Total Cost of Care (TCOC) Workgroup June 27, 2018
Agenda Introductions Updates on initiatives with CMS Amendment to current All-Payer Model (APM) contract TCOC Contract language Bundled Payments for Care Improvement in Maryland (BPCIM) Y1 MPA implementation Update on MPA reporting tool for hospitals New spreadsheet with modeling for CY 2017 vs. CY 2016, etc. Y2 MPA issues Attainment (not doing in Y2) Risk adjustment (or not) Linking doctors to hospitals PSAP zip codes Quality Adjustment 2
Updates on Initiatives with CMS December 2016
APM Amendment #2 to implement MPA was signed and effective June 19, 2018 Medicare Performance Adjustment (MPA) required for our Care Redesign Programs (CRP) to be MACRAtized Participating clinicians who are Qualifying Participants (QPs) will receive 5% incentive payment on Medicare payments* All CRP hospitals (new and prior) had to sign the new Participation Agreement (PA) by yesterday State and federal signatories need to sign by 7/1 for MACRAtization New MACRAtized CRP performance period is 7/1-12/31/18 CRP Performance Period 1 was July 1 – Dec. 31, 2017 CRP Performance Period 2 is Jan. 1 – Dec. 31, 2018 – June 30, 2018 New CRP Performance Period 3 is July 1 – Dec. 31, 2018 CRP Performance Period 4 will be under new TCOC Contract: CY19 4 * See slides from April 4 TCOC Work Group meeting for additional background.
MACRA for CRP Performance Period 3 Since MACRAtization of CRP just occurred … For Maryland clinicians in CCIP and HCIP in 2018 to be assessed for MACRA QP determination, they must be on the Certified Care Partner List: Sent by a CRP hospital* to AMS/CRISP/HSCRC by July 13 Sent by AMS/CRISP/HSCRC to CMS by July 27 To be on the hospital’s Certified Care Partner List, a clinician: (1) must already have been vetted eligible by CMS, (2) meet HCIP/CCIP track criteria, and (3) sign HCIP or CCIP care partner arrangement (or be a downstream care partner in the group’s care partner arrangement). QP Threshold Score for MACRA High-level summary in April 4 TCOC Work Group slides CMS to publish FAQs shortly 5 * That is, a hospital that has an executed new Participation Agreement (i.e., signed by all parties)
TCOC Contract Update Contract language in near-final stages Purpose is to make consistent with provisions agreed to with federal government in Term Sheet, as amended for federal clearance approval (as announced by Gov. Hogan on May 14, 2018) Contract language shared with stakeholders, state partners and Commissioners for any technical comments Hoping for State and Feds to sign in mid-July 6
Bundled Payments for Care Improvement in Maryland (BPCIM) Bundle Basics December 2016 Overview of Federal Programs Tailoring Bundles for Maryland Model Launch Timeline Additional Details in Appendix
Bundle Basics Definition: Bundled Payment noun 1) P roviders and/or healthcare facilities are paid a single payment for all the services performed to treat a patient undergoing a specific episode of care. 2) An “episode of care” is the care delivery process for a certain condition or care delivered within a defined period of time. Objectives of Bundled Payments Promote care redesign and incentivize care coordination Reward high quality care and prevent readmissions Reduce health care costs 8
Overview of Federal Bundled Programs Bundled Payments for Care Initiative (BPCI) - 4 tracks, ends in September 2018 - Saved ~$300 million since 2014 Bundled Payments for Care Initiative Advanced (BPCI-A) Announced in January 2018 • • Features include: Voluntary model, single retrospective payment with 90 day Clinical Episode • duration, 29 Inpatient Clinical Episodes, 3 Outpatient Clinical Episodes, qualifies as an Advanced Alternative Payment Model (APM), payment is tied to performance on quality measures. Comprehensives Care for Episode Payment Models and Joint Replacement (CCJR) Cardiac Rehabilitation (CR) Program Incentive Payment Models - Voluntary in 33 MSAs - Canceled in favor of other programs - Projected to save CMS $189 million - Projected to save Medicare $170 over 5 years million over 5 years 9
Introducing Bundled Payments for Care Initiative for Maryland (BPCIM) BPCIM is based on the BPCI Advanced Model but tailored for Maryland and simplified for implementation ease. What’s the same? Features BPCI- Advanced BPCI-Maryland Participation Voluntary Voluntary Episodes 90-day episode -- from triggering 90-day episode -- from discharge from inpatient stay triggering inpatient stay CMS Savings Episode targets are set 3% below Episode targets are set 3% below Discount average total cost of care average total cost of care 10
Introducing Bundled Payments for Care Initiative in Maryland (BPCIM) BPCIM is based on the BPCI Advanced Model but tailored for Maryland and simplified for implementation ease. What’s NOT the same? Features BPCI- Advanced BPCI-Maryland Clinical 29 Inpatient Clinical Episodes Only Inpatient Clinical Episodes Episodes 3 Outpatient Clinical Episodes Clinical Data MS-DRGs APR-DRGs Formatting Charge Includes Inpatient Anchor Stay, Physician Excludes inpatient (anchor and Inclusion Payment, Post-Acute Care, and readmission) charges Readmission costs Benchmarks Payment adjusted for 1) efficiency, 2) Simplified payment adjustment risk adjustment, and 3) peer group Quality A Composite Quality Score (CQS) is A Composite Quality Score (CQS) is Measures calculated to adjust payments +/- 10% calculated to adjust payments <10% (amount TBD) 11
Hospitals and care partners are offered a flexible menu of care redesign interventions Intervention Category Intervention Standardized, evidence-based protocols are implemented, for example for Clinical Care and discharge planning and follow-up care. Care Redesign Implementation of enhanced coordination with post-acute care providers. Interdisciplinary team meetings address patients’ needs and progress. Pharmacists embedded on unit. Patient education is provided pre-admission and addresses post-discharge Beneficiary and Caregiver options. Engagement Shared decision-making processes and/or tools are implemented to help patients assess treatment options. Methods for fostering "health literacy" in patient/family education are implemented. Patient supports, items, and/or services are furnished to beneficiaries. Care Coordination and Patient risk assessment/stratification is used to target services. Care Transitions Assignment of a care manager/ coordinator/ navigator to follow patient across care settings (e.g., to help coordinate follow-up appointments and to connect patient to needed community resources). Performance of medication reconciliation. Remote patient consultation monitoring. 12
Timeline and Application Process May June 4 Summer Sept./Oct. Oct. 31 Jan. 1, ‘19 • Informational • Participating • BPCIM • Hospital- • Developed • State meetings and hospitals specific launch BPCIM submitted webinars for submit episode Template draft hospitals and Protocol to prices Protocol Protocol to potential care HSCRC for developed CMMI for partners approval • Design approval details • Meeting finalized with CMMI on changes Current Status 13
Y1 Implementation: CRISP MPA Reporting Tools for Hospitals December 2016
Y1 Implementation: New spreadsheet with modeling for CY 2016-7, etc. December 2016
Attribution Algorithm: 2016 data of hierarchy of ACO-Like / MDPCP-Like / Geography Attribution occurs prospectively, 100% based on utilization in prior 2 15% federal fiscal years, but then using 90% 25% their current CY TCOC 80% Beneficiaries attributed first 1. based on service use of clinicians 70% Geography in hospital-based ACO 60% (PSAP): 53% Beneficiaries not attributed 2. Residual #2 48% through ACO-like are attributed 50% MDPCP-Like based on MDPCP-like attribution: 40% Finally, beneficiaries still not Residual #1 3. 30% attributed would be attributed Enrollees in with a Geographic approach a Hospital 20% ACO 28% Performance would be assessed on 27% 10% TCOC spending per capita For hospitals not in an ACO, 0% attribution would be MDPCP-like + TCOC Beneficiaries Geography, among beneficiaries not payments in a hospital-based ACO 16 Source: Draft HSCRC analysis based on CY 2016 Medicare (CCW) data
Y1 MPA Base Year: 2017 data of hierarchy of ACO-Like / MDPCP-Like / Geography Attribution occurs prospectively, 100% based on utilization in prior 2 15% federal fiscal years, but then using 90% 24% their current CY TCOC 80% Beneficiaries attributed first 1. based on service use of clinicians 70% Geography in hospital-based ACO 60% (PSAP): 55% Beneficiaries not attributed 2. Residual #2 48% through ACO-like are attributed 50% MDPCP-Like based on MDPCP-like attribution: 40% Finally, beneficiaries still not Residual #1 3. 30% attributed would be attributed Enrollees in with a Geographic approach a Hospital 20% ACO 31% Performance would be assessed on 29% 10% TCOC spending per capita For hospitals not in an ACO, 0% attribution would be MDPCP-like + TCOC Beneficiaries Geography, among beneficiaries not payments in a hospital-based ACO 17 Source: Draft HSCRC analysis based on CY 2017 Medicare (CCW) data
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