delivery system reform: here comes value-based …...– 2013: 1.2% of the medicare population, but...

Delivery System Reform: Here

Comes Value-Based Care!

Jim Brulé, Solutions Director - Regulatory

Copyright © 2016 Allscripts Healthcare Solutions, Inc. 2

First, a word.The information contained within this presentation is intended for informational purposes only. While the information and recommendations presented in this presentation are good-faith interpretations made by Allscripts based on the publicly available information referenced within, it does not constitute legal advice or guidance. Thus, any decisions, and associated risks, made by the client pertaining to the information within this presentation are solely the responsibility and liability of the client. Clients are strongly advised that such decisions be made in consultation with their legal representatives.

The information presented within this presentation (1) should not be considered complete, exhaustive, or customized to an individual client’s needs; and (2) is subject to change due to new laws, regulations, or Department of Health and Human Services policies issued after May 18, 2016.

This presentation neither modifies any signed agreements Allscripts has with the client nor creates any Allscripts attestations, representations, warranties, guarantees or covenants related to MU or MACRA compliance, meeting MU or MACRA standards and requirements, whether Allscripts EHR software will meet new or modified requirements for certified EHR technology, or for any other matter.

Overview


“Bending the Cost Curve”


Shifting to increased quality & risk

Anticipated distribution of Medicare payments. Source: CMS

• FFS: Fee for Service

• APMs: Alternative

Payment Models

• MIPS: Merit-based

Incentive Payment

System

Alternative Payment Models


Alternative Payment Models (examples)• Medicare Shared Savings Program (MSSP)

• Pioneer ACOs

• Next Generation ACOs

• Comprehensive End Stage Renal Disease (ESRD) Care Model

• Comprehensive Primary Care Plus

• Comprehensive Joint Replacement

• Bundled Payment Care Improvement


Advanced APMs: Eligible for 2017

• Comprehensive Primary Care

Plus (CPC+)

• Comprehensive ESRD Care

Model (Large Dialysis

Organization arrangement)

• Medicare Shared Savings

Program—Track 2

• Medicare Shared Savings

Program—Track 3

• Next Generation ACO Model

List will be updated by CMS annually


Medicare Shared Savings Program (MSSP)

Track 1 Track 2 Track 3

Qualify for QPP? No Yes Yes

ACOs included 411 6 16

Type 1-sided 2-sided 2-sided

Min Med Max

ESRD 0.2% 0.8% 4.1%

Disabled 3.7% 12.9% 59.4%

Aged Dual Eligible 0.5% 4.7% 70.6%

Aged Non-Dual Eligible 21.0% 80.1% 95.3%

Male 35.7% 42.5% 52.9%

Female 47.1% 57.5% 64.3%

Age less than 65 6.2% 16.2% 61.2%

Age 65-74 19.6% 42.7% 55.8%

Age 75-84 11.0% 27.1% 37.5%

Age 85+ 3.2% 12.2% 34.2%


Pioneer / Next Generation ACOs

Pioneer Next Generation

Time Window 2012-2016 2016-2020, 2017-2021

Participants 9 ACOs, 19 participants 18 participants

Financial Risk 5 payment plans: share savings &

losses of up to 60-75%

Plan A: shared savings and losses of up to 80%

Plan B: shared savings and losses of up to 100%

Quality Same as MSSP Same as MSSP, without EHR measure

Enhancements waiver of the SNF 3-day stay rule • SNF 3-Day Rule waiver

• Telehealth originating site expansion

• Post-Discharge Home Visits


Comprehensive End Stage Renal Disease (ESRD) Care Model• Background

– > 600,000 Americans have ESRD: require life sustaining dialysis treatments several times per week.

– 2013: 1.2% of the Medicare population, but 6.3% of total Medicare spending ( >$30.9 billion)

• Model Details

– Dialysis clinics, nephrologists and other providers join together to create an ESCO to coordinate care

– ESCOs are accountable for clinical quality outcomes and financial outcomes measured by Medicare Part A and B spending

• includes all spending on dialysis services for their aligned ESRD beneficiaries.

• Incentives

– Large Dialysis Organizations (LDOs):

• >=200 or more dialysis facilities

• shared savings payments

– Non-LDOs

• Option 1: one-sided track – shared savings, not losses

• Option 2: higher reward, but higher risk & potential for shared losses

• Details

– https://innovation.cms.gov/initiatives/comprehensive-esrd-care/

https://innovation.cms.gov/initiatives/comprehensive-esrd-care/


Comprehensive Joint Replacement (CJR)• Ongoing, mandatory program

– Began 4/1/16

• Involves 67 MSAs (Metropolitan Statistical Areas)

– ~800 hospitals

• Holds participant hospitals financially accountable for the quality and cost of a CJR episode of

care

• Episode ends 90 days post-discharge in order to cover the complete period of recovery for

beneficiaries

• Incentivizes increased coordination of care among hospitals, physicians, and post-acute care

providers

• Depending on the participant hospital’s quality and episode spending performance, the hospital

may receive an additional payment from Medicare or be required to repay Medicare for a

portion of the episode spending


Bundled Payment Care Improvement (1)• Model 1

– Episode of care is defined as the inpatient stay in the acute care hospital

– Hospital paid a discounted amount based on the Inpatient Prospective Payment System

– Physicians paid separately for their services under the Medicare Physician Fee Schedule

• Models 2 & 3

– retrospective bundled payment arrangement where actual expenditures are reconciled

against a target price for an episode of care

– episode includes up to 90 days after hospital discharge

• Model 2: starts with admission to hospital

• Model 3: starts with initiation of post-acute care

– Medicare continues to make fee-for-service (FFS) payments; the total expenditures for the

episode is later reconciled against a bundled payment amount (the target price) determined

by CMS


Bundled Payment Care Improvement (2)• Model 4

– CMS makes a single, prospectively determined bundled payment to the hospital

– encompasses all services furnished by the hospital, physicians, and other practitioners during

the episode of care, which lasts the entire inpatient stay

– Physicians and other practitioners submit “no-pay” claims to Medicare and are paid by the

hospital out of the bundled payment

• Episodes of Care

– Model 1: all MS-DRGs

– Models 2, 3 & 4: 48 episodes that participants choose from


CPC+ highlights• Open to 5,000 practices

– Competitive application process

• Two tracks

– Track 1 – lower risk, fewer tiers

– Track 2 – higher risk, more tiers

• Each track prepays based on enrolled beneficiaries

– Payments made quarterly

– Most payments are independent of outcome

• Small performance-based incentives provided

– These payments are in addition to Medicare payments

• Track two has opportunity for risk-sharing in exchange for higher payments

Other efforts by CMS


Other Efforts to Drive Delivery System Reform

• Data initiatives

– Physician Compare

• Star rating; groups only at this time

• Will include QPP performance data

• https://www.medicare.gov/physiciancompare/search.html

– Hospital Compare

• Patient survey summary star rating

• https://www.medicare.gov/hospitalcompare/search.html?

– Drug Spending Dashboard

• information on prescription drugs Medicare spending

• https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Information-on-Prescription-Drugs/

• Research Initiatives

– Independence at Home Initiative

• Tests whether delivering primary care at home leads to better health outcomes

• Targeted for elderly patients with multiple chronic conditions

– Strong Start / Strong Start II

• Tests enhanced services in maternity settings

• Goals:

– reduce the rate of preterm births

– improve the health outcomes of pregnant women and newborns

– decrease the cost of medical care from pregnancy thru first year of life

https://www.medicare.gov/physiciancompare/search.html

https://www.medicare.gov/hospitalcompare/search.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Information-on-Prescription-Drugs/

In closing…


Delivery System Reform is here!• CMS is engaged in a wide variety of efforts

• Some are regulatory – meaning new, long-term changes

• Some are programmatic – trials that may or may not succeed

• Some assume “market forces” (read – consumer choice)

• Each one has the potential to impact your workflow and finances

• Expect a flurry before 12/31/16

• Stay in touch on ClientConnect!


Questions


Further information• CMS Innovation Center website:

– https://innovation.cms.gov/

• CMS QPP website:

– http://bit.ly/cms-qpp/

• CMS CPC+ website:

– https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus

• Delivery System Reform: Making Health Care Work Better for Everyone (HHS)

– http://www.hhs.gov/blog/2016/03/22/making-health-care-work-better-everyone.html

https://innovation.cms.gov/

http://bit.ly/cms-qpp/

https://innovation.cms.gov/initiatives/comprehensive-primary-care-plus

http://www.hhs.gov/blog/2016/03/22/making-health-care-work-better-everyone.html

Thank you!

delivery system reform: here comes value-based …...– 2013: 1.2% of the medicare population, but...

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