CONCEPTUAL OVERVIEW JANUARY 2018 Intr troducti tion Stev eve - - PowerPoint PPT Presentation

CONCEPTUAL OVERVIEW JANUARY 2018

Intr troducti tion

Stev eve e Farmer er, M MD, FACC, F FASE

• Medical Officer
• CMS Innovation Center
• Practicing Cardiologist

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Webcas ast Ou Outline

• The CMS Innovation Center and BPCI Advanced
• Clinical Concept
• BPCI Advanced Model Overview
• Model Development
• Participation Requirements
• Strategies for Success
• Why Should I Participate in the Model?
• CMS Innovation Center Partnership
• Summary

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INTROD ODUCTION ON The CMS Innovation Center and BPCI Advanced

The CM he CMS I Inn nnovation Cen Center er

• As part of the Center for Medicare and Medicaid Services (CMS), the CMS

Innovation Center provides national leadership in the transition from volume to value

• The center tests innovative service and delivery models that reduce costs

while preserving or enhancing quality

• Guiding principles
• Patient centered care
• Provider choice and incentives
• Choice and competition in the market
• Transparent model design and evaluation

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Model Sce cenarios f for S Succe ccess

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Best

Quality Cost

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Quality Cost

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Quality Cost

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Case

Participants may earn addi dditio ional pay ayments f fro rom CMS, but may owe money back to CMS, if costs are higher than expected

BPC PCI A Advanced T Tests a a Different A Approach ch to P Payment

A bundl bundled c clini nical e epi pisode de links physician, hospital, and post-acute care payments to quality and cost

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CLINICAL C L CON ONCEP EPT

• Providers often treat patients

with incomplete information.

• Patients often receive

conflicting advice.

Under FFS, healthcare can be challenging to navigate

Patients O Often Ex Experience a a Fragmented Healthcare S System

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Status Quo: Fee for Service (FFS) Providers acting independently hold little accountability for cost or

• utcomes of care

Fe Fee-fo for-Service (FF (FFS): H Hospitalization

Pat atient E Exper erien ence Ho Hospit ital Hazard rd

– X –

Ho Hospit italis list

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FFS: H Hospital al D Dischar arge

Skille lled Nursin ing F Facilit ility (SNF) F) Pa Patient Ho Hospit italis list Hazard rd Patien ent t Exper erien ence e

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Pat atient E Exper erien ence SNF S F Stay Patie ient’s Ho Home SNF T F Team

FF FFS: S SNF

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FFS: Primary C Care Ph Physician ( (PC PCP) P) a and Cardiol

• logi
• gist

PCP CP Cardio iolo logis ist Pat atient E Exper erien ence Hazard rd

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FFS Ex Experience: S Summary

Cardiologist Hospitalist SNF Team CARE GAP CARE GAP

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Patient

Bundled C Clinical Ep Episodes: A New ew C Concep ept

• BPCI Advanced requires new thinking
• Participants must now coordinate the entire episode

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Cardio iolo logis ist PCP CP

FFS Bundled Clinical Episode

SNF Ho Hospit ital Ho Hospit ital Patie ient’s Ho Home

Cl Clini nical Epi pisodes es Be Better er R Reflec ect H How Patients Ex Experience ce C Care

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Shifts emphasis from indi ndividu idual s servic ices towards a coordinated cli linical e l epis isode Establishes an “accoun untable ble pa party” Clinical episodes are assessed on the qua quality a and nd cost of care

Clinical Ep Episode: B Bundled Payment Ex Experience

Hosp spitalist a and P nd PCP The S he SNF F Team Patien ent’s C Cardi diologist

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BPCI A ADVANCED ED M MOD ODEL EL OVER ERVIEW EW

BPC PCI A Advanced B Builds o

• n Ex

Experience ce

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Stakeholde lder I Input nput:

• Stable target prices provided in advance
• Performance assessments account for patient and

provider characteristics Evide dence Fr From:

• Commercial payer models
• Centers for Medicare and Medicaid Services (CMS)
• CMS Innovation Center models

BPC PCI A Advanced i is Different T Than B BPC PCI

• Streamline

ined de design

• One model, 90 day episode period
• Single risk track
• Inpatient and Outpatient episodes
• Preliminary target prices provided in advance
• Payment tied to performance on quality measures
• Greater focus on ph

physic icia ian n eng ngagement a and l nd learni ning ng

• Designed as an Advanc

nced A d APM under the Quality Payment Program

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Who L Leads Clinical Ep Episodes?

Acute Care Hospitals (ACHs) Physician Group Practices (PGPs)

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Participants M May Work W With a a Convener

A Con

• nvener is a

a Med edicare en enrolle led p provid ider or

• r s

supplie lier or

• r an en

entit ity t that is n not

• t en

enroll lled i in M Med edicare. Conveners m may:

• Facilitate participation by smaller PGPs or ACHs
• Provide data and analytic feedback
• Offer logistical and operational support
• Bear financial risk to CMS under the Model

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Kidne dney

• Renal failure

Inf nfec ectious D s Disea eases es

• Cellulitis
• Sepsis
• Urinary tract infection

Neurolog

• logy

y

• Stroke

29 I Inpatient ( (IP) P) Clinical Ep Episodes, Cont ntinued

Spine, Bone, and J Joint E Episodes

• Back & neck except spinal fusion
• Spinal fusion (non-cervical)
• Cervical spinal fusion
• Combined anterior posterior spinal fusion
• Fractures of the femur and hip or pelvis
• Hip & femur procedures except major joint
• Lower extremity/humerus procedure

except hip, foot, femur

• Major joint replacement of the lower

extremity

• Major joint replacement of the upper

extremity

• Double joint replacement of the lower

extremity

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29 I Inpatient ( (IP) P) Clinical Ep Episodes

Cardi diac E Epi piso sodes es

• Acute myocardial infarction
• Cardiac arrhythmia
• Cardiac defibrillator
• Cardiac valve
• Pacemaker
• Percutaneous coronary intervention
• Coronary artery bypass graft
• Congestive heart failure

Pu Pulmon

• nary E

y Episod

• des
• Simple pneumonia

and respiratory infections

• COPD, bronchitis,

asthma Gastrointes estinal E Episo sodes es

• Major bowel procedure
• Gastrointestinal hemorrhage
• Gastrointestinal obstruction
• Disorders of the liver excluding malignancy, cirrhosis,

alcoholic hepatitis (New Episode for BPCI Advanced)

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3 Outpatient ( (OP) P) C Clinical Ep Episodes

• Percutaneous Coronary

Intervention (PCI)

• Cardiac Defibrillator
• Back & Neck Except

Spinal Fusion

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Hospital al M Medicine & 11 S Special alties Represen ented ed

Cardiolog iology E y Episod

• des:
• Cardiology
• Cardiac Surgery

Gastrointes estinal E Episo sodes: es:

• Gastroenterology
• General Surgery
• Colorectal surgery

Pu Pulmon

• nary a

y and I Infectiou ious Disea seases E ses Epi piso sodes: es:

• Pulmonary
• Critical Care

Kidne dney E Episode des

• Nephrology

Spin ine, B Bon

• ne, J

Join

• int

Epi piso sodes des

• Orthopedics
• Neurosurgery

Neurolog

• logy E

y Episod

• des
• Neurology

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How D Does BPC PCI A Advanced W Work?

Clinical episode triggered by either an inpatient hospital stay (Anchor Stay) or

• utpatient procedure (Anchor Procedure)

Clinical episode attributed to PGP or ACH Care provided under standard FFS payments At the end of each performance period, quality and cost performance are assessed

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Clinical Ep Episode L Length

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EPISODE

Anchor Stay 90 Days

IP Cl Clinical Ep Episode: : Anchor Stay + 90 days beginning the day of discharge OP Cl Clinical Ep Episode: : Anchor Procedure + 90 days beginning on the day of completion of the

• utpatient procedure

EPISODE

Anchor Stay 90 Days

Servi vice ces I Incl cluded i in the Clinical Ep Episode

• IP or OP hospital services that

comprise the Anchor Stay or Anchor Procedure (respectively)

• Physicians’ services
• Other hospital OP services
• IP hospital readmission services
• Long-term care hospital (LTCH)

services

• Hospice services
• Inpatient rehabilitation facility (IRF)

services

• Skilled nursing facility (SNF) services
• Home health agency (HHA) services
• Clinical laboratory services
• Durable medical equipment

(DME)

• Part B drugs

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Service-level E Exclusions fr from th the Clin linic ical E Epis isode

Blanket e exclusions:

• Blood clotting factors to

control bleeding for hemophilia patients

• New technology add-on

payments under the IPPS

• Payments for items and

services with pass-through payment status under the OPPS Part rt B B servi vice ces:

• Excluded only if incurred

during a excluded ACH admission or readmissions

• BPCI Advanced will not follow

the clinically related criteria guiding Part B exclusions used in BPCI

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Acut ute Car e Care e Hospital ( (ACH CH) Benc ) Benchm hmark k Pr Price

The Hospi pital’s B Benc nchmark P Price accounts for three central factors:

1. 2. 3.

t Patient case-mix Patterns of spending relative to the ACHs peer group Historic Medicare FFS expenditures efficiency in resource use specific

• the ACHs Baseline Period

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PG PGP P Bench chmark P Price ces

• Ph

Physic icians m may ha have di distinctiv ive pr practice pr profiles, i informed by:

• Care philosophy
• Training / experience
• Context
• Limited f

feedb dback on n ho how qua qualit ity and c nd cost pr profiles compare t to pe peers

• PG

PGP P be benc nchmark pr prices are anc nchored d on n the he ACH w whe here e epi pisodes o

• ccur, but

but are adj djusted d for e each PG h PGPs hi historic ical e expe perie ienc nce

• Allows more physicians to participate
• Establishes a pathway for practice refinement over time

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BPC PCI A Advanced Q Qualifies a as an Advanced Alternative P Paym yment M t Model

Eligible clinicians who meet patient count or payment thresholds may become Qualified APM Participants (QPs) and receive the 5% APM Payment. For ACH Participants, eligible clinicians will be assessed individually for purpose of QP determination. For PGP Participants, eligible clinicians will be assessed as a group for purpose of QP determination.

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Advance ced A Alternative P Payment Model (APM) Cr ) Criter eria

• Participants must use CEHRT to

document and communicate clinical care with patients and

• ther healthcare professionals
• Payment will be linked to quality
• Participants are eligible for

payments as much as 20% of the Target Price, but also at risk for as much as 20% of the Target Price

Quality CEHRT Financial Risk 34

Quality M Measures

Addit ition ional me al meas asures with varying reporting mechanisms may be added in the future Will include clai laims-based ed measures es t through gh 2020

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Initial Quality M Measures

Qua uality m measu sures es for: Al All Clinical Epi piso sodes des

All-cause Hospital Readmission Measure (Natio ional l Qualit lity Forum [NQF] #1789) 1789) Care Plan (NQF # #0326) 0326)

Spec ecific Clinical Epi piso sodes des

Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF # #0268) 0268) Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF # #1550) 1550) Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF # #2558) 2558) Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF QF #2881) 2881) AHRQ Patient Safety Indicators (PS PSI I 90)

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Risk W k Will Be Constr trained For Lo Low V Volume Participan ants

• Unusual patient cases can distort

performance for low volume participants

• As a protection, risk will be

constrained for particular clinical episode volumes

Quality CEHRT

Financial Risk

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CMS I S INNO NNOVATION C CENTE NTER P PARTN TNERSHIP

BPCI BPCI A Adv dvanced is a Partne nership Be Between the he CM CMS I Inno nnovation Ce Center a r and P nd Participa pants

• Provider

ers

• Care for patients on the front

line

• Engage in continuous quality

improvement

• CMS I

Innovati tion C Center er

• Provides greater transparency
• n cost and quality of services

provided

• Establishes payment

mechanisms that support improved care processes

• Rewards providers that deliver

greater value

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CM CMS I Inn nnovation n Cen Center er L Lea earning S Systems Have T Three Broad F Funct ctions

Identify and package new ew knowled edge a e and bes est p t practices Build learning g communities es and networks to disseminate successful strategies Lev ever erage d e data a and parti ticipant i input t to guide change and improvement

1 2 3

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Three C Channels For C Care Transformation

CMS MS learn rns f from p part rticipants Partic icip ipants l lea earn f from

• m C

CMS Partic icip ipants l lea earn f from

• m ea

each

• ther

her

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Strategi gies f for S r Success

Data a and nd Dashbo hboards ds Multidiscip iplinary Steering ng C Committees Po Post-Acute C Care Prefer erred P Provi vider er Net etworks Care Nav avigat ation Chang nging ng or Standa dardizing dizing Care P Prot

• toc
• cols
• ls

Pat atient Educ ducatio ion

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Why S Should You P Participate?

• If successful, the model will result in

streamline ned, d, c coordi dina nated c care ep episodes es

• Improve the patient experience
• Improve outcomes
• Decrease costs
• The model affords ne

new f flexi xibili litie ies in care delivery

• As pressure on fee for service

reimbursements continues, the w e world is shi hifting ing towards a alterna native pa payment mode dels

• Advanc

nced d APM under the Quality Payment Program

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BPC PCI A Advanced: T The Patient Ex Experience ce

Seamless, streamlined experience Avoids complications Achieves better outcomes Improves patient experience

“After my hospital admission, I was scared and uncertain. The doctors and nurses made sure I understood the plan. They made sure I knew what to look out for and who to call when problems

• ccurred.”

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Summa mmary

• BPCI A

Advanced ed i is a new ew voluntary A Advanced ed A APM

• Builds on prior experience
• Responsive to stakeholders
• Establishes

es r responsibility f for c clinical episodes es

• Aims to catalyze health system transformation
• Successful participants (quality, cost) may receive additional payments
• Wi

Will b be an A Advan anced A APM i in the Qu Qual alit ity y Paym yment P Prog

• gram

am

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NEXT ST T STEPS PS

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Lear arning R Resources

Questions If you have questions, contact the BPCI Advanced Model team at: BPCIAdvanced@cms.hhs.gov Print Resources You can find a variety of resources, including a Model Timeline, Fact Sheet, FAQs (General and Physician- focused), Episode Definitions, and an Application Process Handout on the CMS Innovation Center website. To Apply by March 12, 2018 Visit the BPCI Advanced Application Portal: https://app1.innovation.c ms.gov/bpciadvancedapp

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Webcasts More details of the model can be found in two presentations:

• Model Overview
• Application Process

Available at the CMS Innovation Center website: https://innovation.cms.gov/initiatives/bpci- advanced

Ke Key D Dates

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