OP OPERATIO IONALIZ IZIN ING B BPCI I ADVA VANCED MAY 2018 - - PowerPoint PPT Presentation

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OP OPERATIO IONALIZ IZIN ING B BPCI I ADVA VANCED MAY 2018 2018 Intr troducti tions Steve F Farm rmer, M , MD, F , FACC, F , FASE Senior Medical Officer CMS Innovation Center Practicing Cardiologist Elizabeth Curri

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OP OPERATIO IONALIZ IZIN ING B BPCI I ADVA VANCED MAY 2018 2018

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Steve F Farm rmer, M , MD, F , FACC, F , FASE

  • Senior Medical Officer
  • CMS Innovation Center
  • Practicing Cardiologist

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Elizabeth Curri Currier, M , MBA/MPH, L LSSGB, F , FACMPE

  • Physician Practice Administrator
  • Senior Improvement Advisor
  • CMS Innovation Center

Intr troducti tions

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Webcas ast Ou Outline

  • The CMS Innovation Center
  • Review of BPCI Advanced Features
  • Application to the Model
  • Participation in the Model
  • Common Challenges
  • Strategies for Success
  • CMS Innovation Center Partnership
  • Reconciliation Process
  • Summary and Conclusions

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INTROD ODUCTION ON The CMS Innovation Center and BPCI Advanced

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The CM he CMS I Inn nnovation Cen Center er

  • As part of the Centers for Medicare & Medicaid Services (CMS), the CMS Innovation

Center provides national leadership in the transition from volume to value

  • The center tests innovative payment and service 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
  • Benefit design and price transparency
  • Small scale testing

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Model Sce cenarios f for S Succe ccess

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Bes est Case Qua uality Cost

1

Qua uality Cost

2

Qua uality Cost

3

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REVI EVIEW EW Bundled Payments for Care Improvement Advanced

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BPC PCI A Advanced T Tests a a Different Payment A Approac ach

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Shifts emphasis from in indiv ivid idual l servi vice ces towards a coordinated clinic ical e al episod

  • de

Establishes an “accountable p e party” Clinical episodes are assessed

  • n the quality

ty a and c cost of care

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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?

Ac Acut ute C Care Ho e Hospitals s (ACHs Hs) Physician G n Group up Practices ( s (PGP GPs)

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Participants M May Work w with a a Convener

A C Conven ener er is a a Medicare-enrolled pr provide der o

  • r suppl

upplier or a an n entity t tha hat is no not enr nrolle led i d in n Medic dicare. Conven ener ers 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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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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Setting B Bench chmark P Price ces

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1. Anchored on hospital 2. Accounts for PGP– specific historical practice pattern Ph Physic ician Group up P Practice (PG PGP) P) Benc nchmark Price: Hospital al’s Benchmark P ark Price:

1.

Patient case-mix

2.

Peer group trends

3.

Historic efficiency

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KEY POI POINTS

  • 1. PGPs may practice at multiple hospitals
  • 2. Hospital pricing varies
  • 3. Limited time PGP adjustment, anchored on hospital price

PG PGP P P Prici cing

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PGP PGP

Ur Urban an

ACH: $20,000 PGP: $22,000 ACH: $18,000 PGP: $20,000

Rura ral

ACH: $25,000 PGP: $27,000

Acad ademic ic M Medic ical al Cente ter ( (AMC)

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BP BPCI CI A Adv dvanc anced ed Prec eced eden ence R Rul ules es

At Attendi nding ng P PGP

1

Opera rating ng P PGP

2

ACHs Hs

3

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Pati tient A Attr tributi tion: M Multi tiple P PGPs, B Both th Participating i in Pneumonia Clinical Ep Episode

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KEY POINT NTS 1. Multiple PGPs may exist at an ACH 2. All PGPs need not participate 3. Attending identified through UB-04 and Part B Claim

Non-Partic icip ipatin ing A g ACH

Partic icip ipatin ing g PGP GP 3 3

PG PGP3 P3

Partic icip ipatin ing P g PGP 1

PG PGP1 P1

Attribution Clinic ical E Epis isode

No Non-Partic icip ipatin ing PGP GP 2 2

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PG PGP1 P1

Partic icip ipatin ing P g PGP 1

Patient A Attribution: A ACH and Multiple PG PGPs, Participating i in Pneumonia Clinical Ep Episode

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PG PGP3 P3

Partic icip ipatin ing g PGP GP 3 3

Attribution Clinic ical E Epis isode

KEY POINT NTS 1. ACHs and PGPs may participate 2. If ACH participates, all clinical episodes are in the model No Non-Partic icip ipatin ing PGP GP 2 2

ACH

Partic icip ipatin ing A ACH

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Patient A Attribution: A ACH and Multiple PGPs, D Dif ifferent C Clin linic ical Epis isodes

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KEY POINT NTS 1. PGPs and ACH may participate in different episode categories 2. Exclusive participant would get all episodes, subject to trigger rules

Partic icip ipatin ing A ACH Attribution Clinic ical E Epis isode

PG PGP1 P1

Partic icip ipatin ing P g PGP 1

ACH

No Non-Partic icip ipatin ing PGP GP 2 2

PG PGP3 P3

Partic icip ipatin ing g PGP GP 3 3

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APPLICATION TO THE MODEL

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Applicants W Will Rece ceive Data i in Advance

  • CMS will provide preliminary target prices to applicants in May 2018
  • Applicants who submit a Data Request and Attestation form
  • Three years of aggregate (summary) and/or raw (beneficiary line-

level) Historical Claims data for the Medicare beneficiaries who would have been included in a Clinical Episode and attributed to the applicant

  • Convener appl

pplicants receive target prices for all of their episode initiators (EIs)

  • No

Non-convener appl pplicants receive their own target prices

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Clinical Ep Episode S Select ction

  • Participants will enter into an agreement with CMS
  • May be renewed annually
  • Commits to selected Clinical Episodes until the start of the

following Agreement Term

  • Episode selections must be submitted to CMS by August 1,

1, 2018 2018

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Considerati tions f for P Parti ticipation

  • Are there other potential Participants for the same

Clinical Episode at the same ACH?

  • Are there clear opportunities for improvement within

the model?

  • Can operational investments be spread across

multiple clinical episodes?

  • Can Participants safely assume financial risk?
  • Does it make sense to work with a Convener?
  • Would Participants qualify for incentive payments as a

Qualifying APM Participant in the Quality Payment Program?

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? ?

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PARTIC ICIP IPATIO ION I IN THE M E MOD ODEL EL

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Exam ample S Strategy: y: Data T Transpar arency

  • Utilize care management software to share data between

hospital and PAC providers; include physician, hospital, and regional-level data.

  • Create patient dashboards with real-time data that physicians

and partners can easily access.

  • Utilize a data analytic tool to help staff identify patients needing

additional care during their SNF stay.

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Example S Str trategy: Uti tilize a a Risk k Asse Assessment T Tool

  • Incorporate a readmission prediction tool into your electronic

health record (EHR) for both high and middle risk patients.

  • Use a tool, which includes a section for identifying patient

risk for readmission, in tandem with "At-Risk" meetings.

  • Use a tool, which includes care pathways and “change in

condition” tools, to manage care and prevent readmissions.

  • Use an index scoring tool for risk assessment of death and

readmission.

  • Use an analysis platform, which assists with risk assessment and

discharge planning decisions.

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Exampl ple S Strategy: Redes edesign Car Care e Pa Pathway ays

  • Update and simplify patient forms/checklists to ease pre-

screening and post-acute care transfer. Support consistent use by all providers.

  • Provide telephone number/toll-free hotline for patients to call

with questions or concerns post-discharge to reduce readmissions.

  • Modify clinical pathways to incorporate therapy interventions.

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Exampl ple S Strategy: Cr Crea eate o e or H Hire K e Key Staf affing P Positions

  • Create or hire positions:
  • Inpatient care coordinator (ICC) to help determine the next

site of care.

  • Skilled inpatient care coordinator (SICC) to focus on

reducing SNF length of stay and readmissions.

  • Create or hire “SNFist” position for PCPs working entirely

within SNFs specializing in PAC and/or geriatrics.

  • Use regional care nurse navigators or transitional care

managers to engage patients throughout the episode and to build relationships with community partners.

  • Create or hire a non-clinical data analyst for BPCI.

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Ex Example Strategy: I Incr crease P Patient and Pr Provider E Educa cation

  • Designate a physician champion, either for a particular clinical

episode or for all BPCI patients.

  • Initiate a pilot program to determine which patients qualify for a

home health aide (HHA). Offer the patients targeted information to support their acceptance of an HHA referral.

  • Invite family members or caregivers to participate in therapy

sessions.

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Example e Strateg egy: I Improve e Coordination with P PAC P Provi viders

  • Develop preferred provider networks.
  • Meet weekly with SNF/HHA staff.
  • Use care management software/data platform that promotes

information transfer and helps coordinate care between hospital and PAC providers.

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Example Str trategy: I Innovati tive U Use of f Technol

  • logy
  • gy
  • Provide a telemonitoring device post discharge to high-risk

patients for education and communication.

  • Provide access to a smartphone app for physicians to view

patient and quality data.

  • Create a video library for patients and families, with a computer

available in the facility for families to do research.

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Participan ants Engag age i in Continuous Quality I Improvement

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CMS I S INNO NNOVATION C CENTE NTER P PARTN TNERSHIP

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BPCI BPCI Adv dvanced i is a Partne nership

  • Cli

linicia ians

  • Care for patients on the front

line

  • Engage in continuous quality

improvement

  • CMS I

Inno nnovatio ion C n Center

  • 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 kno nowledge a and nd be best pr practices 1 Lev ever erage d e data and pa partic icipant i input nput to guide change and improvement 2 Build learni ning ng communit nities and networks to disseminate successful strategies 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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RECON ONCILI ILIATION ON P PROCESS

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Per erformanc nce Will be be Assessed ed S Sem emi- Annually

  • Semi-annual Reconciliation will include two (2) “True-Ups” to allow for claims run-
  • ut
  • Clinical Episodes will be reconciled based on the Performance Period in wh

which the episode e ends:

OR

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Participants Will R Rece ceive a a Workbook at the En End o

  • f E

Each ch Performance P Period

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Actual c costs f s for clinical epi piso sodes es Net et P Payment Rec econciliation A Amounts s (NPRA), by c y clin linical ep epis isode Aggreg egate q e qua uality m measu sure p e performance Fin inal t target p pric ice f for

  • r ea

each c clin linic ical ep l epis isode

  • Preliminary target price revised for

realized case mix

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Reconciliati tion P Process

  • All non-excluded Medicare FFS expenditures will be compared against the

final Target Price, resulting in a Positiv ive o

  • r N

Negative Reconcilia iatio ion Amount for each Clinical Episode

  • All Positive and Negative Reconciliation Amounts will be netted across all

Clinical Episodes attributed to a Participant, resulting in a Pos

  • sitive or
  • r

Negativ ive Total R l Reconcil iliation A Amount

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Reconciliati tion P Process, C Conti tinued

  • The Positive or Negative Total

Reconciliation Amount is then adjusted based on quality performance, resulting in the Adj djus usted d Positive or Negativ ive T Total Reconcili liation A n Amoun unt

  • This final number may result in either:
  • A payment from CMS
  • A repayment to CMS

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Settl tling U Up

  • After

er n number ers revi eview ewed ed

  • Within 30 calendar days, may contest any

calculation or omission errors

  • CMS must respond to appeals within 30 days
  • BPC

PCI A I Adv dvanced P d Payments

  • Following 30-day appeal window
  • Participants will receive either payment or a

demand letter

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30 days

OR Payment Demand letter

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Ex Exiting t the Model

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Participants not working with a convener may terminate from the model at any time in accordance with the participation agreement. Physician group practices and hospitals working with a convener may terminate from the model at any time, but the convener remains responsible for the clinical episodes until the next agreement period, or until they wholly terminate their participation in the model

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SUMMA MMARY A AND CONCLUSI SIONS NS

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Summa mmary

  • BPC

PCI I Adv dvanced d is a ne new v volun untary A Adv dvanced APM PM

  • Builds on prior experience
  • Responsive to stakeholders
  • Establis

ishes r responsib ibil ilit ity f for clin inical e epis isodes

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

be an n Adv dvanc nced A APM PM i in n the he Qua ualit ity P Payment Program

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As As a Model T Test, , Future R Revisions Are L e Likel ely

  • As an entirely new model, some features may work well, while others may

need improvements

  • Evaluation results and stakeholder feedback is critical
  • In the future, the Innovation Center may:
  • Revise design features
  • Add Clinical Episodes
  • Add performance measure options

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Lear arning R Resources

Ques esti tions

If you have questions, contact the BPCI Advanced Model team at: BPCIAdvanced@cms.hhs.gov

Print R Resources es

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.

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Web ebcasts

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

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APP APPENDIX

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Key Differences: BPC PCI v

  • vs. B

BPC PCI A Advance ced

BPCI CI BPCI I Advan anced

48 Inpatient (IP) clinical episodes 29 IP and 3 OP clinical episodes Not an Advanced APM since lacking CEHRT requirement and quality not tied to payment Model is an Advanced APM No quality measures required for payment purposes Quality measures are reportable and performance on these measures will be tied to payment Excludes cost of care associated with services according to 13 unique exclusion listings of “unrelated” care Limited exclusions; Excludes the Part A & B costs associated with ACH readmissions qualifying based on a limited set of MS-DRGs Model 3 includes PAC providers triggering episodes in the post-discharge period No equivalent for Model 3; design is similar to Model 2 with PGPs and ACHs as EIs; PAC Providers, and other Medicare-enrolled, as well as non-Medicare-enrolled entities can participate as Convener Participants Risk corridor of 20% of spending above the upper limit of the selected risk track One risk track Risk is capped at +/-20% Target Prices provided at reconciliation Preliminary Target Price provided prospectively, before the start of each Model Year

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Question

  • ns?

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