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Advancing Care Coordination Through Episode Payment ModelsProposed RuleAug.10, 2016

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Mark Hiller, MBA, Vice President, Innovative Solutions, Premier Inc.Danielle Lloyd, MPH, Vice President, Policy and Advocacy, Deputy Director, DC Office, Premier Inc.Aisha Pittman, MPH, Director, Quality Policy and Analysis, Premier Inc.

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Mark Hiller, Vice President, Innovative Solutions, Premier Inc.

Danielle Lloyd, VP, Policy and Advocacy, Deputy Director, DC Office, Premier Inc.

Aisha Pittman, Director, Quality Policy and Analysis, Premier Inc.

Faculty

Agenda

5

• Applicable Hospitals• Applicable Beneficiaries• Episode Definitions• Payment Methodology• Quality Performance• Reconciliation • Gainsharing• Appeal Procedures• Data Sharing• Payment and Legal Waivers• Cardiac Rehab Incentive Payment

Released July 25, published on August 2, Federal RegisterEstablishes 3 new bundled payment models for AMI, CABG, and Surgical Hip/Femur Fracture Treatment (SHFFT)

• All Parts A & B services from hospital admission through 90-days post discharge• Mandatory model in select geographic areas

• AMI and CABG: 98 MSAs (TBD)• SHFFT: Same 67 regions as CJR

• Requires 3% discount, discount lowered based on “good” or “excellent” quality performance e

• Requires two-sided risk starting year 2 with stop loss/gain• Model runs from July 1, 2017- December 31, 2021

Modifies Comprehensive Care for Joint Replacement (CJR)Creates a track in all models to meet CEHRT requirements in order to be considered an Advanced APM under MACRACreates the Cardiac Rehabilitation Incentive Payment Model

• Provides incentive payments for coordination or rehabilitation services for heart attach and bypass patients

• Available to 45 MSAs within AMI/CABG models and 45 MSAs outside of AMI/CABG

Comments due October 3, 2016

Proposed Rule

Annual Medicare spending for all EPM episodes

Adm

issi

on

Dis

char

ge90 Days

All Medicare Part A & Part B fee-for-service payments

Target price ≈ 3% blended discount of historical hospital costs/broader geographic region

Triggers: CJR: Lower extremity joint replacement - MS-DRG 469/470EPM-SHFFT: Surgical hip and femur fracture- MS-DRG 480-482EPM-AMI: AMI w/o revascularization/PCI- MS-DRG 280-282/246-251;ICD-10 CM of AMIEPM-CABG: Coronary Artery Bypass Graft- MS-DRG 231-236

Epis

ode

Rec

onci

liatio

n pa

ymen

ts

Below spending target

Above spending target

$$$$$$$$$$$$$$$ Hospital repays Medicare $$$$$$$$$$$$$$$

$$$$$$$$$$$$$$$ Reconciliation payment to hospital $$$$$$$$$$$$$$$

Quality Composite Score is Adequate, Good, or ExcellentCJR/SHFFT: Complications, Patient Experience, Patient-Reported Outcomes (voluntary)CABG: Mortality, Patient ExperienceAMI: Mortality, Excess Days, Patient Experience, Mortality eMeasure (voluntary)

Current and Proposed Episode Payment Models

CMS proposed rule for the Episode Payment Models• Comments due 60 days from the date of display (October 3, 2016)1. Go to proposed rule2. Click “Submit a Formal Comment”, the green button on the right-

hand side of the page below the title.OR1. Go to http://www.regulations.gov2. Type “CMS-5519-P” into the search box3. Find “Medicare Program: Advancing Care Coordination Through

Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)

4. Click on “Comment Now”, the blue button to the right of the title.

EPM Proposed Rule: How to Submit a Comment

https://www.federalregister.gov/articles/2016/08/02/2016-17733/medicare-program-advancing-care-coordination-through-episode-payment-models-epms-cardiac

http://www.regulations.gov/

EPM Clinical DefinitionsProposed rule includes three new EPMs

• Patients who receive medical therapy but no revascularization (MS DRGs 280-282) and includes discharges for Percutaneous Coronary Intervention (PCI) (MS DRGs 246-251)

• CMS proposed to adjust target prices based on complexity of treating a heart attack• Excludes intracardiac procedures

Acute Myocardial Infarction (AMI)

• Patients discharged with MS-DRGs 231-236 • CMS proposed to adjust target prices based on complexity of providing bypass surgery• Including beneficiaries undergoing elective CABG in the CABG model as well as beneficiaries with

AMI who have a CABG during their initial AMI anchor hospitalization.

Coronary Artery Bypass Graft (CABG)

• Patients discharged with MS-DRGs 480-482• In conjunction with the existing CJR model (DRGs 469-470)

Surgical Hip/Femur Fracture Treatment (SHFFT)

PY 1July 1, 2017 to December 31, 2017

PY 2January 1, 2018 to December 31, 2018




EPM Performance YearsEPM program runs for a total of five performance years –Starting on July 1, 2017 through December 31, 2021.Similar to CJR – EPM episodes that would begin in a given calendar year may be captured in the following performance year due to some EPM episodes ending after December 31st of a given calendar year

• Example: EPM Episodes beginning in December 2017 and ending in March 2018 (90-day episodes), would be part of Performance Year 2.

Target price is based on a 3% discount and is lowered based on “good” or “excellent” quality performance Target prices are adjusted for complexity (e.g. MS-DRG, timeframe, and episode service overlap) Updated every other yearPhased in risk: No downside risk for Model Year 1, but risk begins with EPM episodes that begin in 2nd Quarter of PY 2 (April-June 2018)

Payment Methodology – Phased-in Risk

Model Year Date Range Repayments (i.e. Risk) Stop Loss/Stop Gain*Year 1 7/1/17 – 12/31/17 • No repayments • Upside only of 5%

Year 2 CY 2018 • No repayments in 1st quarter• 2nd, 3rd, and 4th quarters a

maximum required discount of 2%

• Upside/Downside of 5%

Year 3 CY 2019 • Maximum required discount of 2%.


Year 4 and 5 CY 2020 – CY 2021 • Maximum required discount of 3%.


*Stop-loss thresholds for certain hospitals, including rural and sole-community hospitals are 3% for PY2 (Downside Risk) and 5% for PY3-PY5.

Propose to exclude:• Drugs that are paid outside of the MS-DRGs included in

the EPM episode definition, specifically hemophilia clotting factors

• Technology add-on payments (excluded from historical data and actual EPM episode payments and applies to anchor hospitalization and related readmissions)

• OPPS transitional pass-through payments for medical devices

• Readmissions for oncology, trauma medical admissions, surgery for chronic conditions unrelated to EPM episode (same as CJR)

Propose to identify unrelated Part B services and readmissions based on BPCI Model 2 “Part B Exclusions List”Included EPMs may also include certain Per Member/Per Month (PMPM) payments

Payment Methodology – Excluded/Included Payments

Blended Target Pricing

100% regional

Year 4 & 5

1/3 hospital

2/3 regional

Year 3

2/3 hospital

1/3 regional

Year 1 & 2

Target rates begin as a combination of hospital-specific and regional (US census region) historical payments and transition to regional-only rates

Baseline is comprised of 3 years historical data –January 1, 2013 through December 31, 2015

• NOTE: Separate pricing for January 1st through September 30th vs. October 1st through December 31st due to Medicare payment system update timeframe differences.

• Episode price periods apply to episodes that initiate during those periods except Performance Year 5.

• Prices will be communicated prior to beginning of performance periods.• Prices will be set for each clinical definition.

Treatment of reconciliation and Medicare repayment:• EPMs: Include both reconciliation payments and Medicare repayments

when calculating historical EPM-episode payments to update EPM-episode benchmark and quality-adjusted target prices Plan to also include BPCI NPRA amounts PROPOSING TO CHANGE CJR METHODOLOGY TO MATCH

Price Setting

Reconciliation TimelineProposed Timeframe for Reconciliation for EPMs

EPM Performance Year

EPM Performance Period

Reconciliation Claims Submitted

ByNPRA

Calculation

SecondReconciliation, ACOOverlap, and Post-Episode Spending

Calculations

Calculation Amounts Included in

Reconciliation Payment and

Repayment Amounts

Year 1*

Episodes beginning on or after July 1, 2016 and ending through December 31, 2017

March 1, 2018 Q2 2018 March 1, 2019 Q2 2019

Year 2Episodes ending January 1, 2018 through December 31, 2018

March 1, 2019 Q2 2019 March 1, 2020 Q2 2020


March 1, 2020 Q2 2020 March 2, 2021 Q2 2021


March 2, 2021 Q2 2021 March 1, 2021 Q2 2021


March 1, 2022 Q2 2022 March 1, 2023 Q2 2023

* Note that the reconciliation for Year 1 would not include repayment responsibility from EPM participants.

In contrast to the CJR model, AMI episodes will have price adjustments in the cases of certain transfers (i.e. “chained hospitalizations”) and readmissions. Proration – Use same methodology as CJR for prorating payments for services that extend beyond 90 day post discharge High cost episodes – Outlier ceilings based on regional data and by MS-DRG“CABG Readmission AMI Model episode Benchmark Price" –Episode benchmark price assigned to certain AMI model episodes with price MS-DRG 280-282 or 246-251 and with a readmission for MS-DRG 231-236"Price MS-DRG" – For AMI model episodes with a chained anchor hospitalization, the price MS-DRG is the MS-DRG assigned to the AMI model episode according to the hierarchy outlined in the following table on the following slide.

EPM Pricing Scenarios

Scenario “Price MS-DRG”

Anchor Price MS-DRG

Post-Acute CarePrice MS-DRG

AMI (Single Hospitalization– Not Chained):• AMI AMI

AMI (Chained Hospitalization of):• AMI PCI

• CABG CABG CABG with AMI

AMI with CABG Readmission:

• CABG (without chained hospitalization) AMI+ CABG

• CABG (with chained hospitalization that is not a CABG)

AMI+ CABG

CABG (Single Hospitalization – Not Chained):

• CABG with AMI CABG CABG with AMI

• CABG without AMI CABG CABG without AMI

SHFFT:• Without total joint replacement SHFFT

• With total joint replacement CJR

EPM Pricing Scenarios (Cont.)

Beneficiaries must meet all the following criteria:• Enrolled in Medicare Part A and Part B.

• Eligible for Medicare not on the basis of end-stage renal disease (ESRD).

• Not enrolled in any managed care plan (for example, Medicare Advantage, Health Care Prepayment Plans, cost-based health maintenance organizations)

• Not covered under a United Mine Workers of America health plan, which provides health care benefits for retired mine workers.

• Have Medicare as their primary payer.

• Not aligned to an ACO in the Next Generation ACO model or an ACO in a track of the Comprehensive ESRD Care Initiative incorporating downside risk for financial losses.

• Not already in any BPCI model episode.

• Not already in an AMI, SHFFT, CABG or CJR model episode with an episode definition that does not exclude the MS-DRG that would be the anchor MS-DRG under the applicable EPM.

• Not under the care of an attending or operating physician, as designated on the inpatient hospital claim, who is a member of a physician group practice that initiates BPCI Model 2 episodes at the EPM participant for the MS-DRG that would be the anchor MS-DRG under the EPM.

Beneficiary Inclusions

Not aligned to the following ACO types:• Next Generation ACO model• Comprehensive ESRD Care Initiative track, incorporating downside risk

Beneficiary death during an anchor hospitalization of EPM episodes would cancel the EPM.

• NOTE: This is different than CJR where beneficiary death at any point during the episode cancels the episode.

EPM episode begins with initial hospitalization – Not prior to admission

• NOTE: The episode does NOT begin three days prior, only that services provided in the three days prior would be included in the MS-DRG payment would be included (72-hour rule).

• Example: This is important as transfers from another hospital’s ED within the three day period would not be included.

Beneficiary/Other Exclusions

Since many hospitals do not provide PCI or CABG services, CMS has created a chained hospitalization pricing model. For example:

Payment Methodology – Special Transfer Rules

Scenario 1 Scenario 2

Scenario 3 Scenario 4

Initial IP Hospitalization(NOT in AMI/CABG EPM)

Transfer

2nd IP Hospitalization*(AMI/CABG EPM)

Result: Episode will initiate with participating EPM Hospital

2nd IP Hospitalization(NOT in AMI/CABG EPM)

Transfer

Initial IP Hospitalization*(AMI/CABG EPM)

Result: Episode will initiate with initial EPM HospitalNOTE: Episode would be cancelled if the discharge MS-DRG from the 2nd hospital is not an AMI/CABG EPM MS-DRG

Initial IP Hospitalization*(AMI/CABG EPM)

Transfer

2nd IP Hospitalization(AMI/CABG EPM)

Result: Initial EPM Hospital will retain responsibility for EPM episode regardless of transferNOTE: Episode would be cancelled if the discharge MS-DRG from the 2nd hospital is not an AMI/CABG EPM MS-DRG

CABG does NOT cancel an AMI Episode

Result: There would be an AMI pricing adjustment by paying the AMI Model participant based on a MS-DRG price that is different from the anchor MS-DRG to reflect Medicare payment for the CABG

*Day of Anchor Discharge = Day 1 of Post-Acute 90-day Period****However, in AMI chained hospitalizations, Day 1 would be day of discharge from transfer (e.g. 2nd hospital)

Initial IP Hospitalization(AMI EPM)

2nd IP Hospitalization(CABG EPM)

BPCI: “CMS believes that BPCI supports the design of the proposed EPM models.”

• BPCI takes precedence – whether hospital, PGP or other BPCI Awardee

• Precedence is based on specific episode overlap – not just overlap at the program level

• Initiation of a BPCI episode would cancel the EPM

Precedence Rules

BPCI Hospital/PGP

(Model 2 – CABG)

EPM MSA

?

YES

NO

Included for AMI

No Changes

Scenario 1 – AMI/CABG

BPCI Hospital/PGP

(Model 2 – LEJR)

CJR MSA

?

YES

NO

Included for SHFFT

No Changes

Scenario 2 – SHFFT

Creates a track in each model that would potentially qualify for the Advanced Alternative Payment (APM) bonus under MACRA in CY 2019 (payment year 2021).

Track 1 – Qualifies organization for APMs: Participants must use and attest to Certified Electronic Health

Record Technology (CEHRT) Target price with 3% discount AND 5% aggregate risk in Year 2 Physician will have to be in a Sharing Agreement with an EPM

participant (a.k.a. hospital)

Track 2 – Does not qualify as APMNOTE: CMS proposed to build upon the Bundled Payment for Care Improvement (BPCI) initiative by implementing a new voluntary bundled payment model for CY 2018 that would be designed to meet the criteria to be an Advanced APM under MACRA.

Advanced APM Tracks

Required discount factor of 3%Hospitals with “good” or “excellent” quality are awarded a quality incentive payment (1 or 1.5%) which reduces the discount factorHospitals with “acceptable”, “good”, or “excellent” quality are eligible for to receive a reconciliation payment if actual spending is less than target spending

Discount Factor Depends on Quality Performance

*discount factor lowered due to quality incentive payment

Year 1 Discount Factor %

Eligible for Reconciliation

Repayment %

Below acceptable 3.0 No No Repayment in Year 1Acceptable 3.0 Yes

Good 2.0* YesExcellent 1.5* Yes

Discount Factor Depends on Quality Performance

Years 4/5 Discount Factor %


Repayment %

Below acceptable 3.0 No 3.0Acceptable 3.0 Yes 3.0Good 2.0* Yes 2.0Excellent 1.5* Yes 1.5

Years 2/3 Discount Factor %


Repayment %

Below acceptable 3.0 No 2.0Acceptable 3.0 Yes 2.0Good 2.0* Yes 1.0Excellent 1.5* Yes 0.5

*discount factor lowered due to quality incentive payment

EPM Proposed Quality Measures:

EPM Quality Measures

• Mortality (NQF #0230)

• Excess Days, HCAHPS (NQF # 0166)

• Mortality eMeasure (voluntary) (NQF #2473

• Mortality (NQF #2558)

• HCAHPS (NQF #0166)

• Complications for THA/TKA (NQF #1550)

• HCAHPS (NQF #0166)

• Patient-Reported Outcomes (voluntary)

AMI CABG SHFFT

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (NQF #0230) (MORT-30-AMI)

• 3 year rolling performance period: July 1, 2014- June 30, 2017• Cohort may be slightly different from IQR cohort• Not publicly reported if fewer than 25 cases

Excess Days in Acute Care after Hospitalization for AMI (AMI Excess Days)

• 3 year rolling performance period: July 1, 2014- June 30, 2017• Cohort includes all hospitals in the model and may be slightly different

from IQR cohort• Not publicly reported if fewer than 25 cases; hospital-specific reports will

be distributed

HCAHPS Survey (NQF #0166)• 4 consecutive quarters of survey data• Data submission the same as IQR

Voluntary Hybrid Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following Acute Myocardial Infarction (AMI) Hospitalization (NQF #2473) (Hybrid AMI Mortality) data submission

Measures- AMI

Combines claims and EHR data to calculate a risk-standardized mortality rate following AMI

Cohort identical to current measure, enhanced with EHR data• Five clinical data elements included in risk adjustment

• Age• Heart Rate within 2 hours• Systolic Blood Pressure within 2 hours• Troponin within 24 hours• Creatine within 24 hours• Intended to reflect clinical status when first presenting for AMI

• Collecting six additional variables• CCN• HIC• Date of Birth• Gender• Admission Date• Discharge Date

• Seek comment on submission mechanism: QRDA, spreadsheet, or both for year 1; QRDA for subsequent years

Successful submission• Year 1: 50% of qualifying AMI hospitalizations; Year 2-5: 90%• All additional elements (able to indicate troponin test was not performed)• Submit within 60 days of end of data collection period

Not publicly reported, hospitals will receive hospital-specific reports

AMI- Voluntary Data Submission for Hybrid AMI Mortality Measure

Measure Weight Max Points (20) Scoring

AMI Mortality 50% 10

1.0 improvement point*

90th percentile and above:1080th- 90th percentile: 9.2570th- 80th percentile: 8.5060th- 70th percentile: 7.7550th- 60th percentile: 7.0040th- 50th percentile: 6.2530th- 40th percentile: 5.5Below 30th percentile: 0

AMI Excess Days 20% 4

0.4 improvement points*

90th percentile and above: 480th- 90th percentile: 3.770th- 80th percentile: 3.460th- 70th percentile: 3.150th- 60th percentile: 2.840th- 50th percentile: 2.530th- 40th percentile: 2.2Below 30th percentile: 0

HCAHPS 20% 40.4 improvement points*

Same as above

Hybrid AMI Mortality voluntary

10% 2 2 points for successful submission

Quality Composite Scoring-AMI

* Improvement points awarded for any year-over-year improvement in a participant’s own measure point estimates if the participant falls into the top 10 percent of participants based on the national distribution of measure improvement.

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft (CABG) Surgery (NQF #2558) (MORT-30-CABG)

• 3 year rolling performance period: July 1, 2014- June 30, 2017

• Cohort may be slightly different from IQR cohort• Not publicly reported if fewer than 25 cases

HCAHPS Survey (NQF #0166)

Measures- CABG

Measure Weight Max Points (20) Scoring

CABG Mortality 75% 15

1.0 improvement point*


HCAHPS 25% 5

0.5 improvementpoints*


Quality Composite Scoring-CABG

* Improvement points awarded for any year-over-year improvement in a participant’s own measure point estimates if the participant falls into the top 10 percent of participants based on the national distribution of measure improvement.

Hospital-level RSCR (complications) following elective primary THA and/or TKA (NQF #1550)

• 3 year rolling performance period: April 1, 2014-March 31, 2017

• Cohort may be slightly different from IQR cohort• Not publicly reported if fewer than 25 cases

HCAHPS Survey measure

Considered an alternative approach that would only use HCAPS

Measures- SHFFT

Hospital-Level Performance Measure(s) of Patient-Reported Outcomes Following Elective Primary THA or TKA measure or both

• In development, voluntary data submission will help continue development• Pre- and post-operative data elements (examples):

• Demographic info (age, DOB, admission date, discharge date, procedure date)• PROMIS Global or VR-12• Knee-specific PROM instrument (e.g. HOOS JR, HOOS Pain Subscale, HOOS

Function)• Hip-specific PROM Instrument (e.g., VR-12, PROMIS, HOOS Jr, HOOS Function)

Reporting Period: • Year 1: Pre-operative data (10-month period)• Year 2: Post-operative data for prior year (10-months) and pre-operative data for

current year (12-month period) • Years 3 and beyond: Pre-operative and post-operative data for a 12-month period

Successful Submission• All required data elements• Year 1: 60% of patients; Year 2: 70% of patients. Year 3-5: 80% of patients• Voluntary submission must occur within 60 days of the end of the most recent 12-

month period

SHFFT- Voluntary Data Submission for Patient-Reported Outcome Data

Measure Weight Max Points (20)

Scoring

Hospital-level RSCR (complications) following elective primary THA and/or TKA

50% 10

1.0improvement point*


HCAHPS Survey 40% 8

0.8 improvement points*

90th percentile and above: 880th- 90th percentile: 7.4070th- 80th percentile: 6.8060th- 70th percentile: 6.2050th- 60th percentile: 5.6040th- 50th percentile: 5.0030th- 40th percentile: 4.40Below 30th percentile: 0

THA/TKA voluntary PRO data

10% 2 2 points for successful submission

Quality Composite Scoring- SHFFT

* Improvement points awarded for substantial improvement (2 deciles or more in comparison to national average) from prior years performance.

Category Discount Factor %

AMI CABG SHHFT/CJR

Belowacceptable

3.0 Less than 3.6 Less than 2.8 Less than 5.0

Acceptable 3.0 3.6 to less than 6.9

2.8 to less than 4.8

5.0 to less than 6.9

Good 2.0 6.9 to lessthan 14.8

4.8 to lessthan 17.5

6.9 to lessthan 15.0

Excellent 1.5 Above 14.8 Above 17.5 Above 15.0

Quality Composite Score Categories

Hip and Femur Fracture• Claims-based or hybrid risk-standardized hospital-

level mortality, complication, and/or readmission measures for patients with hip fracture

• Patient-reported outcome data-based measures of functional status, symptom burden, number of days at home and/or return to home and/or independent living suitable for patients with hip fractures and/or patients undergoing total hip or knee arthroplasty

Measures attributable to post-acute care facilities and clinicians

Potential Future Measures

Hospitals included in distribution is all that meet minimum case thresholds rather than allChanges aligning with SHFFT

• Improvement points for an increase of at least 2 (rather than 3) deciles on the performance percentile scare compared to prior years performance

• Categorization of composite scores• Capping maximum score at 20 points, rather than 21.8• Publicly report successful submission (rather than all

submissions) of voluntary measure data• Remove Pain Management from calculation of

HCAHPS score

CJR Quality Changes

Hospitals may have “sharing arrangements” with “collaborators” to share:

• reconciliation payments,• internal cost savings, and • alignment payments.

Must have written policies on selecting collaborators that include quality metrics and do not include criteria directly or indirectly based on volume or value of referrals in the past or anticipated.

GainsharingCollaborators may include:• Physician and non-physician

practitioners (NPP)• Home health agencies

(HHA)• Skilled nursing facilities

(SNF)• Long term care hospitals

(LTCH)• Physician Group Practices

(PGP)• Inpatient rehabilitation

facilities (IRF)• Provider or supplier of

outpatient therapy services• Hospital/CAH* • ACO*

*new

Must be voluntary, without penalty for non-participation, associated with quality scores and paid once a year

Must comply with §512: beneficiary notification, access to records, record retention, and participation in evaluation, monitoring, compliance and enforcement activities

Collaborators other than PGPs/ACO must furnish services during episode to be eligible for incentives

• PGPs/ACOs must assist with clinical activities and have at least one physician/NPP provide services to an applicable beneficiary

Methodology may vary payments based on relative contribution of collaborators activities

Cap on individual physicians and NPPs is 50% of FFS payments made in relation to applicable beneficiaries

Gainsharing (continued)

Financial ResponsibilityAs only Episode Initiators, risk accrues solely to the hospital

Participant hospitals may assign a portion of the two-sided risk to “collaborators”

• CMS will solely interact with the hospital• The hospital is responsible for interacting with collaborators to pay or

recoup funds

Hospitals are required to retain 50% of downside risk

Hospitals cannot share more than 25% of repayment responsibility with any one collaborator other than ACOs, which may absorb up to 50% of the risk

An alignment payment is a collaborator payment back to the hospital as a result of shared risk arrangements

Dated, written agreement memorializing: purpose and scope of the sharing arrangement. identities and obligations of the parties, including specified EPM activities and other services to be performed by the parties under the sharing arrangement. management and staffing information, including personnel primarily responsible for EPM activities. financial terms for payment, including the following:

• Eligibility criteria for a gainsharing payment. • Eligibility criteria for an alignment payment. • Frequency of gainsharing or alignment payment. • Methodology for determining the amount of a gainsharing payment

that is substantially based on quality of EPM activities. • Methodology for determining amount of an alignment payment.

Must not reduce or limit medically necessary services

Sharing Arrangements

Gainsharing: Figure 2

EPM participant must:Document the sharing arrangement contemporaneously with the establishment of the arrangement; Maintain accurate current and historical lists of all EPM collaborators, including EPM collaborator names and addresses; update such lists on at least a quarterly basis; and publicly report current/historical lists collaborators on a webpage on the EPM participant's website; and Maintain and require each EPM collaborator to maintain contemporaneous documentation with respect to the payment or receipt of any gainsharing/alignment payment that includes--

• Nature of the payment (gainsharing payment or alignment payment); • Identity of the parties making and receiving the payment; • Date of the payment; • Amount of the payment; • Date and amount of any recoupment of all or a portion of an EPM collaborator's

gainsharing payment; and • Explanation for each recoupment, such as whether the EPM collaborator received

a gainsharing payment that contained funds derived from a CMS overpayment on a reconciliation report, or was based on the submission of false or fraudulent data.

Documentation

EPM participant must keep records for the following:

• Its process for determining and verifying its potential and current EPM collaborators' Medicare participation.

• Its plan to track internal cost savings. • Information on the accounting systems used to track

internal cost savings; • A description of current health information technology,

including systems to track reconciliation payments and internal cost savings; and

• Its plan to track gainsharing/alignment payments. Collaborator to retain and provide access to, the required documentation in accordance with §512.110.

Documentation (continued)

Summary reports on episodes during the baseline (Jan. 1, 2013-Dec. 31, 2015) and performance periods

Includes all expenditures and claims for an EPM episode for all care covered under Medicare Parts A and B within the 90 days after discharge for those beneficiaries for applicable anchor diagnosis billed by participant

Summary reports will contain at least inpatient, outpatient, SNF, HHA, hospice, carrier/Part B and DME servicesMay request raw claims data including services furnished by the participant and other entities during the episode

For both formats, quarterly files and excludes substance use related patient recordsAggregate expenditure data on US Census Divisions through 90-day episode

Data Sharing- Beneficiary Level Data

Provides certain waivers of Fraud and Abuse Laws

• For gainsharing and alignment payments the model waives:

• Federal Anti-kickback statute• Physician self-referral prohibitions• Civil monetary penalties (inapplicable due to MACRA law)

• For beneficiary incentives furnished to CJR beneficiaries during a CJR episode of care provided the program requirements are met, the model waives:

• Beneficiary inducements CMP• Federal Anti-kickback statute

Legal Waivers

Permits participating hospitals (not collaborators) to provide “in-kind patient engagement incentives” for free or below fair market value subject to the following conditions:

• The incentive must be provided during an episode of care. • The item or service provided must be reasonably connected to

the beneficiary's medical care during an episode and engage the beneficiary in better managing his or her own health.

• The item or service must be a preventive care item or service oradvance one of the following clinical goals:

• Beneficiary adherence to drug regimens. • Beneficiary adherence to a care plan. • Reduction of readmissions and complications resulting from LEJR

procedures. • Management of chronic diseases and conditions that may be

affected by the LEJR procedure.

Beneficiary Incentives

• The incentive must not be tied to the receipt of items or services from a particular provider or supplier.

• The incentive must not be tied to the receipt of items or services outside the episode of care.

• The item or service may only be provided by a participating hospital directly or through an agent who is under the hospital’s control and direction. In the final rule, CMS notes that if a reasonable beneficiary would perceive the item or service as being from the agent rather than the hospital, the incentive would not be treated as provided by the hospital and thus is not eligible for protection under this provision.

• The cost of the item or service may not be shifted to another federal health care program.

Beneficiary Incentives (continued)

Must maintain contemporaneous documentation of beneficiary incentives that exceed $25 in value Must include the date the incentive is provided as well as the identity of the beneficiary to whom it was provided. May provide items of technology if the value of the technology does not exceed $1,000 for any one beneficiary.

• hospital must retain ownership of the technology where the cost of the technology exceeds $100

• hospital must retrieve the technology at end of the episode and maintain documentation of the date of retrieval

• the agency will deem “documented, diligent, good faith attempts to retrieve items of technology” to meet the retrieval requirement

Beneficiary Incentive (continued)

Payment Waivers for EPMsSkilled Nursing

Facility• Waives the SNF 3-

day rule beginning in PY2 for AMI only

• SNF must be rated 3-stars or higher to apply waiver

• Premature discharges to SNF are not allowed

• Freedom of choice for SNF without patient steering

• Hospital liable if waiver mis-used

• Hospital and beneficiary held harmless if beneficiary eligibility changes for CJR

Home Visits

• Waives the direct supervision rule for “incident to” services

• Licensed clinical staff to furnish visit

• Applies to beneficiaries that don’t qualify for home health coverage

• Waives 90-day post-operative global surgical period for up to 9 visits (13 for AMI)

• Will bill HCPCS G codes (~$50)

Telehealth

• Waives geographic site and originating site requirements

• Cannot substitute for in-person home health services paid under Home Health PPS

• Must be furnished in accordance with all other coverage and payment criteria

• Will bill HCPCS G codes

GOAL: test the cost and quality effects of providing explicit financial incentives to encourage care coordination and increased CR use during 90 days after hospitalization for beneficiaries treated for AMI or CABGCardiac rehab (CR)—physician-supervised program that furnishes prescribed exercise, cardiac risk factor modification, psychological and outcomes assessments.

• 2 one-hour sessions per day for up to 36 sessions over 36 weeks with option of additional 36 sessions if MAC approved

Intensive cardiac rehab (ICR)—physician-supervised program that furnishes cardiac rehab and has shown, in peer-reviewed published research, that improves patient’s cardiovascular disease through specific outcome measurement

• Limited to 72 one-hour sessions, up to 6 sessions per day, over a period of up to 18 weeks

Cardiac Rehab for AMI and CABG

Timing—coincides with EPM; July 1, 2017-Dec. 31, 2021Areas—4 matched groups by MSA: FFS-CR, FFS-non CR, EPM-CR, and EPM-non CR.

• Will select 45 MSAs from 98 finalized under EMP and another 45 from the remainder of the 294 eligible areas

• Will stratify based on percent starting I/CR, percent completing I/CR, and number of I/CR providers.

Incentive payments—will go to hospital if any provider/ supplier furnishes I/CR to applicable beneficiaries

• $25 per I/CR for up to 11 services; $175 per I/CR for 12 or more services for rest of the episode

• Paid once a aggregate amount once per performance year• Will not be part of EPM reconciliation; cannot be in gainsharing

Waiver— allows non-physician practitioners to supervise, prescribe exercise and establish, review, and sign plans

• Will allow some beneficiary incentives such as transportation

Cardiac Rehab for AMI and CABG

HCPCS Code Descriptor

93797Physician services for outpatient cardiacrehabilitation; without continuous ECG monitoring(per session)

93798Physician services for outpatient cardiacrehabilitation; with continuous ECG monitoring(per session)

G0422Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise, per session

G0423Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise, per session

TABLE 37: HCPCS CODES FOR CARDIAC REHABILITATION AND INTENSIVE CARDIAC REHABILITATION SERVICES

Due to narrow scope, FFS-CR participants, upon request, will receive:

• Inpatient claims -- potential admissions for CABG and AMI MS-DRGs, plus PCI MS-DRGs if paired with an AMI ICD-CM diagnosis as a principal or secondary code, and

• Carrier and Outpatient claims -- CR/ICR services occurring in the 90-day period after discharge for treatment of AMI or for CABG surgery (AMI or CABG “care period”).

Either summary or claims-level format on a running quarterly basis on data portal. Participants would receive data for up to the current quarter and all of the previous quarters going back to July 1, 2017. Subsequent data would be released as often as quarterly and would include up to 6 quarters of prior data.

Cardiac Rehab Data Sharing

Premier detailed summary

Proposed rule

CMS press release

CMS fact sheet

Important Links

https://www.federalregister.gov/articles/2016/08/02/2016-17733/medicare-program-advancing-care-coordination-through-episode-payment-models-epms-cardiac

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-07-21.html

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-25.html


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Appendix

Appendix AMSA

CJR/SHFFT Region

AMI/CABG Eligible Region

Akron, OH Yes IncludeAlbuquerque, NM Yes IncludeAnaheim-Santa Ana-Irvine, CA Yes IncludeAsheville, NC Yes IncludeAthens-Clarke County, GA Yes IncludeAustin-Round Rock, TX Yes IncludeBeaumont-Port Arthur, TX Yes IncludeBismarck, ND Yes IncludeCape Girardeau, MO-IL Yes IncludeCarson City, NV Yes IncludeCharlotte-Concord-Gastonia, NC-SC Yes IncludeCincinnati, OH-KY-IN Yes IncludeColumbia, MO Yes IncludeCorpus Christi, TX Yes IncludeDecatur, IL Yes IncludeDenver-Aurora-Lakewood, CO Yes IncludeDothan, AL Yes IncludeDurham-Chapel Hill, NC Yes IncludeDutchess County-Putnam County, NY Yes IncludeFlint, MI Yes IncludeFlorence, SC Yes IncludeFort Lauderdale-Pompano Beach-Deerfield Beach, FL Yes IncludeGainesville, FL Yes IncludeGainesville, GA Yes IncludeGreenville, NC Yes IncludeHarrisburg-Carlisle, PA Yes IncludeHot Springs, AR Yes Include

MSACJR/SHFFT Region


Indianapolis-Carmel-Anderson, IN Yes IncludeKansas City, MO-KS Yes IncludeKilleen-Temple, TX Yes IncludeLincoln, NE Yes IncludeLos Angeles-Long Beach-Glendale, CA Yes IncludeLubbock, TX Yes IncludeMadison, WI Yes IncludeMemphis, TN-MS-AR Yes IncludeMiami-Miami Beach-Kendall, FL Yes IncludeMilwaukee-Waukesha-West Allis, WI Yes IncludeModesto, CA Yes IncludeMonroe, LA Yes IncludeMontgomery, AL Yes IncludeNaples-Immokalee-Marco Island, FL Yes Include

Nashville-Davidson--Murfreesboro--Franklin, TN Yes IncludeNassau County-Suffolk County, NY Yes IncludeNew Haven-Milford, CT Yes IncludeNew Orleans-Metairie, LA Yes IncludeNew York-Jersey City-White Plains, NY-NJ Yes IncludeNewark, NJ-PA Yes IncludeNorwich-New London, CT Yes IncludeOakland-Hayward-Berkeley, CA Yes IncludeOgden-Clearfield, UT Yes IncludeOklahoma City, OK Yes Include

Potentially “included” in All ModelsCJR/SHFFT + potential AMI/CABG

Potentially “included” in All Models (cont.)

MSACJR/SHFFT

RegionAMI/CABG

Eligible RegionPensacola-Ferry Pass-Brent, FL Yes IncludePittsburgh, PA Yes IncludePort St. Lucie, FL Yes IncludePortland-Vancouver-Hillsboro, OR-WA Yes IncludeProvo-Orem, UT Yes IncludeReading, PA Yes IncludeSaginaw, MI Yes IncludeSan Francisco-Redwood City-South San Francisco, CA Yes IncludeSan Rafael, CA Yes IncludeSeattle-Bellevue-Everett, WA Yes IncludeSebastian-Vero Beach, FL Yes IncludeSt. Louis, MO-IL Yes IncludeStaunton-Waynesboro, VA Yes IncludeTacoma-Lakewood, WA Yes IncludeTampa-St. Petersburg-Clearwater, FL Yes IncludeToledo, OH Yes IncludeTopeka, KS Yes IncludeTuscaloosa, AL Yes IncludeTyler, TX Yes IncludeWest Palm Beach-Boca Raton-Delray Beach, FL Yes IncludeWichita, KS Yes Include

Potentially “included” AMI/CABG only

MSACJR/SHFFT

RegionAMI/CABG

Eligible RegionAbilene, TX No IncludeAlbany, GA No IncludeAlexandria, LA No IncludeAllentown-Bethlehem-Easton, PA-NJ No IncludeAltoona, PA No IncludeAmarillo, TX No IncludeAmes, IA No IncludeAnchorage, AK No IncludeAnn Arbor, MI No IncludeAnniston-Oxford-Jacksonville, AL No IncludeAppleton, WI No IncludeAtlanta-Sandy Springs-Roswell, GA No IncludeAtlantic City-Hammonton, NJ No IncludeAuburn-Opelika, AL No IncludeAugusta-Richmond County, GA-SC No IncludeBangor, ME No IncludeBarnstable Town, MA No IncludeBaton Rouge, LA No IncludeBay City, MI No IncludeBeckley, WV No IncludeBellingham, WA No IncludeBend-Redmond, OR No IncludeBillings, MT No IncludeBirmingham-Hoover, AL No IncludeBloomington, IL No IncludeBloomington, IN No Include

MSACJR/SHFFT Region


Bloomsburg-Berwick, PA No IncludeBoise City, ID No IncludeBoston, MA No IncludeBridgeport-Stamford-Norwalk, CT No IncludeBrownsville-Harlingen, TX No IncludeBrunswick, GA No IncludeBurlington-South Burlington, VT No IncludeCambridge-Newton-Framingham, MA No IncludeCamden, NJ No IncludeCanton-Massillon, OH No IncludeCape Coral-Fort Myers, FL No IncludeCarbondale-Marion, IL No IncludeCedar Rapids, IA No IncludeChambersburg-Waynesboro, PA No IncludeChampaign-Urbana, IL No IncludeCharleston, WV No IncludeCharleston-North Charleston, SC No IncludeCharlottesville, VA No IncludeChattanooga, TN-GA No IncludeCheyenne, WY No IncludeChicago-Naperville-Arlington Heights, IL No IncludeChico, CA No IncludeClarksville, TN-KY No IncludeCleveland-Elyria, OH No IncludeCoeur d'Alene, ID No Include


MSACJR/SHFFT

Region


College Station-Bryan, TX No IncludeColorado Springs, CO No IncludeColumbia, SC No IncludeColumbus, GA-AL No IncludeColumbus, IN No IncludeCorvallis, OR No IncludeCrestview-Fort Walton Beach-Destin, FL No IncludeDallas-Plano-Irving, TX No IncludeDaphne-Fairhope-Foley, AL No IncludeDavenport-Moline-Rock Island, IA-IL No IncludeDayton, OH No IncludeDeltona-Daytona Beach-Ormond Beach, FL No IncludeDes Moines-West Des Moines, IA No IncludeDetroit-Dearborn-Livonia, MI No IncludeDover, DE No IncludeDuluth, MN-WI No IncludeEau Claire, WI No IncludeEl Paso, TX No IncludeElgin, IL No IncludeElizabethtown-Fort Knox, KY No IncludeElkhart-Goshen, IN No IncludeElmira, NY No IncludeErie, PA No IncludeEugene, OR No IncludeEvansville, IN-KY No IncludeFargo, ND-MN No Include

MSACJR/SHFFT Region


Farmington, NM No IncludeFayetteville, NC No IncludeFayetteville-Springdale-Rogers, AR-MO No IncludeFlorence-Muscle Shoals, AL No IncludeFort Collins, CO No IncludeFort Wayne, IN No IncludeFort Worth-Arlington, TX No IncludeFresno, CA No IncludeGadsden, AL No IncludeGary, IN No IncludeGrand Forks, ND-MN No IncludeGrand Junction, CO No IncludeGrand Rapids-Wyoming, MI No IncludeGreeley, CO No IncludeGreen Bay, WI No IncludeGreensboro-High Point, NC No IncludeGreenville-Anderson-Mauldin, SC No IncludeGulfport-Biloxi-Pascagoula, MS No IncludeHartford-West Hartford-East Hartford, CT No IncludeHattiesburg, MS No IncludeHickory-Lenoir-Morganton, NC No IncludeHilton Head Island-Bluffton-Beaufort, SC No IncludeHomosassa Springs, FL No IncludeHouma-Thibodaux, LA No IncludeHouston-The Woodlands-Sugar Land, TX No Include


MSACJR/SHFFT

Region


Huntington-Ashland, WV-KY-OH No IncludeHuntsville, AL No IncludeIdaho Falls, ID No IncludeIowa City, IA No IncludeJackson, MI No IncludeJackson, MS No IncludeJacksonville, FL No IncludeJanesville-Beloit, WI No IncludeJefferson City, MO No IncludeJohnstown, PA No IncludeJonesboro, AR No IncludeJoplin, MO No IncludeKalamazoo-Portage, MI No IncludeKankakee, IL No IncludeKennewick-Richland, WA No IncludeKingsport-Bristol-Bristol, TN-VA No IncludeKnoxville, TN No IncludeLa Crosse-Onalaska, WI-MN No IncludeLafayette, LA No IncludeLafayette-West Lafayette, IN No IncludeLake Charles, LA No IncludeLake County-Kenosha County, IL-WI No IncludeLake Havasu City-Kingman, AZ No IncludeLakeland-Winter Haven, FL No IncludeLansing-East Lansing, MI No IncludeLas Cruces, NM No Include

MSACJR/SHFFT Region


Las Vegas-Henderson-Paradise, NV No IncludeLawton, OK No IncludeLewiston-Auburn, ME No IncludeLexington-Fayette, KY No IncludeLima, OH No IncludeLittle Rock-North Little Rock-Conway, AR No IncludeLongview, TX No IncludeLouisville/Jefferson County, KY-IN No IncludeLynchburg, VA No IncludeMacon, GA No IncludeManchester-Nashua, NH No IncludeMansfield, OH No IncludeMedford, OR No IncludeMichigan City-La Porte, IN No IncludeMidland, MI No IncludeMinneapolis-St. Paul-Bloomington, MN-WI No IncludeMissoula, MT No IncludeMobile, AL No IncludeMonroe, MI No IncludeMontgomery County-Bucks County-Chester County, PA No IncludeMorgantown, WV No IncludeMuncie, IN No IncludeMuskegon, MI No IncludeMyrtle Beach-Conway-North Myrtle Beach, SC-NC No IncludeNew Bern, NC No Include


MSACJR/SHFFT

Region


Niles-Benton Harbor, MI No IncludeNorth Port-Sarasota-Bradenton, FL No IncludeOdessa, TX No IncludeOlympia-Tumwater, WA No IncludeOmaha-Council Bluffs, NE-IA No IncludeOwensboro, KY No IncludePalm Bay-Melbourne-Titusville, FL No IncludePanama City, FL No IncludeParkersburg-Vienna, WV No IncludePeoria, IL No IncludePhiladelphia, PA No IncludePhoenix-Mesa-Scottsdale, AZ No IncludePortland-South Portland, ME No IncludePrescott, AZ No IncludeProvidence-Warwick, RI-MA No IncludePueblo, CO No IncludePunta Gorda, FL No IncludeRaleigh, NC No IncludeRapid City, SD No IncludeRedding, CA No IncludeReno, NV No IncludeRichmond, VA No IncludeRiverside-San Bernardino-Ontario, CA No IncludeRoanoke, VA No IncludeRochester, MN No IncludeRochester, NY No Include

MSACJR/SHFFT

RegionAMI/CABG

Eligible RegionRockford, IL No IncludeRockingham County-Strafford County, NH No IncludeRocky Mount, NC No IncludeRome, GA No IncludeSacramento--Roseville--Arden-Arcade, CA No IncludeSalem, OR No IncludeSalinas, CA No IncludeSalisbury, MD-DE No IncludeSalt Lake City, UT No IncludeSan Angelo, TX No IncludeSan Diego-Carlsbad, CA No IncludeSan Jose-Sunnyvale-Santa Clara, CA No IncludeSan Luis Obispo-Paso Robles-Arroyo Grande, CA No IncludeSanta Fe, NM No IncludeSanta Maria-Santa Barbara, CA No IncludeSanta Rosa, CA No IncludeSavannah, GA No IncludeScranton--Wilkes-Barre--Hazleton, PA No IncludeSebring, FL No IncludeSherman-Denison, TX No IncludeShreveport-Bossier City, LA No IncludeSilver Spring-Frederick-Rockville, MD No IncludeSioux City, IA-NE-SD No IncludeSioux Falls, SD No IncludeSpartanburg, SC No Include


MSA

CJR/SHFFT

Region


Spokane-Spokane Valley, WA No IncludeSpringfield, IL No IncludeSpringfield, MO No IncludeSt. Cloud, MN No IncludeSt. George, UT No IncludeSt. Joseph, MO-KS No IncludeStockton-Lodi, CA No IncludeSyracuse, NY No IncludeTallahassee, FL No IncludeTerre Haute, IN No IncludeThe Villages, FL No IncludeTrenton, NJ No IncludeTucson, AZ No IncludeTulsa, OK No IncludeUrban Honolulu, HI No IncludeUtica-Rome, NY No IncludeVictoria, TX No IncludeVisalia-Porterville, CA No IncludeWaco, TX No IncludeWarner Robins, GA No Include

MSA

CJR/SHFFT

Region


Warren-Troy-Farmington Hills, MI No IncludeWashington-Arlington-Alexandria, DC-VA-MD-WV No IncludeWaterloo-Cedar Falls, IA No IncludeWausau, WI No IncludeWeirton-Steubenville, WV-OH No IncludeWenatchee, WA No IncludeWheeling, WV-OH No IncludeWilliamsport, PA No IncludeWilmington, DE-MD-NJ No IncludeWilmington, NC No IncludeWinchester, VA-WV No IncludeWinston-Salem, NC No IncludeWorcester, MA-CT No IncludeYakima, WA No IncludeYork-Hanover, PA No IncludeYoungstown-Warren-Boardman, OH-PA No IncludeYuba City, CA No IncludeYuma, AZ No Include

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