All Payer Hospital System Modernization Payment Models Workgroup Meeting Agenda August 5, 2016 9:30 am to 12:00 pm Health Services Cost Review Commission Conference Room 100 4160 Patterson Avenue Baltimore, MD 21215 I. Introductions and Meeting Overview II. GME Pilot Program in Rural and Medically Underserved Areas III. GBR Contract Addendum IV. Market Shift Update V. TCOC Dashboards CY16 TCOC Data Update CRISP Presentation ALL MEETING MATERIALS ARE AVAILABLE AT THE MARYLAND ALL-PAYER HOSPITAL SYSTEM MODERNIZATION TAB AT HSCRC.MARYLAND.GOV
Pilot Program to Expand Graduate Medical Education in Rural and Medically Underserved Areas for Primary Care 1
Introduction All payers contribute to GME through hospital rates. GME funding is part of the hospital’s total rate structure. The Innovations in Graduate Medical Education Workgroup proposed using partial rate reviews for hospitals seeking to change or establish new residency programs. Partial rate reviews would only look at GME funding and not the full rate structure of the hospital. 2
2016 PCNA Quartile Rankings by Jurisdiction based on PQI & SHIP Indicators Health Measures in Rural Areas The 2016 Primary Care Office Needs Assessment (PCNA) created a matrix using Prevention Quality Indicators (PQI) and State Health Improvement Process (SHIP) that ranks counties based on health indicator scores. Fifty percent of the 18 state- designated rural areas fall in the third or bottom quartile for PQI and SHIP measures. 3
Pilot Program We have outlined a policy for a targeted 5-year pilot program for a new primary care GME program based on population health needs. Only direct medical education expenses will be funded through partial rate reviews. Applicants will be expected to submit a narrative describing how their program will meet the goals and objectives outlined in the policy. 4
Criteria for GME Funding Located in a state-designated rural area Located in or near an Medically Underserved Area (MUA) or Health Professional Shortage Area (HPSA) Hospital not part of a Maryland health system with existing GME program Quality and population health indicators identify improvement needs 5
Additional Requirements Hospitals submitting a GME partial rate application must provide information on the following: Needs Justification: hospitals should justify their need for the program. Examples would include low population health metrics and provider shortages. Triple Aim: hospitals should describe how the program would enhance care delivery quality, reduce cost, and improve population health outcomes. Retention: hospitals should describe a plan to retain residents after their program ends to ensure the growth of primary care physicians in the area. 6
Measurement of Success The HSCRC will consider the following factors in evaluating the success of the GME program over the course of the 5-year pilot: Physician retention Health status improvement Care coordination efforts T otal cost of care performance 7
SECOND ADDENDUM TO GLOBAL BUDGET AGREEMENT OF ________________________ UNDER DATE OF ___________________ EFFECTIVE JULY 1, 2016 Purpose: The purpose of this Second Addendum is to address the application of penalties to charges that exceed the December 31 target. This Second Addendum will also clarify conditions the Hospital must meet to receive increased inflation dollars for the time period January through June 2017. Amendment 1: This modification is intended to add clarification surrounding overcharge penalties that may occur relative to the December 31 target. Section V. C. of the Addendum to the Global Budget Agreement effective July 1, 2014, as amended herein, is provided in its entirety to avoid confusion: V.C. December 31 Target As indicated in Section V. A. above, the Hospital agrees that it will not overcharge the limits of the Approved Regulated GBR Revenue. In order to assure compliance with the All-Payer Model limits, the Hospital is provided a December 31 interim limit in Approved Regulated GBR Revenue of one-half of the total Approved Regulated GBR Revenue for the year, unless otherwise specified in the Agreement. For Rate Year 2017, the limit for the first half of the year is lower, to reflect that the Commission approved a higher update for the second half of the Rate Year, subject to certain conditions. The Hospital agrees that it will maintain its charges at or below this limit in calculating revenue compliance for December 31 of the Rate Year. The Hospital also agrees that should charges exceed the December 31 target, the overcharge and any accumulated penalties will be applied to the total Approved Regulated GBR Revenue for the same Rate Year. Amendment 2: Section XIV Inflation Amount for RY17 is amended to add new section. This modification is intended to detail the conditions which the Hospital must meet in order to receive an increased inflation amount for the time period January through June 2017. For rate year 2017, the Hospital agrees to charge lower rates (.56% lower) in the first half of the rate year to achieve a mid-year target that is 49.73% of the total Approved Regulated GBR target to help meet the needs of the calendar year waiver test. In addition to the lower mid-year target, the Hospital agrees to the following: a. Monitor the growth in Medicare’s total cost of care and total hospital cost of care for its service area; b. Work with CRISP, HSCRC, and MHA to obtain available information to support monitoring and implementation efforts;
c. Work with CRISP, HSCRC, and CMMI to obtain data for care redesign activities as soon it is available; d. Monitor the H ospital’s performance on PAUs for both Medicare and All Payers; e. Implement programs focused on complex and high needs patients with multiple chronic conditions, initially focusing on Medicare patients; f. Work with CRISP to exchange information regarding care coordination resources aimed at reducing duplication of resources, ensuring more person centered approaches, and bringing additional information to bear at the point of care for the benefit of patients; g. Increase efforts to work in partnership with physicians, post-acute and long term facilities, and other providers to create aligned approaches and incentives to improve care, health, and reduce avoidable utilization for the benefit of patients; h. Participate in the All Payer Model progression planning efforts, and; i. Work with physicians with the goal of developing and enhancing value based approaches that are applied under MACRA (Medicare Access and CHIP Reauthorization Act of 2015). a. Hospitals and any care redesign participants must agree to use CEHRT (Certified Electronic Health Record Technology) to document and/or communicate clinical care to their patients or other health care providers. b. In addition to CEHRT, Hospitals must attest to the following three items relating to information exchange and blocking: i. Hospitals will not knowingly and willfully take action to limit or restrict the compatibility or interoperability of certified EHR technology; ii. Hospitals will implement technologies, standards, policies, and agreements reasonably calculated to ensure, to the greatest extent practicable and permitted by law, that the certified EHR technology was, at all relevant times: connected in accordance with applicable law; compliant with all standards applicable to the exchange of information, including the standards, implementation specifications, and certification criteria adopted at 45 CFR part 170 (Health Information Technology Standards, Implementation Specifications, and Certification Programs for Health Information Technology); implemented in a manner that allowed for timely access by patients to their electronic health information; and implemented in a manner that allowed for the timely, secure, and trusted bi- directional exchange of structured electronic health information with other health care providers; iii. Hospitals will respond in good faith and in a timely manner to requests to retrieve or exchange electronic health information, including from patients, health care providers.
IN WITNESS WHEREOF, the parties have caused this Second Addendum to be executed by their duly authorized representatives as of the effective date below: Effective Date: July 1, 2016 Attest: ________________________ by_______________________ Date____________ Chief Executive or Financial Officer Attest: ________________________ by_______________________ Date____________ Executive Director Health Services Cost Review Commission
Market Shift Adjustments Update
Market Shift Adjustments Market shift adjustment should not undermine the incentives to reduce avoidable utilization Market shift adjustment should provide necessary resources for services shifted to another hospital Calculations are based on 66 inpatient and outpatient service lines Zip codes and county level Excludes Potentially Avoidable Utilization Hospital service line average charge per ECMAD** 50% variable cost factor applied Staff send out preliminary results for outpatient oncology service lines *AHRQ Prevention Quality Indicators **Equivalent CaseMix Adjusted Discharges 2
Market Share vs. Market Shift 300 300 250 250 250 250 200 200 Hospital A 150 Hospital A 150 Hospital B 100 Hospital B 100 100 50 50 50 50 50 50 25 0 0 YEAR1 YEAR2 YEAR1 YEAR2 Market Shift Adjustment=0 Market Shift Adjustment=25
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