LESS THAN THE BENCHMARK,

BETWEEN 0 AND 90 POINTS WILL BE AWARDED USING A PROPOSED FORMULA

RLH Consulting 19


• SNF PART A PAYMENT ADJUSTMENT WILL BE BASED ON REHOSPITALIZATION SCORE RANKING

• FACILITIES WILL BE TOLD THE PAYMENT ADJUSTMENT AT LEAST 60 DAYS PRIOR TO RATE

EFFECTIVE DATE

• REMEMBER, FIRST PAYMENT ADJUSTMENTS EFFECTIVE OCTOBER 1, 2018

RLH Consulting 20

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UPCOMING SNF VBP COMPONENTS

• CMS IS NOW PROVIDING QUARTERLY CONFIDENTIAL FEEDBACK REPORTS SO THAT FACILITIES CAN

MONITOR THEIR PERFORMANCE

• CMS HAS POSTED A FILE WITH EVERY SNF 2015 BASELINE (2015) RISK STANDARDIZED READMISSION

RATE

• THE FY2018 PPS UPDATE RULE WILL PROVIDE ADDITIONAL INFORMATION RELATED TO THE PAYMENT

SPECIFICS

IMPACT ACT

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• THE IMPACT ACT (2014) REQUIRED CMS TO SPECIFY STANDARD

ASSESSMENT TOOLS ACROSS PAC PROVIDERS (HH, SNF, IRF, LTCH)

ALONG WITH CROSS-SETTING QMS BY OCTOBER 2015 IN FOUR

DOMAINS:

• FUNCTIONAL STATUS

• COGNITIVE FUNCTION AND CHANGES IN COGNITION

• SKIN INTEGRITY AND CHANGES IN SKIN INTEGRITY

• INCIDENCE OF MAJOR FALLS

IMPACT ACT

• COLLECTION AND SUBMISSION OF DATA REQUIRED WITHIN TWO

YEARS OF FINAL MEASURE SPECIFICATION (OCTOBER 2017)

• PROPOSED MEASURES REQUIRE TWELVE MONTHS OF DATA, SO

DATA SUBMISSION REQUIRED BEGINNING OCTOBER 2016

• 2% PENALTY FOR FAILURE TO REPORT REQUIRED DATA

• (IMPLICATION OF DASHES ON MDS)

• FUTURE IMPLICATIONS FOR VBP

SNF QUALITY REPORTING PROGRAM (QRP)

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SNF PART A DISCHARGE ASSESSMENT

• THE MEASURES SPECIFIED FOR SNFQR REQUIRES AN ASSESSMENT BE COMPLETED AT THE END

OF EACH PART A STAY TO CAPTURE QUALITY MEASURE ITEMS. DISCHARGE ASSESSMENTS ARE

COMPLETED FOR PART A BENEFICIARIES WHO GO HOME AT THE END OF THE EPISODE OF CARE,

BUT THERE IS CURRENTLY NOT AN END OF CARE ASSESSMENT REQUIRED FOR THOSE WHO WILL

REMAIN IN THE FACILITY AT THE END OF PART A COVERAGE

• EFFECTIVE OCTOBER 1, 2016 A NEW “SNF PART A PPS DISCHARGE ASSESSMENT” IS REQUIRED

IN THESE CIRCUMSTANCES


• THE MEASURES SPECIFIED FOR SNFQR REQUIRES AN ASSESSMENT BE COMPLETED AT THE END

OF EACH PART A STAY TO CAPTURE QUALITY MEASURE ITEMS. DISCHARGE ASSESSMENTS ARE

COMPLETED FOR PART A BENEFICIARIES WHO GO HOME AT THE END OF THE EPISODE OF CARE,

BUT THERE IS CURRENTLY NOT AN END OF CARE ASSESSMENT REQUIRED FOR THOSE WHO WILL

REMAIN IN THE FACILITY AT THE END OF PART A COVERAGE

• EFFECTIVE OCTOBER 1, 2016 A NEW “SNF PART A PPS DISCHARGE ASSESSMENT” IS REQUIRED

IN THESE CIRCUMSTANCES

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• REVIEW CODING INSTRUCTIONS FOR A2400C AS WELL AS RETURN ANTICIPATED VS. RETURN

NOT ANTICIPATED

• FOR A MEDICARE PART A DISCHARGE WHERE THE BENEFICIARY LEAVES THE FACILITY, THIS

ASSESSMENT WILL BE COMBINED WITH THE OBRA DISCHARGE ASSESSMENT

• FOR A RESIDENT WHO WILL REMAIN IN THE FACILITY AFTER BEING DISCHARGED FROM

MEDICARE, THIS WILL BE A STAND ALONE ASSESSMENT


SNF QRP ASSESSMENT-BASED QUALITY MEASURES

• NQF #0674: APPLICATION OF PERCENT OF RESIDENTS EXPERIENCING ONE OF MORE FALLS

WITH A MAJOR INJURY

• NQF #0678: PERCENT OF PATIENTS OR RESIDENTS WITH PRESSURE ULCERS THAT ARE NEW OR

WORSENED

• NQF #2631 APPLICATION OF PERCENT OF LONG-TERMCARE HOSPITAL ADMISSIONS WITH AN

ADMISSION AND DISCHARGE FUNCTIONAL ASSESSMENT AND A CARE PLAN THAT ADDRESSES

FUNCTION

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SNF QRP CLAIMS-BASED MEASURES

• DISCHARGE TO COMMUNITY – POST ACUTE CARE (PAC) SKILLED NURSING FACILITY QUALITY

REPORTING PROGRAM (QRP)

• POTENTIALLY PREVENTABLE 30-DAYS POST-DISCHARGE READMISSION MEASURE FOR SKILLED

NURSING FACILITY QUALITY REPORTING PROGRAM

• MEDICARE SPENDING PER BENEFICIARY – POST ACUTE CARE (PAC) SKILLED NURSING FACILITY

MEASURE

SNF QRP MEASURES

• CMS HAS POSTED SEVERAL RESOURCES:

• TABLE OF MDS ITEMS USED TO GENERATE SNF QRP MEASURES

• SNF QRP QUALITY MEASURES USER’S MANUAL

• REVIEW AND CORRECT REPORTS

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BUNDLING UPDATE

Bundled Payments

for Care

Improvement (BPCI)

Comprehensive Care

for Joint Replacement

(CJR)

Episode Payment

Models (EPMs)

• Voluntary for all Medicare

acute and PAC providers

• 4 models: acute, PAC, and

acute+PAC

• Providers can select from 48

clinical episodes to test within a

specific timeframe (ranging

from inpatient acute care to 30,

60, or 90 days after discharge)

• 5-year demo

• Mandatory bundles in 67

markets for Medicare

beneficiaries who receive hip

and knee replacements (also

called lower extremity joint

replacements or LEJR)

• Hospital is risk-bearer, impacts

~800 hospitals

• 90-day episodes

• 5-year demo

• Mandatory bundles in 98

markets for heart attack, bypass

surgery

• Mandatory surgical hip/femur

fracture treatment episode

added to 67 CJR markets

• Proposed in 2016, subsequently

delayed twice (current start date

is January 2018)

• Hospital is risk-bearer

• 90-day episodes

April 2013April 2016

January 1, 2018…?

MAJOR BUNDLING INITIATIVES

?

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CMS SCALES BACK MANDATORY BUNDLING DEMOS

1. Completely withdraw

proposed AMI, CABG, and

SHFFT episodes

2. Reduce mandatory CJR

markets from 67 to 34

(remaining 33 become

voluntary)

3. No longer mandatory for rural

and low-volume hospitals

August 17, 2017

Proposed Rule

Source: https://www.gpo.gov/fdsys/pkg/FR-2017-08-17/pdf/2017-17446.pdf

HALF OF CJR MARKETS WOULD GO VOLUNTARY

https://www.gpo.gov/fdsys/pkg/FR-2017-08-17/pdf/2017-17446.pdf

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IS SCALE-BACK A GOOD THING?

• SCALING BACK OF MANDATORY BUNDLING PROGRAMS COULD EASE

THE PRESSURE ON SNFS, PARTICULARLY IN REFORM-HEAVY MARKETS

WITH MANY COMPETING OVERLAPPING VALUE-BASED INITIATIVES

• SNF OPPORTUNITY TO SHARE RISK IN HOSPITAL-CONTROLLED,

MANDATORY PROGRAMS IS LIMITED

• CONCERNS OVER UNINTENDED CONSEQUENCES ON PATIENT ACCESS

TO SNF SERVICES

• DOESN’T MEAN BUNDLING GOES AWAY…

CMS TO EXPAND VOLUNTARY OPTIONS

“…WE EXPECT TO CONTINUE TO OFFER

OPPORTUNITIES FOR PROVIDERS TO

PARTICIPATE IN VOLUNTARY INITIATIVES,

INCLUDING EPISODE PAYMENT

MODELS.”

“BUILDING ON THE BPCI INITIATIVE,

CMMI EXPECTS TO DEVELOP NEW

VOLUNTARY BUNDLED PAYMENT

MODEL(S) DURING CY 2018 THAT

WOULD BE AN ADVANCED APM.”

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ADVANCED BPCI: DETAILS STARTING TO EMERGE

• MODELS 1 AND 4 OF BPCI NOT LIKELY TO BE CONTINUED

• LOOKING TO BUILD OFF EXISTING BPCI RISK-BEARING ARCHITECTURE

• LIKELY TO CONTINUE TO USE CONVENER AND EPISODE INITIATORS STRUCTURE

• TWEAKS UNDER CONSIDERATION BY CMS INNOVATION CENTER:

• ALLOWING NEW PARTICIPANTS

• NEWLY DEFINED EPISODES

• LONGER PERFORMANCE PERIODS

• TARGET PRICE CALCULATION

• ENSURING THAT THE NEW MODEL QUALIFIES AS MACRA ADVANCED APM

ADVANCED BPCI: WHAT WE’RE WATCHING FOR…

• DOES IT MAINTAIN A MODEL 3-LIKE OPTION FOR PAC PROVIDERS TO

DIRECTLY BEAR RISK FOR A PAC-ONLY EPISODE OF CARE?

• WILL EPISODE OPTIONS BE MAINTAINED? WILL THERE BE NEW EPISODE

OPTIONS? (E.G., CHRONIC CARE EPISODE)

• WILL THERE BE BETTER RISK ADJUSTMENT AND RISK MITIGATION?

• WHAT TYPE OF DATA AND HOW FREQUENTLY WILL CMS PROVIDE TO

APPLICANTS/PARTICIPANTS?

• WHAT WILL THE TECHNOLOGY REQUIREMENTS BE?

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WHY ENGAGE IN VOLUNTARY BUNDLES?

Learn by doing; force culture change

Understand markets through data

Improve quality through care redesign

Earn positive margins

Master skills for gainsharing in other arenas

ACTION STEPS

Consider participating in Advanced BPCI

Understand who in your market is

bearing downside risk

Find out if referral hospitals are

staying in CJR –could impact BPCI

Evaluate potential convener

relationship

Identify clinical/ episode

focus areas

Systematically reach out with your (quality &

cost) value proposition

If you are serious about participating in Advanced BPCI…

Immediate…

medicare updates: vbp, snf qrp, bundling - ohca - r hillier.pdf · medicare updates: vbp, snf qrp,...

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