Quality Methodology Center for Medicare and Medicaid Innovation - - PowerPoint PPT Presentation

Center for Medicare and Medicaid Innovation (CMS Innovation Center)

August 2018

Quality Methodology

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• BP

BPCI CI Adv Advance ced O d Overvi view

• Qua

uality M Measurement

• Application of Q

Quality M Mea easu sures

• Summa

mary

Webcast Outline

BPCI Advanced Overview

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BPCI Advanced Tests a Different Payment Approach

Establishes an “accountable party” Shifts emphasis from individual services towards a coordinated Clinical Ep Episode Clinical Episodes are assessed on the quality and cost of care

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Prom

• motes

es a a patien ent-cen enter ered ed approac

• ach t

to care b e by:

Why Bundled Clinical Episodes?

Providing i import rtan ant A Advanced A Altern rnative P Paym yment Model (Adv dvanced A d APM) an and Merit-Based ed I Incen centi tive P e Payment S t System (MIPS) A ) APM op

• ppor
• rtu

tuniti ties f for

• r s

speci ecialty ty physici cians Applying l les esson

• ns l

lea earned from Bundled ed P Paymen ents ts f for

• r Care

e Im Improvement ( (BPCI) i initiative Employing C Clinical E Episodes that are clinically i intuitive, con

• ncr

crete, a , and acti ction

• nable

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• St

Streamline ned d desi sign

• One Model, all 90 day episodes
• Single risk track
• Payment is tied to performance on clinically relevant quality

measures

• Target Prices are largely set in advance
• Greater focus on physici

cian en engagem emen ent a t and lea earnin ing

• Designated as an Advanced

ed AP APM under the Quality Payment Program

How is BPCI Advanced Different Than BPCI?

Quality Measurement

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The CMS Innovation Center

The e Innovati tion

• n C

Cen enter er t tes ests ts innovati tive p payment a t and ser ervi vice ce d del eliver ery mod

• dels

els th that t are i e inten ended ed to

• red

educe e ce expen enditu tures w while e preser erving or

• r

enhan ancing q qual ality. Bes est C Cas Quality Ex Expenditur ures

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e Quality Ex Expenditur ures

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Quality Ex Expenditur ures

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• The Positive or Negative Total

Reconciliation Amount will be adjusted based on quality ty p per erform rmance

• The adjustment is limited to a maximum
• f 10% in 2018 and 2019

Premise of Value Value = Expenditures and Quality

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How Does the Quality Payment Program Benefit Clinicians and Patients?

Clinicians Patients

• Streamlines reporting
• Standardizes measures

(evidence-based)

• Eliminates duplicative

reporting which allows clinicians to spend more time with patients

• Promotes industry

alignment through multi- payer models

• Incentivizes care that

focuses on improved quality

• utcomes
• Increases access to

better care

• Enhances coordination

through a patient- centered approach

• Improves results

Quality Measures Correlation to Clinical Episodes Model Years 1 & 2

Quality Measure Guidance Applicable Clinical Episode Categories All-cau ause H e Hos

• spital

al R Read admission

• n M

Meas asure NQF #1789 QPP #0458 All Inpatient and Outpatient Clinical Episodes Ad Advance Ca Care P Plan* NQF #0326 QPP #047 All Inpatient and Outpatient Clinical Episodes Hospital-Level R Risk-Stan andar ardized ed C Complication Rate ( (RSCR) F Follo lowin ing E Electiv ive Pri rimary ry T Total H l Hip p Arthroplas asty ( (THA) a and/or

• r T

Total al K Knee ee Arthroplasty ( (TKA) A) NQF #1550

• Double Joint Replacement of the Lower

Extremity: MS-DRGs: 461, 462

• Major Joint Replacement of the Lower Extremity:

MS-DRGs: 469, 470 Hospital 3 30-Day, y, A All-Cau ause, e, R Risk-St Standardized ed Mortal ality R Rate ( e (RSMR) F Following C Coron

• nar

ary Art rtery ry B Bypa pass Graft S Sur urgery ry ( (CABG) NQF #2558 CABG: MS-DRGs: 231, 232, 233, 234, 235, 236 Exces ess D Days in Ac Acute e Care af e after er H Hospital alization

• n

for Ac Acute M e Myocar ardial al I Infar arct ction

• n (

(AMI) NQF #2881 AMI: MS-DRGs: 280, 281, 282 CMS P Patien ent S Saf afety I Indicator

• rs

NQF #0531

• All Inpatient and Outpatient Clinical Episodes

Clinical Episodes

• The CMS PSI 90 will variably apply to individual

clinical episodes. Performance on this measure is specific to the clinical episode. (Only included

• nes that are available)

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*NQF-endorsed at Physician level; others lacking asterisk are endorsed at the Hospital level.

Quality Measures Correlation to Clinical Episodes Model Years 1 & 2

Quality Measure Guidance Applicable Clinical Episode Categories Periop

• per

erative Care: e: S Select ction

• n
• f P

Prop

• phylact

ctic c Antibioti tic: c: F First

• r S

Seco cond Gen eneration

• n

Cephalosporin* NQF #0268; QPP #021 Back and Neck Except Spinal Fusion (Inpatient and Outpatient)[2] MS-DRGs: 518, 519, 520; HCPCS: 62287, 63005, 63011, 63012, 63017, 63030, 63040, 63042, 63045, 63046, 63047, 63056, 63075 Cervical Spinal Fusion: MS-DRGs: 471, 472, 473 Combined Anterior Posterior Spinal Fusion: MS-DRGs: 453, 454, 455 CABG: MS-DRGs: 231, 232, 233, 234, 235, 236 Double Joint Replacement of the Lower Extremity: MS-DRGs: 461, 462 Hip and Femur Procedures Except Major Joint: MS-DRGs: 480, 481, 482 Lower Extremity and Humerus Procedure Except Hip, Foot, Femur: MS-DRGs: 492, 493, 494 Major Bowel Procedure: MS-DRGs: 329, 330, 331 Major Joint Replacement of the Lower Extremity: MS-DRGs: 469, 470 Major Joint Replacement of the Upper Extremity: MS-DRG: 483 Cardiac Valve: MS-DRGs: 216, 217, 218, 219, 220, 221, 266, 267

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*NQF-endorsed at Physician level; others lacking asterisk are endorsed at the Hospital level.

• The Five Inpatient Quality Reporting Measures will be

calculated by CMS from Administrative Claims (#1789; #1550; #2558; #2881; #0531).

• The Perioperative Care (#0268) measure will be calculated

from MIPS QCDR submission.

• The Advance Care Plan (#0326) will be calculated based on

submitted claims, from ANY Physician or Advanced Practice Provider (regardless of BPCI Advanced participation) for the episode time period and nine months prior.

• Performance data is calculated based on Calendar Year data

beginning with CY 2019.

Quality Measures Submission

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Benchmark data based on CY 2017 Adjustments for PP1 & PP2 Performance Period

Model Year 1

• Oct. 1, 2018 –
• Dec. 31, 2018

Model Year 2

• Jan. 1, 2019 – Dec. 31, 2019

2018

• Jan. 1, 2019

July 1, 2019

• Jan. 1, 2020

July 1, 2020 Performance Period 1 (10/1/18 – 6/30/19) Performance Period 2 (7/1/19 – 12/31/19)

Model Year 3

• Jan. 1, 2020 –
• Dec. 31, 2020

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• The first two Performance Periods are a staggered approach where quality

performance is accrued but not initially applied

Quality Data Timeline

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Quality Measures: Model Years 3 – 6

Ad Additional m measures with varying reporting mechanisms may be added thereafter Will include claims ms-based measures t thr hroug ugh 2020 2020

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The e Innovati tion Cen Center is working with c clinicians t s to r refine t the e quality m y measures es a aligned ed wi with t the mod

• del

el. Aspiration

• nal

al G Goa

• als:
• Measures should be evidence based and have a clear

relationship to quality;

• Measure sets should be timely, actionable, and should reflect

care delivered within the model;

• Measure selection should minimize participant burden;
• Data are readily available for incorporation into the model.

CMS Plans to Refine Measures for Model Year 3 (2020)

Application of Quality Measures

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Quality Measure Performance

Compared to

Clinical Episode Performance Clinical Episode Performance

+ Q S + C Q S + C Q S

EI #1 EI #2

CA CABG BG

Qual ality

CA CABG BG

Qual ality

Positive or Negative Reconciliation Amount

• Not all of the measures apply to all of the Clinical Episodes.
• Quality measure performance is only compared across the same

clinical episodes.

Clinician Tip

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• Performance is relative to peers
• For each Quality Measure, raw data is converted into scaled scores

using deciles

Quality Measures Assessed by Clinical Episode

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Clinical Episode Quality Scores are Combined into a Composite Quality Score (CQS)

60 40 80

CHF HF COPD OPD TKA KA

70

Sep epsi sis

Composite Quality Score is Calculated at the Episode Initiator Level Quality Score is Calculated at the Clinical Episode Level

62 Episod

• de

e In Initiator (PGP/ACH)

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Composite Quality Score (CQS) Converted to CQS Adjustment Percentage

Composite Quality Score

0.67

Adjustment Percentage

3%

Application of Quality Measures

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Payment Adjustment for Quality

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For each Quality Measure, convert raw data into scaled scores based on national cohort comparison by decile. Apply minimum observation rule to each measure for each Episode Initiator, replacing missing values with 50th percentile values Step 1

Payment Adjustment for Quality

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For each Quality Measure, convert raw data into scaled scores based on national cohort comparison by decile. Apply minimum observation rule to each measure for each Episode Initiator, replacing missing values with 50th percentile values Step 1 Roll up scaled quality points into a quality score at the Clinical Episode level Step 2

Payment Adjustment for Quality

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For each Quality Measure, convert raw data into scaled scores based on national cohort comparison by decile. Apply minimum observation rule to each measure for each Episode Initiator, replacing missing values with 50th percentile values Step 1 Roll up scaled quality points into a quality score at the Clinical Episode level Step 2 Roll up quality scores from individual Clinical Episodes into a Composite Quality Score at the Episode Initiator level Step 3

Payment Adjustment for Quality

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For each Quality Measure, convert raw data into scaled scores based on national cohort comparison by decile. Apply minimum observation rule to each measure for each Episode Initiator, replacing missing values with 50th percentile values Step 1 Roll up scaled quality points into a quality score at the Clinical Episode level Step 2 Roll up quality scores from individual Clinical Episodes into a Composite Quality Score at the Episode Initiator level Step 3 Assign each Episode Initiator a CQS Adjustment Amount Step 4

Payment Adjustment for Quality (Continued)

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For each Episode Initiator, multiply the Total Positive/Negative Reconciliation Amount by the corresponding CQS Adjustment Amount to find the Net Payment Reconciliation Amount or Repayment Amount for Non-Convener Participants. Step 5

Payment Adjustment for Quality (Continued)

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For each Episode Initiator, multiply the Total Positive/Negative Reconciliation Amount by the corresponding CQS Adjustment Amount to find the Net Payment Reconciliation Amount or Repayment Amount for Non-Convener Participants. For Convener Participants: Combine Net Payment Reconciliation Amounts or Repayment Amounts for Episode Initiators. Step 5 Step 6

Payment Adjustment for Quality (Continued)

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For each Episode Initiator, multiply the Total Positive/Negative Reconciliation Amount by the corresponding CQS Adjustment Amount to find the Net Payment Reconciliation Amount or Repayment Amount for Non-Convener Participants. For Convener Participants: Combine Net Payment Reconciliation Amounts or Repayment Amounts for Episode Initiators. Finalize Net Payment Reconciliation Amount or Repayment Amount, notify Participant Step 5 Step 6 Step 7

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Step 1: Scale Quality Scores by Decile

Quality M Measure Actual Score Percenti tile Scaled Score All C Cause R Readmission 20 20 48 48 50 50 Ad Advanced C Care p plan 89 89 61 61 60 60 CMS P Patient Safety I Indicators 78 78 40 40 40 40 RS RSMR CABG 1. 1.5 72 72 70 70 Periop

• per

erative A Antibiot

• tic

50 50 50 50 50 50

• For each Quality Measure, convert raw data into scaled

scores based on national cohort comparison by decile.

CABG CABG

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Step 2: Combine Scaled Quality Measure Scores into a Quality Score by Clinical Episode

Quality M Measure Sc Scale led Sc Score All C Cause R Readmission 50 50 Ad Advanced C Care Pl Plan 60 60 CMS P Patient Safety I Indicators 40 40 RS RSMR CABG 70 70 Periop

• per

erative A Antibiot

• tic

50 50 Quality Score 54 54

Scaled ed Q Quality ty M Mea easure s e scor

• res are c

e com

• mbined f

for ea each ch Clinical Episod

• de

e into a

• a Q

Quality ty Score

• Measures are weighted equally
• Quality Score is the mean of individual Quality Measure scores

CAB ABG

CE Speci ecific Q c Quality ty Mea easures es 1. 1. RSMR C R CABG 2. 2. Periop

• per

erative Antibiotic

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Step 3: Individual Clinical Episode Quality Scores calculated as a Composite Quality Score

1. 1. All C Cause Rea eadmission 2. Advanced ed C Care Plan an 3. CMS P Pati tien ent Safet ety Indi dicators 1. 1. All C Cause Rea eadmission 2. 2. Ad Advanced ed C Care Plan an 3. 3. CMS P Pati tien ent Safet ety Indi dicators 4. RSMR C R CABG 5. Periop

• per

erative Antibiotic

EI #1 #1: ACH CH

CAB ABG CHF HF

CORE Quality ty M Mea easures 1. All C Cause Rea eadmission 2. Advanced ed C Care P e Plan 3. CMS P Pati tien ent S t Safety ty Indi dicators

EI #1: #1: ACH

Quality ty M Mea easure Scaled ed S Score

Al All Ca Cause e Readmission 40 40 Ad Advanced Ca Care p e plan 90 90 CMS MS Patient S Safety I Indi ndicators 70 70

Qu Quality ty Score re 66 Qu Quality ty Score re 54 Composi site e Qu Quality ty S Score 61

Quality ty M Mea easure Scaled ed S Score

Al All Ca Cause e Readmission 50 50 Ad Advanced Ca Care p e plan 60 60 CMS MS Patient S Safety I Indi ndicators 40 40 RSMR CABG CABG 70 70 Perioperativ tive A Antib tibiotic

• tic

50 50

Step 3, Continued: Clinical Episode Quality Scores calculated as a Composite Quality Score

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(n = 30) = 30)

CHF HF

(n = 20) = 20)

CAB ABG

Quality ty Scor

• re

61 Quality ty Scor

• re

50 Quality ty Scor

• re

70

ACH CH #1 #1 (n=1 =12) ACH CH #2 #2 (n= 1 = 19) ACH CH #3 #3 (n=1 =19)

Quality ty Scor

• re

20 Quality Scor

• re

70 Quality Scor

• re

66

ACH CH #1 #1 (n=20) 20) ACH CH #2 #2 (n=35) 35) ACH CH #3 #3 (n=15) 15)

Quality ty Scor

• re

61

Wei eighted ed Hosp spital

Quality ty Scor

• re

55

Wei eighted ed Hosp spital

(n = 50) = 50)

CHF HF

(n = 70) = 70)

CAB ABG

Co Composite e Qu Quality S Score 57 57

Step 3, Continued : Clinical Episode Quality Scores calculated as a Composite Quality Score

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EI #2: #2: PGP

Step 4: Assign a CQS Adjustment Amount

Participant A = 98% of NPRA Participant B = 95.7% of NPRA

Percent Adj. to NPRA

Participant A = 80 Participant B = 57

CQS

100% 90% 80% 70% 100 80 60 40 20

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Step 4 Continued: Assign a CQS Adjustment Amount

Participant A = 92% of NNRA Participant B = 94.3% of NNRA

Percent Adj. to NNRA

Participant A = 80 Participant B = 57

CQS

70% 80% 90% 100% 100 80 60 40 20

If an EI exceeds the target price for a clinical episode, it may owe a Net Negative Reconciliation Amount (NNRA).

KEY

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Step 5: Quality Performance Adjustments for Non-Convener Participant (PGP or ACH)

Adjusted Positive Total Reconciliation Amount

.95

Episode I Initiator r (PGP/ P/ACH) # #1

Net Payment Reconciliation Amount (NPRA)

Episode I Initiator r (PGP/ P/ACH) # #2

Repayment Amount Adjusted Negative Total Reconciliation Amount

.95

Composite Quality Score is Calculated for all EIs Clinical Episodes Adjust for Composite Quality Score for Positive Reconciliation Amounts NPRA or Repayment Quality Score is Calculated at the Clinical Episode level

+ $

CHF CHF

+

COPD PD

+ $

TK TKA

• $

Sep epsis

+ $

CHF CHF

+ $

COPD PD

• $

TK TKA

• $

Sep epsis

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Step 6: For Convener Participant, Combine Multiple Episode Initiators

CONVENER P PARTICIPAN ANT

$52K $30K Net Payment Reconciliation Amount (NPRA) $22K Adjusted Positive Total Reconciliation Amount Adjusted Negative Total Reconciliation Amount Ep Episode I Initiator ( (PGP/ACH) #1 #1 Composite Quality Score is Calculated for all Clinical Episodes Adjust for Composite Quality Score for Positive Reconciliation Amounts NPRA or Repayment Quality Score is Calculated at the Clinical Episode level

+ $ CHF HF + $ COPD PD + $ TKA + $ CHF HF + $ COPD PD

• $

TKA

• $

Sepsi sis

• $

Sepsis is

Ep Episode I Initiator ( (PGP/ACH) #2 #2

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Summary

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• BPCI Advanced is a new voluntary Advanced APM and MIPS APM (beginning

in 2019)

• Successful Participants (quality, expenditures) may receive additional

payments in the form of NPRA

• All measures are derived from administrative claims for Model Years 1 & 2

(2018 & 2019)

• Future Model Years may include different measures drawn from multiple

sources

Summary

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Thank You

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