FORHP Policy Updates November 8, 2017 CY 2018 Quality Payment - - PowerPoint PPT Presentation

FORHP Policy Updates – November 8, 2017

• CY 2018 Quality Payment Program Final Rule (Effective 01/01/18)
• Increases in the low volume threshold to ≤$90,000 or ≤200 beneficiaries

(Part B)

• Method II CAHs are required to participate if above the low volume threshold
• CY 2018 Outpatient PPS Final Rule (Effective 01/01/18)
• Reinstates the non-enforcement of direct supervision requirement for
• utpatient therapeutic services in CAHs for CY 2018 and CY 2019
• Reduces reimbursement for 340B-purchased drugs from ASP+6% to ASP
• 22.5% with exception for rural sole community hospitals.
• Note: CAHs will continue to receive cost-based reimbursement for their

340B-purchased drugs since they are not paid under OPPS.

• CY 2018 Physician Fee Schedule Final Rule (Effective 01/01/18)
• Creates a general care management bundled code for RHCs/FQHCs
• Policy updates for Medicare Diabetes Prevention Program

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• CMS Innovation Center Request for Information (RFI) – New Direction
• In particular, the Innovation Center is interested in testing models in the

following eight focus areas: 1.Increased participation in Advanced Alternative Payment Models (APMs); 2.Consumer-Directed Care & Market-Based Innovation Models; 3.Physician Specialty Models; 4.Prescription Drug Models; 5.Medicare Advantage (MA) Innovation Models; 6.State-Based and Local Innovation, including Medicaid-focused Models; 7.Mental and Behavioral Health Models; and 8.Program Integrity.

• Comment by November 20, 2017
• More information available at:

https://innovation.cms.gov/initiatives/direction/

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FORHP Policy Updates continued

Projection only, subject to change Flex Grant Timeline

Major reporting for 2017 - 2022

Updated 11-3-2017 S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A NCC Progress Reports PIMS Reports Competing Applications Financial Reports S O N D J F M A M J J A S O N D J F M A M J J A S O N D J F M A M J J A S O N D NCC Progress Reports PIMS Reports Competing Applications Financial Reports Y3 FFR FY18 FFR FY19 FFR FY20 FFR FY21 Y1 Y2 Y3 Y4 Y1 Y2 2019

2020 2021 2022

New Project Year 1 (FY19) New Project Year 2 (FY20) New Project Year 3 (FY21) Year 4 Y2 Y3 FFR FY15 FFR FY16 FFR FY17 Y1 New Project Year 2 (FY 16) Project Year 3 (FY 17) Project Year 4 (FY18) Y2 Y3

2016 2017 2018 2019

Rural Health Value Tools and Resources

TASC 90 November 8, 2017

Center for Rural Health Policy Analysis

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Rural Health Value

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Vision: To build a knowledge base through research, practice, and collaboration that helps create high performance rural health systems

• 3-year HRSA FORHP Cooperative agreement
• Partners
• RUPRI Center for Rural Health Policy Analysis and Stratis

Health

• Support from Stroudwater Associates, WIPFLI, and Premier
• Activities
• Resource development and compilation, technical

assistance, research

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Tools and Resources

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www.ruralhealthvalue.org

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More tools and resources

• Critical Access Hospital Financial Pro Forma for Shared

Savings

• Critical Access Hospital Financial Pro Forma
• Demonstrating Critical Access Hospital Value: A Guide to

Potential Partnerships

• Care Coordination: A Self-Assessment for Rural Health

Providers and Organizations

• Guide to Selecting Population Health Management

Technologies for Rural Care Delivery

• Catalog of Value-Based Initiatives for Rural Providers

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Profiles in Innovation

• Medical-Legal Partnership Addresses Social Determinants of Health:

FirstHealth of the Carolinas, North Carolina

• Rural Accountable Care Organization Care Coordination: MaineHealth

ACO, Maine

• A Rural Accountable Care Organization: South East Rural Physicians

Alliance (SERPA) ACO, Nebraska

• Rural Health Networks and New Forms of Governance: Wilderness

Health Network, Minnesota

• Using Community Connectors to Improve Access: Tri County Rural

Health Network, Arkansas

• Investing in Population Health: Hidalgo Medical Services, Center for

Health Innovation, New Mexico

https://cph.uiowa.edu/ruralhealthvalue/InD/Profiles/

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Karla Weng, MPH, CPHQ

kweng@stratishealth.org www.ruralhealthvalue.org

Center for Rural Health Policy Analysis

Cooperative Agreement funded by the Federal Office of Rural Health Policy: 1 UB7 RH25011-04. The information, conclusions and

• pinions expressed in this report are those of the authors and no endorsement by FORHP, HRSA, HHS, or [grantee institutions(s), if

necessary/desired] is intended or should be inferred.

TASC 90 November 8, 2017 Xi Zhu, PhD University of Iowa College of Public Health RUPRI Center for Rural Health Policy Analysis

• 61 in 2011 to 923 in 2017
• Increase of 2.2 million covered lives in year

ending with first quarter of 2017 to reach 32 million

• In all states; only 15 hospital referral regions

not served by an ACO

Source: David Mulestein, Robert Saunders, and Mark McClellan (2017) “Growth of ACOs and Alternative Payment Models in 2017,” Health Affairs Blog June 28. accessed June 29: http://healthaffairs.org/blog/2017/06/28/growth-of-acos-and-alternative-payment-models-in-2017.

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• 480 Shared Savings ACOs in 2017
• 9.0 million assigned beneficiaries (in MSSP) in

50 states, Washington D.C., and Puerto Rico

• 438 Track 1
• 42 Tracks 2 and 3
• 45 ACO Investment Model (subset of MSSPs)
• Plus 44 Next Generation ACOs

Source: Centers for Medicare and Medicaid Services (2017) “ Fast facts: Medicare Shared Savings Program ACO,” Baltimore, MD: CMS. accessed August 17, 2017: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/All-Starts-MSSP-ACO.pdf

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• Began with a model relying on physician group

practices to control utilization

• Serve Medicare FFS beneficiaries
• Not HMOs – beneficiaries have the freedom
• Not MA – beneficiaries are assigned retrospectively*
• Control costs while maintaining quality
• Financial benchmark is set specifically for each ACO
• Quality metrics and benchmarks are defined for all ACOs

* Except for Track 3 of the MSSP

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• Formed by pre-existing integrated delivery

networks

• Physician groups played prominent role in

formation and management

• 13 of 27 included hospitals with quality-based

payment experience, and 11 included hospitals with risk-sharing experience; 12 included physician groups with both

• Managing care across continuum considered very

important

Source: Abiodun Salako et al (2015) “Characteristics of Rural Accountable Care Organizations (ACOs) – A Survey of Medicare ACOs with Rural Presence” Rural Policy Brief RUPRI Center for Rural Health Policy Analysis, University of Iowa. www.ruprihealth.org

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• $429 million in total savings in 2015
• 23.6% in 2013  25.8% in 2014  30.4% in 2015

earned shared savings

• Better financial performance associated with:
• Longer experience
• Higher benchmarks
• Physician-group ACOs
• Smaller size

Sources: CMS (2016) “Medicare Accountable Care Organizations 2015 performance year quality and financial results.” Baltimore, MD: CMS. August 25.

• S. Lawrence Kocot and Ross White (2016) “Medicare ACOs: Incremental Progress, But Performance Varies.” Health Affairs Blog. September 21.

J Michael McWilliams et al (2016) Early Performance of Accountable Care Organizations in Medicare. New England Journal of Medicine. April 13.

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• Success (savings) associated with

physician-based

• Advanced Payment Program

ACOs more likely to generate savings

• No association with ACO size or

experience

Source: Matthew C Nattinger et al (2016) Financial Performance of Rural Medicare ACOs The Journal of Rural Health

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• Quality scores improved over time, but no direct

relationship to savings

• 91% earned Quality Improvement Reward points in 2015
• Better quality performance associated with:
• Post 1st year of participation
• Hospital-system ACOs
• Larger size
• Advance Payment Model
• Postacute follow-up visits

Sources: CMS (2016) “Medicare Accountable Care Organizations 2015 Performance Year Quality and Financial Results.” Baltimore, MD: CMS. August 25.

• S. Lawrence Kocot and Ross White (2016) “Medicare ACOs: Incremental Progress, But Performance Varies.” Health Affairs Blog. September 21.

J Michael McWilliams et al (2016) Early Performance of Accountable Care Organizations in Medicare. New England Journal of Medicine. April 13. X Zhu et al (2o17) Better ACO Quality Performance Associated with Hospital-System Sponsorship, Large Beneficiary Panels, and High Postacute Follow-Up Rates. RUPRI Center for Rural Health Policy Analysis at the University of Iowa. October.

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• Rural ACOs performed

similarly as urban ACOs on average, but with larger variation

• FQHC/RHC and advanced

practice providers’ provision

• f primary care services

associated with better quality scores (preliminary evidence)

Source: X Zhu et al (2o17) Better ACO Quality Performance Associated with Hospital-System Sponsorship, Large Beneficiary Panels, and High Postacute Follow-Up Rates. RUPRI Center for Rural Health Policy Analysis at the University of Iowa. October.

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• Physician engagement and leadership, including prior

activities

• Scale needed for investment or an initial outside source of

capital (e.g., AIM)

• Sophisticated information systems
• Physician-hospital partnership
• Effective feedback loops to care providers
• Effective postacute care coordination
• Engagement of FQHCs and RHCs

Source: D'Aunno, T., Broffman, L., Sparer, M. and Kumar, S. R. (2016), Factors That Distinguish High-Performing Accountable Care Organizations in the Medicare Shared Savings Program. Health Serv Res. doi:10.1111/1475-6773.12642 Source: X Zhu et al (2o17) Better ACO Quality Performance Associated with Hospital-System Sponsorship, Large Beneficiary Panels, and High Postacute Follow-Up Rates. RUPRI Center for Rural Health Policy Analysis at the University of Iowa. October.

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The RUPRI Center for Rural Health Policy Analysis http://cph.uiowa.edu/rupri The RUPRI Health Panel http://www.rupri.org Rural Telehealth Research Center http://ruraltelehealth.org/ The Rural Health Value Program http://www.ruralhealthvalue.org

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Keith Mueller Interim Dean, College of Public Health Gerhard Hartman Professor, Health Management & Policy Director, RUPRI Center for Rural Health Policy Analysis 145 Riverside Drive, S153A, CPHB Iowa City, IA 52242 319-384-1503 keith-mueller@uiowa.edu

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 The National Rural Health Resource Center

https://www.ruralcenter.org/

 The Rural Health Information Hub

https://www.ruralhealthinfo.org/

 The National Rural Health Association

https://www.ruralhealthweb.org/

 The National Organization of State Offices

• f Rural Health

https://nosorh.org/

 The American Hospital Association

http://www.aha.org/ 13

RURAL ACOS

How can the Flex Program Help? TASC 90 Agenda November 8, 2017

Agenda

 Illinois Flex Program - ICAHN  Describe an ACO and how it operates  Illinois Rural Community Care Organization  Value of an ACO for Rural  How Flex Program can support ACO efforts  Value of Innovation – Healthcare 2020

Illinois Critical Access Hospital Network

 ICAHN is a not-for-profit 501(c)3 corporation established in 2003 for

the purposes of sharing resources, education, promoting efficiency and best practice and improving health care services for member critical access hospitals and their rural communities. ICAHN, with 55 member hospitals, is an independent network governed by a nine-member board of directors.

 Members = 38 Independent; 17 Systems  8 providing OB Services  11 Long Term Care  1 Inpatient Psych Unit  Incubator for rural programs and services  Statewide rural network  Illinois Rural Community Care Organization



Rural ACO/Medicare Shared Savings Program 2015 /Sole Member LLC

Illinois Flex Program

 Partnership with Illinois Department of Public

Health Center for Rural Health

 ICAHN administers the program – working

relationship with all 51 CAHs since 2004

 Current Flex Grant

 Activities/projects to support CAHs  Innovation model – rural ACO

 Health Care Reform – What does that mean for

rural?

 Triple Aim  Clinically Integrated Networks  Coordinated Care Program – Navigator Programs  Transitional Care and High Costs  Primary Care Driven  Quality Reporting and Data Based Decisions  Consumer – the new patient  Market Share – fast growing systems  Changing Reimbursement System  Accountable Care Organizations

Moving from Volume to Value Based Care

Business Options for CAHs Prepare for VBP - Population

 Very difficult alone – Lose revenues in time  Become part of a system  Become part of an ACO as an independent  Partner with a resource hospital  Do nothing…pass you by

Accountable Care Organizations



Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients.



The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.



When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program. Centers for Medicare & Medicaid Services



Shared Savings Models – Track 1, 1+, 2 and 3 and Next Generation ACO



Various levels of risks and options

IRCCO



Illinois Statewide Rural ACO



24 Critical Access and Rural Hospitals;40+ rural health clinics



4 Independent physician practices



>250 Medical providers providing care for > 28,000 Medicare Beneficiaries



Medicare Shared Savings Program Year 3; AIM Investment Funds 2016



BCBSIL ACO 2017-2018



www.iruralhealth.org

Where does an ACO Start?

Target - Reduce Individual Beneficiary Cost

 $11,400 average cost per beneficiary (2017

adjusted)

 Strategies on how do we reduce 5%...then 10%

 Breaking down the $11,400 using dashboards

 ED Utilization – target more than 4 visits per year; CHF and

COPD

 Primary Care – target more than 4 visits per year  Hospitals (participant and tertiary care)  Well visits  Utilization  Skilled Care/post hospitalizations (coming soon)  Medications - Benchmark of 90% generic utilization  Downstream spend - highest cost factor  Care coordination

To Change the Culture/Value

 Change must come from within the hospital and

practice setting

 Move from volume to value

IRCCO Population Health Strategies

Healthy Patients 50% Early Onset Chronic Disease Full Onset Chronic Disease Complex Diseases

Medicare Well Visits Screenings Immunizations Healthy Eating Exercise Programs Newsletter Patient Education Building relationship with patients Provider Benchmarks  Diabetes  Hypertension  Cholesterol  Mental Health positive screen  Medication abuse  Traumatic injury  Arthritis Cardiac Rehab Physical Therapy Group counseling Support Groups Primary care monitoring  Chronic Care Management Program  Health Coach  Community Care Worker Program  Self-management skill-building  Specialty care referral monitoring  ADTs All beneficiaries should be in a care coordination program Start Here Specialty care vetting  Outcomes  Cost  Relationship primary care  Support for family Care coordination tracking/ADTs

Key Parts to an ACO

 Healthcare is local…building patient loyalty  Managing and understanding data

 Claims and patient information/registries

 Care coordination – case management  Control costs and ensure quality  Prevention and healthy life styles  Value of primary care  Patient engagement

….toughest challenge

Data Management “What claims tell you”

 Beneficiary usage – local or specialty

 Ex: Medicare patient visited ED 150 times/18 months

 Hospital care = Inpatient and Outpatient  Post Acute Care – ED Usage  Primary Care  Cost Utilization  Coding – health of beneficiary  Participant – Provider – Other organizations

 ACO IT Platform….drills down to provider level

What Claims Do Not Provide

 Immediate care and treatment – 3 to 6 mos. old  What action to take for better management  Disease registries – B/P; A1C  Time frames – comparison pricing  Social Services needs of beneficiaries  Medication costs

 Use EMR and other tools for care management  Screening/prevention

Key is Care Coordination

 Care Coordination = patient management  All care settings…office, hospital, ED, nursing

homes, specialty care

 CHANGE in Culture and Workflow  Work as a team  Patient centered care…rural healthcare is best  Follow the money – payors covering care

coordination

Heart of ACO: Care Coordination “ IRCCO Regional Approach”

Care Management Model

Individual or Team Based Approach

IRCCO TEAM REGIONAL CARE COORDINATOR LOCAL CARE COORDINATOR LOCAL CARE COORDINATOR REGIONAL CARE COORDINATOR LOCAL CARE COORDINATOR LOCAL CARE COORDINATOR

Regional Approach

LOCAL CARE COORDINATION

MWV TCM CARE GAP CLOSURE UTILIZATION REDUCTION CCM

Medical Staff Engagement - Critical

 Chief Medical Officer /Family Practice  Inclusion in Governance/Decision-making  Medical Provider Workgroups (chronic care)  Physician Meetings  Importance of Culture Change  Consideration work flow/schedule  Standards and Data  Patient Outcomes

Value of Primary Care

 Care Coordination – case management  Coding!!!  Revenues – primary care

 Medicare Well Visits  Chronic Care Management  Transitional Care Management  Gap Closure /prevention screening

 Increase primary care – loyalty  Transfer process evaluation  Patients are our neighbors – high

Post Acute Hospitalization

 Rural providers – high cost is not necessarily

due to swing beds

 Other reasons

 Beneficiaries use all available Medicare days  Limited management and supervision of care in

skilled and long term care

 Frequent readmissions or to ED and patient has a

DNR

 Solution – hospital and nursing home

readmission huddles; transition care tracking includes medication evaluation

Quality Improvement - Scores

Measur e Number Measure Name 2015 Actual Rate 2016 Estimated Rate ACO-13 Screening for Future Fall Risk 22.20% 58% ACO-14 Influenza Immunization 52.71% 66% ACO-15 Pneumonia Vaccination Status for Older Adults 46.62% 63% ACO-16 Body Mass Index (BMI) Screening and Follow-Up 58.15% 66% ACO-17 Tobacco Use: Screening and Cessation Intervention 86.38% 87% ACO-18 Screening for Clinical Depression and Follow-up Plan 13.35% 34% ACO-19 Colorectal Cancer Screening 32.79% 52% ACO-20 Breast Cancer Screening 54.52% 63% ACO-21 Screening for High Blood Pressure and Follow-Up Documented 70.36% 65% ACO - 42 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease — 80% At-Risk Population ACO-40 Depression Remission at Twelve Months — — ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control 25.63% 12% ACO-41 Diabetes: Eye Exam 38.63% 34% ACO-28 Hypertension: Controlling High Blood Pressure 67.86% 76% ACO-30 Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic 80.88% 93% ACO-31 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 93.58% 99% ACO-33 Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy - for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%) 75.20% 96%

Healthcare Today

 How we take care of patients has not

changed; it is how we manage the care

• f the patient that has. Pat Schou

Challenges for Rural ACOs

 Geography – Independent hospitals and their

providers spread out

 Hospitals – limited financial and human

resources

 Rural Health Clinics – mid-level providers and

do not have beneficiaries initially attributed; not included in MACRA/MIPS (fix 2019)

 Emergency Department – inappropriate use as

many communities do not have 24/7 prompt care; EMS transport

Other Challenges

 Limited access to behavioral health services  Social determinants rural versus urban  Care giver availability for rural elderly living

alone

 Specialty referral okay but seldom are patients

returned to local community

 Rural Medicare beneficiaries – many have not

seen a medical provider for 20 years (i.e. farmers)

 Controlling “downstream” spend /PRIORITY

Benefits of Rural ACO

 Rural is primary care and the basis for MSSP  Share best practices and ideas and problem

solve together

 An opportunity to earn physician financial incentives

 Leverage numbers as a small provider  Support group decision-making for both

hospitals and medical providers

 Understand the value of community

Value of the ACO - Participant

 Access to information – knowledge about

beneficiary use

 Monitor market share and develop tools to grow

primary care/loyalty

 Quality Reporting (100%) / MIPS

 IRCCO 70% Quality Scores (50% aggregate + 20%

participation in APM)

 Learn how to better manage patients/population 

Access to Good Commercial Payor Contracts

IRCCO Participant

Primary Care Market Share

 Local rural health care = lower costs  Reduce beneficiary spend = seek increase

volume and/or new revenue sources

 Well Visits, Gap Closers, CCM, Prevention

 Can then begin to manage population health  Population will seek providers/practitioners who

focus on health and cost savings

 Rural refocus on its services

 IL CAHs lost 10% market share/year

IRCCO Participants – Say “Yes”

 Be prepared for value based care – CMS

 Ready for 2020 and Population Health

 Understand leverage of numbers moving to risk  Better together – sharing of resources  Best practices and learning

from our data for improvements

 Wellness ROI on prevention  Real patient situations where better

management of care has made the difference

Flex Program Offers

Flex Grant – Examples

 Specific areas of focus may include:  • Clinically integrated networks  • Population Health Management  • Projects addressing frequent/high cost users of

health care or emergency department

 • Care Coordination

 Other suggestions…tele-medicine, stroke care,

immunization and prevention campaigns – partnering with community organizations

ICAHN – Flex Grant

 Initially started with funds for education and

Value Based Purchasing system change

 Hospital Transformation Workshops  Hospital Readiness Assessment Tool  Patient Centered Medical Home  Wellness Training  Care Coordination Certification  Motivational Interviewing

ICAHN - Flex Grant /New Project

 Health Coaching Program with hospitals and

university

 Care Navigator Training  Project Awards for hospital

Transformation programs “Innovation” Projects (disease related)

IRCCO Flex Activities -

 Grant awarded to ACO/IDPH – 3 focus areas

I. Hospital Transition/Transfer Project II. CHF and COPD Emergency Department Readmission III. Immunization Campaign – all beneficiaries flu and pneumonia

Hospital Transfer Project

 Looked at CAH transfer to resource hospital and

long term care and decided to focus on LTC

 Pilot project – 8 ACO hospitals…funding for data

and meetings

 Transfer sheet – communication tool/identify gaps  LTC readmission huddles inpatient and ED  Nursing Home luncheons…CAH and LTCs in

community

 Outcomes…decreasing readmits to ED; improved

communication…next layer

CHF and COPD Project

 All hospitals (24) participated in project…funding

for hospitals to collect data

 Discharge instructions…only 1/3 had self-

management and clear information (EMR instructions hard to read and understand)

 Focus area for each hospital to develop own

discharge program

 ED staff encouraged to make follow up appointment

with primary care provider

 Self-management best practices for CHF and COPD

Immunization Project

 All ACO Participants will offer/track flu and

pneumonia vaccines given

 No Funding assigned  Educational Campaign  Nearly 100%

Care Coordination - Learning

 https://www.iruralhealth.org/

Still about the patient…

Rural ACOs can Lead the Way and Flex Grant Can Support

Questions/Comments

Pat Schou, FACHE

Executive Director Illinois Rural Community Care Organization Illinois Critical Access Hospital Network 245 Backbone Road East Princeton, IL 61356 Phone: 815-875-2999 Email: pschou@icahn.org Websites: www.icahn.org www.iruralhealth.org