UNBUNDLING THE CARDIAC BUNDLE Success with Episode Payment Models - - PDF document
4/12/2017 UNBUNDLING THE CARDIAC BUNDLE Success with Episode Payment Models April 13, 2017 Eric Rogers X. Lucy Zhang, RN David W. Stein, MD, FACS, ENT Senior Managing Consultant Senior Consultant Physician and President of erogers@bkd.com
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Success with Episode Payment Models
Senior Consultant xzhang@bkd.com Eric Rogers Senior Managing Consultant erogers@bkd.com April 13, 2017
David W. Stein, MD, FACS, ENT Physician and President of Strategic Medical Consultants
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15 business days of live webinar
Success with Episode Payment Models
Senior Consultant xzhang@bkd.com Eric Rogers Senior Managing Consultant erogers@bkd.com April 13, 2017
David W. Stein, MD, FACS, ENT Physician and President of Strategic Medical Consultants
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July 1 to October 1
further delaying until January 1, 2018
“We insist CMMI stop experimenting with Americans’ health & cease all current & future planned mandatory initiatives within the CMMI”
– Letter from Tom Price to
CMMI in September 2016
Best Time to Act is Now
Regardless of political climate, quality‐based reimbursement is here to stay. Providers who prepare early are better poised to succeed
Acute Myocardial Infarction (AMI) Model
Three AMI MS‐DRGs
Six PCI MS‐DRGs (with AMI diagnosis in principle or secondary positions on IPPS claim)
Coronary Artery Bypass Graft (CABG) Model
Six MS‐DRGs
Cardiac Rehabilitation (CR) Incentive Payment Model
Four HCPCS
Surgical Hip & Femur Fracture Treatment (SHFFT) Model
Three MS‐DRGs
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beneficiary discharged under MS‐DRGs within EPM scope
Downside risk begins Voluntary downside risk begins
Included Excluded
related to care provided during EPM episode
during EPM episode
factors)
technologies & services
devices
Hospitals are financially accountable for all related Part A & B claims that occur during episode, significant amount of which fall in post‐acute phase
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sided risk model with hospitals bearing financial responsibility
usual
EPM performance year where hospital’s financial performance will be compared against quality‐adjusted target price
reconciliation payment will be paid to hospital from CMS
CMS gets their cut –
$50M total CMS savings during five‐ year cardiac bundles
Using random selection, three MSA groups were chosen
MSAs
CJR, mostly to same providers
AMI/CABG MSAs
*CJR providers list updated January 1, 2017
148 out of 374 MSAs, or 40% of MSAs, are subject to mandatory bundles
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greater variation in these pathways
Compared to CJR, EPM beneficiaries will be more complex to care for & higher in acuity
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risk is available starting January 1, 2018
episode (if applicable) for initial hospital
percentile of all hospitals in same MSA eligible to be in that EPM), who will have same lower stop‐loss limits as rural hospitals, SCHs, MDHs & RRCs
Scenario Episode Initiation & Attribution Policy No transfer (participant)
MS‐DRG
No transfer (nonparticipant)
Inpatient to inpatient (i‐i) transfer (nonparticipant to participant)
hospital
Inpatient to inpatient transfer (participant to nonparticipant)
Inpatient to inpatient transfer (participant to participant)
CABG episode at i‐i transfer hospital
Outpatient to inpatient (o‐i) transfer (nonparticipant to participant
MS‐DRG at o‐i transfer hospital
Outpatient to inpatient transfer (participant to nonparticipant)
If participant hospital does not admit or discharge beneficiary, episode will not occur
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infarction (NQF #0230)
following acute myocardial infarction hospitalization (NQF #2473)
bypass graft (CABG) surgery (NQF# 2558)
performance based on a combination of 11 NQF‐endorsed CABG process & outcomes measures (NQF #0696)
Percentile 30‐Day Mortality (+1 for improvement) AMI Excess Days (+0.4 for improvement) HCAHPS (+0.4 for improvement) Hybrid AMI Mortality (Voluntary) WEIGHT 50% 20% 20% 10% ≥90th 10.00 4.00 4.00 Two points awarded for successful submission ≥80th & <90th 9.25 3.70 3.70 ≥70th & < 80th 8.50 3.40 3.40 ≥60th & <70th 7.75 3.10 3.10 ≥50th & <60th 7.00 2.80 2.80 ≥40th & <50th 6.25 2.50 2.50 ≥30th & <40th 5.50 2.20 2.20 <30th 0.00 0.00 0.00
15.2 & placed them in excellent category
<3.8 >=3.8 & <6.3 >=6.3 & <=15.0 >15.0
<=3.7 >3.7 & <=6.25 >6.25 & <=15.0 >15.0 Shrank Grew Grew No change
Max 20 pts
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1.
Age
2.
Heart rate
3.
Systolic blood pressure
4.
Troponin
5.
Creatinine
& discharge date)
PY AMI Voluntary Measure Successful Submission Requirements 2017 At least 50% of qualifying hospitalizations 2018–2021 At least 90% of qualifying hospitalizations
First captured, measured within two hours of presentation to hospital First captured, measured within 24 hours of presentation to hospital
15.2 & not have affected their quality category
Percentile 30‐Day Mortality (+1.4 for improvement) HCAHPS Survey (+0.4 for improvement) STS Composite CABG (Voluntary) WEIGHT in Composite Score 70% 20% 10% ≥90th 14.00 4.00 Two points awarded for successful submission ≥80th & <90th 12.95 3.70 ≥70th & < 80th 11.90 3.40 ≥60th & <70th 10.85 3.10 ≥50th & <60th 9.80 2.80 ≥40th & <50th 8.75 2.50 ≥30th & <40th 7.70 2.20 <30th
<2.2 >2.2 & <=3.4 >3.4 & <=16.2 >16.2
Grew Shrank Shrank No change
Below Acceptable
<2.5 >=2.5 & <3.5 >=3.5 & <=16.2 >16.2
Max 20 pts
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PY 1 (2017) PY 2 (2018) PY 3 (2019) PY 4 (2020) PY 5 (2021) MORT‐30‐AMI July 1, 2014– June 30, 2017 July 1, 2015– June 30, 2018 July 1, 2016– June 30, 2019 July 1, 2017– June 30, 2020 July 1, 2018– June 30, 2021 AMI Excess Days MORT‐30‐CABG HCAHPS July 1, 2016– June 30, 2017 July 1, 2017– June 30, 2018 July 1, 2018– June 30, 2019 July 1, 2019– June 30, 2020 July 1, 2020– June 30, 2021 Voluntary AMI & CABG measures July 1, 2017– August 31, 2017 September 1 2017 – June 30, 2018 July 1 2018 – June 30, 2019 July 1 2019 – June 30, 2020 July 1, 2020 – June 30, 2021
Poor quality scores can affect your composite quality score three years later, thus impacting your payment amounts
Effective Discount Factors for Reconciliation Effective Discount Factors for Repayment Quality Score 2017 2018 2019 2020 2021 Quality Score 2017 2018 (Voluntary) 2019 2020 2021 Below Acceptable N/A N/A N/A N/A N/A Below Acceptable N/A 2.0% 2.0% 3.0% 3.0% Acceptable 3.0% 3.0% 3.0% 3.0% 3.0% Acceptable N/A 2.0% 2.0% 3.0% 3.0% Good 2.0% 2.0% 2.0% 2.0% 2.0% Good N/A 1.0% 1.0% 2.0% 2.0% Excellent 1.5% 1.5% 1.5% 1.5% 1.5% Excellent N/A 0.5% 0.5% 1.5% 1.5%
Composite quality score Effective discount factor Higher reconciliation payments from CMS or lower repayment amount
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application of effective discount factor
Benchmark price
Effective discount factor
Quality‐adjusted target price
Net Payment Reconciliation Amount (NPRA)
Stop‐gain limit
Stop‐loss limit
Reconciliation payment
Repayment amount
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AMI PRICING SCENARIO Episode Benchmark Price
Single AMI or PCI MS‐DRG (with AMI dx) Standard episode benchmark price based on anchor MS‐DRG AMI or PCI MS‐DRG (with AMI dx) with CABG readmission Standard episode benchmark price of AMI anchor MS‐DRG + CABG anchor hospitalization benchmark price corresponding to CABG readmission MS‐DRG Single hospital CABG MS‐DRG with AMI diagnosis CABG anchor hospitalization benchmark price for MS‐DRG + CABG post‐anchor hospitalization benchmark price based on presence of AMI ICD‐CM diagnosis code & whether anchor MS‐DRG is with MCC or without MCC Single hospital CABG MS‐DRG without AMI diagnosis CABG anchor hospitalization benchmark price for MS‐DRG + CABG post‐anchor hospitalization benchmark price based on no AMI ICD‐CM diagnosis code & whether anchor MS‐DRG is with MCC or without MCC
Limited risk‐stratification in setting benchmark prices to allow for additional spending for CABG beneficiaries with AMI & with MCC
regions
historical performance at the beginning, then that of the region’s at the end
PY 1 & 2 (2017 & 2018)
PY 3 (2019)
PY 4 & 5 (2020 & 2021)
2013–2015 Historical Data 2017–2019 Historical Data 2015–2017 Historical Data
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2017 2018 2019 2020 2021
Stop‐Gain Limit 5.0% 5.0% 5.0% 10.0% 20.0% Stop‐Loss Limit N/A 5.0% (voluntary) 5.0% 10.0% 20.0% Stop‐Loss Limit for Certain Hospitals* N/A N/A 3.0% 5.0% 5.0% *Rural hospitals, SCHs, MDHs, RRCs & EPM low‐volume protection hospitals
($24,000×3%)) = $23,280
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payment from CMS
Above quality‐ adjusted target price Below quality‐ adjusted target price
Quality category can determine whether participant hospital makes or owes money
For example, two hospitals have same benchmark price & episode spend
10.PGP
subject to the following
risk & gain
during EPM
& never on volume of current & future referrals
pay max 25%
reconciliation amount
Hospitals may recommend preferred providers, but may not restrict beneficiaries’
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Only waived for AMI episodes beginning October 4, 2018 Medicare will cover SNF stay if patient is discharged from inpatient stay in less than three days SNF must have at least three‐ star rating for seven out of last 12 months Hospitals that elect early downside risk in PY2 are not eligible for early waiver
SNF three‐ day rule
For EPM beneficiaries who would otherwise not qualify for home health, e.g., not homebound, waiver allows them to receive home health visits Nonphysician practitioners may provide visits AMI EPM beneficiaries may receive maximum of 13 visits CABG & SHFFT EPM beneficiaries may receive maximum of nine visits
Home visits
Waives the rural & other geographic requirements so that all EPM beneficiaries may receive telehealth Beneficiaries may receive visits while at home Service must be Medicare‐ approved telehealth service with ICD‐10 code that is not excluded from EPM episode definition
Tele‐ health waiver
intensive cardiac rehab (ICR) for beneficiaries in AMI &/or CABG EPMs
participant in order for them to receive incentive
$25/ session
$175/ session
$4,650 total available incentive*
First 11 sessions Subsequent sessions during episode
*Assumes current limitations on number of covered cardiac rehab sessions to two one-hour sessions per day, for a total of 36 sessions over 36 weeks
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EPM‐CR
FS‐CR
AMI/CABG MSA selection
CR MSAs
include nonphysician practitioner (except for medical director)
functions of supervisory physician
individualized treatment plan for provider
to EPM beneficiary during AMI or CABG episode
Physician Definition Waiver Beneficiary Incentives
to beneficiaries in AMI care period or CABG care period under CR incentive payment model
EPMs
towards providing transportation
Hospitals cannot pay for or subsidize patient’s co‐pay for CR
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patients
episodes
post‐acute care providers
based practices & high performers
build a team
acute providers
system that works for you
input & buy‐in
CMS is planning to make historical data & benchmark prices available by midspring to CR & EPM participants
Physician 1 Physician 2 Physician 3 Physician 4
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CPE Sponsors through its website: www.nasbaregistry.org The information contained in these slides is presented by professionals for your information only & is not to be considered as legal advice. Applying specific information to your situation requires careful consideration of facts & circumstances. Consult your BKD advisor or legal counsel before acting on any matters covered
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FOR MORE INFORMATION Eric Rogers | 417.865.8701 | erogers@bkd.com Lucy Zhang | 314.231.5544 | xzhang@bkd.com
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